Oropharyngeal Dysphagia Pathophysiology, Complications and Science-Based Interventions

Abstract

The etiology of oropharyngeal dysphagia can be broad, and includes aging with atrophy, debilitation, stroke, neurodegenerative and muscular diseases, tumor and postsurgical deformity, as well as effects due to medications and drying of the mucosal membranes. Pathophysiology depends on the multiple causative factors, including the cortex and neural connections to generate the swallow, as well as the oropharyngeal musculature. While chronic debilitation and age may result in nutritional deficiency and poor hydration, the other causes generally present with aspiration risk more acutely. Bacteriologically, aspiration pneumonia is usually polymicrobial with a predominance of Gram-negative enteric bacilli. However, there is emerging evidence to suggest that odontogenic sources may complicate the severity of bacterial load. The principles behind science-based interventions are primarily aspiration assessment with bedside evaluation, and ultimately modified barium swallow (videofluoroscopy) or functional endoscopic evaluation of swallowing (with or without sensory testing). Each has its advantages and logistical concerns. Intervention and rehabilitation is unique to the patient's needs, but may include reconditioning and therapy with a speech and language pathologist, and surgical options. The emerging roles of neuroplasticity and external neuromuscular stimulation are also discussed.

Evaluation of the natural history of patients who aspirate

“…Many studies in this area of dysphagia research suffer from challenges in defining aspiration and pneumonia. The repercussions of pulmonary infection can be clinically varied in severity, and pulmonary insults are wide‐ranging between mild pneumonitis and fulminate pneumonia with sepsis . Studies have shown prevalence of aspiration on VFSS to be extremely variable, and mortality rates can be as high as 70% in selected patient populations .…”

“…The repercussions of pulmonary infection can be clinically varied in severity, and pulmonary insults are wide-ranging between mild pneumonitis and fulminate pneumonia with sepsis. 21 Studies have shown prevalence of aspiration on VFSS to be extremely variable, and mortality rates can be as high as 70% in selected patient populations. 3 The penetration aspiration scale was designed in 1996 by Rosenbek et al to attempt to categorize the severity of aspiration seen on VFSS exams, and to allow clinicians to not only score severity but also evaluate changes in swallowing function over time.…”

Dysphagia: implications for older people

“…[32][33][34][35][36] Cause and course of dysphagia Table 1 lists conditions with which dysphagia is commonly associated, though it is by no means exhaustive for all possible causes and associations. Several works differentiate between anterior The basic anatomy, physiology and neurology of swallowing are covered in most standard textbooks.…”

“…From instrumental studies, it is apparent that many people with dysphagia who aspirate do not cough on swallow, 96 and many known aspirators do not develop aspiration pneumonia. 36,100 Ideally then, screening encompasses oral health. [97][98][99] This has led several to argue that maybe the key issue is not the presence or degree of aspiration, but whether there is aspiration or not in relation to other risk factors, in particular oral health, as a source of pathogens.…”

Dysphagia after stroke

“…К их числу относится аспирация жидкости и пищи с развитием аспирационной пневмонии. Эпидемиологические исследования свидетельствуют о том, что риск развития пневмонии после инсульта прямо пропорционален тяжести аспирации [6][7][8][9][10]. Наличие дисфагии, кроме того, может вызывать нарушения нормального потребления жидкости и пищи с развитием истощения и дегидратации.…”