Makindo Medical Notes

⚠️ Aspiration pneumonia can occur after inhaling food, drinks, or saliva into the lungs. 🤐 Absolute dysphagia is when a patient cannot even swallow their own saliva — this is a red-flag finding requiring urgent assessment.

🚨 Acute Dysphagia Management

Causes are usually mechanical obstruction (e.g., tumour, stricture) or neurological (e.g., stroke, MND). Always prioritise the airway 🫁 — call senior/anaesthetics if compromised. Keep the patient Nil by Mouth (NPO) 🚫🍽️ and provide IV fluids; insert an NG tube only if safe and after swallow assessment. Ensure essential drugs (e.g., Parkinson’s medication) are delivered via NG or transdermal route. Refer to Speech and Language Therapy (SALT) 🗣️ and consider ENT/GI input. Investigations may include barium swallow or endoscopy.

About Dysphagia

• 🍽️ Dysphagia = difficulty swallowing, not a diagnosis but a symptom pointing to underlying disease.
• It carries risks of malnutrition, dehydration, and aspiration pneumonia.

Swallowing Mechanism

• Swallowing involves >30 muscles 🤯 and is divided into three phases:
• Oral Phase 🦷: Chewing and forming a bolus; tongue pushes food backwards.
• Pharyngeal Phase 🫁: Reflex closure of airway, larynx elevates, bolus moves into oesophagus.
• Oesophageal Phase 🧵: Peristalsis + LOS relaxation moves bolus into the stomach.

Mechanical Causes ⚙️

• Dry mouth / sore mouth
• Benign oesophageal strictures
• Achalasia
• Oesophageal cancer 🎗️
• Oesophageal webs
• Extrinsic compression (e.g., mediastinal mass)

Neurological Causes 🧠

• Stroke (bilateral or brainstem)
• Multiple Sclerosis (MS)
• Parkinson’s disease
• Bulbar palsy (MND, polio)
• Myasthenia gravis
• Muscular dystrophy
• Functional dysphagia

Painful Causes 🔥

• Infectious mononucleosis
• Acute epiglottitis (urgent airway involvement)
• Quinsy (peritonsillar abscess)
• Lemierre’s syndrome (rare septic thrombophlebitis)

Clinical Signs 👀

• Coughing/choking during meals
• Regurgitation of food (sometimes through the nose 🤧)
• Sensation of food sticking in throat/chest
• Persistent drooling 💧
• Difficulty chewing
• “Wet” or gurgling voice after swallowing

Investigations 🔬

• Bloods: FBC, U&E, CRP, TFTs
• CXR: Look for aspiration pneumonia, mediastinal mass
• FEESST: Endoscopic swallow test with airway assessment
• VFSS (Barium swallow): Visualises bolus transit and aspiration
• OGD: To assess oesophageal pathology
• CT chest: For extrinsic compression/masses

Management 🛠️

• Depends on cause → neurological vs structural.
• SALT input 🗣️: Teaches safe swallow techniques and postures.
• Dietary modifications 🍲: Texture-modified diet, thickened fluids.
• Feeding support 🧪: NG or PEG feeding if unsafe swallow persists.
• Endoscopic/surgical therapy 🪡: Dilatation or stenting for strictures.

Dietary and Swallowing Advice 🍽️

• Sit upright (90°) while eating.
• Remain upright 15–20 min post-meal.
• Avoid distractions while eating.
• Do not talk while swallowing 🛑🗣️.
• Eat slowly, chew thoroughly.

Thickened Fluids 💧➡️🥄

• Use the thinnest liquid the patient can safely swallow.
• IDDSI framework:
• 0️⃣ Thin (water)
• 1️⃣ Slightly thick
• 2️⃣ Mildly thick (nectar)
• 3️⃣ Moderately thick (honey)
• 4️⃣ Extremely thick (pudding)

References 📚

• Dysphagia Management Guide

Cases — Dysphagia

• Case 1 (Neurological — Post-stroke): 🧠 A 76-year-old man develops difficulty swallowing liquids and solids after a left MCA stroke. He coughs during meals, and his voice becomes “wet” after drinking water. Management: Kept Nil by Mouth, urgent Speech and Language Therapy (SALT) assessment arranged. Started on thickened fluids (IDDSI 2) and pureed diet. NG tube placed for medications and nutrition. Outcome: Gradual improvement with swallow therapy. At 6 weeks he tolerates soft solids; NG removed. Residual mild dysphagia managed with ongoing SALT support.
• Case 2 (Mechanical — Oesophageal stricture): ⚙️ A 58-year-old woman with long-standing reflux presents with progressive dysphagia, first to solids, later to liquids. She reports retrosternal discomfort and regurgitation of undigested food. Management: Upper GI endoscopy shows benign peptic stricture; dilatation performed. High-dose PPI started to prevent recurrence. Outcome: Able to swallow normally after dilatation. Continues PPI therapy. Follow-up arranged to monitor for recurrence.
• Case 3 (Malignant — Oesophageal carcinoma): 🎗️ A 70-year-old man with a 50-pack-year smoking history presents with rapidly progressive dysphagia, weight loss, and iron-deficiency anaemia. Endoscopy reveals an obstructing distal oesophageal mass; biopsy confirms adenocarcinoma. Management: MDT discussion; not fit for curative surgery. Palliative self-expanding metallic stent inserted to relieve obstruction, plus nutritional support. Outcome: Able to eat soft diet again, weight stabilises. Referred to palliative oncology for ongoing support.

Teaching Commentary 🧑‍⚕️

Dysphagia can be broadly divided into neurological (stroke, MND, Parkinson’s), mechanical benign (strictures, webs, achalasia), and malignant causes. 🔑 Key discriminators: • Difficulty with liquids + solids from onset → neurological or motility disorder. • Progressive solids → liquids → mechanical obstruction (stricture, tumour). • Red flags 🚩 → absolute dysphagia, weight loss, aspiration pneumonia, anaemia → urgent referral. Management must address nutrition, airway safety, and underlying pathology.