Introduction Neurogenic dysphagia defines swallowing disorders caused by diseases of the central and peripheral nervous system, neuromuscular transmission, or muscles. Neurogenic dysphagia is one of the most common and at the same time most dangerous symptoms of many neurological diseases. Its most important sequelae include aspiration pneumonia, malnutrition and dehydration, and affected patients more often require long-term care and are exposed to an increased mortality. Based on a systematic pubmed research of related original papers, review articles, international guidelines and surveys about the diagnostics and treatment of neurogenic dysphagia, a consensus process was initiated, which included dysphagia experts from 27 medical societies. Recommendations This guideline consists of 53 recommendations covering in its first part the whole diagnostic spectrum from the dysphagia specific medical history, initial dysphagia screening and clinical assessment, to more refined instrumental procedures, such as flexible endoscopic evaluation of swallowing, the videofluoroscopic swallowing study and high-resolution manometry. In addition, specific clinical scenarios are captured, among others the management of patients with nasogastric and tracheotomy tubes. The second part of this guideline is dedicated to the treatment of neurogenic dysphagia. Apart from dietary interventions and behavioral swallowing treatment, interventions to improve oral hygiene, pharmacological treatment options, different modalities of neurostimulation as well as minimally invasive and surgical therapies are dealt with. Conclusions The diagnosis and treatment of neurogenic dysphagia is challenging and requires a joined effort of different medical professions. While the evidence supporting the implementation of dysphagia screening is rather convincing, further trials are needed to improve the quality of evidence for more refined methods of dysphagia diagnostics and, in particular, the different treatment options of neurogenic dysphagia. The present article is an abridged and translated version of the guideline recently published online (https://www.awmf.org/uploads/tx_szleitlinien/030-111l_Neurogene-Dysphagie_2020-05.pdf).

The results of swallowing therapy in 58 patients with neurologic disorders are presented. All patients received tube feeding, either partially or exclusively, at admission, and successful outcomes, defined as exclusively oral feeding, were achieved in 67% of patients over a median treatment interval of 15 weeks. A subset of 11 patients who had experienced disease onset 25 weeks or more prior to admission nonetheless had a similar success rate of 64%. No other pretreatment variable, including age, localization of lesion, type or degree of aspiration, or cognitive status, correlated with successful outcome. Indirect therapy methods such as stimulation techniques and exercises to enhance the swallowing reflex, alter muscle tone, and improve voluntary function of the orofacial, lingual, and laryngeal musculature were utilized in all but 1 patient. Direct methods including compensatory strategies such as head and neck positioning, and techniques such as supraglottic swallowing and the Mendelsohn maneuver were additionally employed in nearly one-half of patients. Swallowing therapy is associated with successful outcome, as defined by exclusively oral feeding, among patients with neurogenic dysphagia, regardless of pretreatment variables including time since disease onset. Indirect treatment methods appear to be effective when used either alone or in combination with direct methods. Achievement of oral feeding is not associated with undue risk of pneumonia. Further rigorous scientific studies are needed.

The results of swallowing therapy in 28 patients with neurological disorders causing cricopharyngeal (CP) dysfunction are reported. Variables described include the type of swallowing disorder, type and degree of aspiration, and therapeutic strategies. Patients were monitored by cineradiography before, during, and after therapy. Success of therapy was defined by progress in type, ease and safety of feeding, and range of diet. As an example, a case of an unusually severe disorder of a CP opening subsequent to brainstem meningoencephalitis is described. The bedside clinical evaluation, otolaryngologic findings, and radiographic studies helped determine an individualized program of swallowing therapy. Therapy goals, direct and indirect therapeutic strategies, and the treatment outcome are presented. Ninety percent of patients with CP dysfunction improved with swallowing therapy, 65% by objective and 25% by subjective criteria. We conclude that in neurological patients with CP, dysfunction can effectively be treated with swallowing therapy and that surgical approaches to CP dysfunction should be deferred pending the outcome of conservative management.

During the last decade, videoendoscopic evaluation of structures and sensorimotor functions of the pharynx and larynx has been established as a valuable tool in the assessment of dysphagia. This method is feasible at a very early stage and in critically ill patients, is not invasive and frequently repeatable. Several authors described the high sensitivity and specificity of this method in detecting the presence of the most important symptoms of swallowing dysfunction: retention, penetration and aspiration. In our study of 39 patients with neurogenic dysphagia, we found high agreement between the results of videoendoscopic and videofluoroscopic examination regarding the registration of the most critical symptom, i.e. aspiration. Moreover, we observed patients who aspirated only their saliva and whose endoscopically verified aspiration problem remained undetected by radiographic examination, probably due to the lower sensory input of saliva as compared to a contrast medium. Since the detection of aspiration of saliva is of high clinical relevance for pulmonary function, the endoscopic examination turned out to be superior, in this particular respect, to the radiographic examination. However, the method fails to provide sufficient information regarding the cause of the observed symptoms or the amount of aspirated material. Six patients in our study exhibited, in addition to the neurological signs, structural changes (diverticula, pouches) or unexpected functional esophageal disturbances (persistent opening of the upper esophageal sphincter, retrograde peristalsis) which could only be detected by radiographic examination. The two methods should therefore be considered complementary.

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