Makindo Medical Notes

Dysphagia = difficulty in swallowing. It is common in older adults and carries risks of malnutrition, aspiration pneumonia, dehydration, and reduced quality of life. 👉 Always distinguish between oropharyngeal vs oesophageal dysphagia.

📌 Basic Physiology of Swallowing

• 👅 Oral phase – bolus formation and voluntary transfer to pharynx.
• 🧠 Pharyngeal phase – reflex, coordinated by brainstem; larynx elevates, epiglottis closes, pharyngeal muscles propel food.
• 🫀 Oesophageal phase – peristaltic waves move bolus to stomach via lower oesophageal sphincter.
• 👂 Requires intact cranial nerves (V, VII, IX, X, XII), muscles, and coordination.

🔎 Causes in Older Adults

🚩 Red Flags

• Unintentional weight loss 📉
• Progressive dysphagia (esp. solids → liquids) 🍞➡️🥤
• Haematemesis, anaemia, melaena 🩸
• Neck lump, hoarseness, or odynophagia
• Recurrent aspiration pneumonia 🤒

🧪 Clinical Assessment

• 📚 History: Onset (sudden vs gradual), intermittent vs progressive, solids vs liquids, aspiration episodes, associated pain/weight loss.
• 👀 Examination: Cranial nerves, gag reflex, tongue movements, oral cavity inspection, cervical lymph nodes.
• ⚠️ Bedside swallow assessment (water swallow test).

📊 Investigations

• 🦻 ENT referral if oropharyngeal suspicion.
• 📈 Videofluoroscopic swallow study (gold standard for aspiration).
• 📸 Endoscopy (OGD) for suspected oesophageal pathology.
• 📡 Barium swallow or manometry for motility disorders.
• 🧪 Bloods: FBC, U&E, iron studies if anaemia present.

🛠️ Management Principles

• 🍽️ Dietary modification: Thickened fluids, soft/pureed diet.
• 🧑‍⚕️ Speech & Language Therapy (SALT): swallow rehabilitation, safe feeding techniques.
• 💊 Treat cause: PPIs for reflux strictures, dilatation/stenting for oesophageal obstruction, botulinum toxin for achalasia.
• 🧠 Neurological causes: posture, swallow training, NG or PEG feeding if high aspiration risk.
• 🚫 Aspiration prevention: Sit upright during meals, oral hygiene, avoid sedating drugs.

🎯 Teaching Pearls

• Solids then liquids dysphagia → mechanical obstruction 🚧.
• Solids + liquids from onset → motility disorder ⚡.
• Choking/coughing at start → oropharyngeal cause 🧠.
• Always check SALT assessment before prescribing “nil by mouth”.

🥣 Food Consistencies in Dysphagia

The safest diet for swallowing problems depends on the underlying cause (neurological vs mechanical). The IDDSI framework (Levels 0–7) standardises fluids and food textures worldwide.

📊 IDDSI Levels (Simplified)

🧠 Matching Food Texture to Diagnosis

• 🧠 Stroke / Parkinson’s / Dementia → often need pureed (Level 4) meals or thickened fluids (Levels 1–3) due to aspiration risk.
• 🩻 Oesophageal stricture / cancer → soft & bite-sized (Level 6); avoid dry solids. May tolerate thin fluids if lumen not completely obstructed.
• 🔥 Acute painful swallowing (e.g. severe tonsillitis, oesophagitis, mucositis from chemo/radiotherapy) → prefer liquidised (Level 3) or pureed (Level 4) foods to reduce pain, plus cool/thickened fluids.
• 🔄 Achalasia → often struggle more with liquids than solids; better with soft & bite-sized (Level 6) and may need slightly thick (Level 1–2) fluids.
• 🧬 Myasthenia gravis / Motor Neurone Disease (MND) → progressive weakness leads to fatigue with chewing; may require minced & moist (Level 5) or pureed (Level 4), plus thickened drinks as bulbar symptoms worsen.
• 👶 Paediatrics with congenital dysphagia / cerebral palsy → textures depend on individual swallow study, but often liquidised (Level 3) or pureed (Level 4), with close SALT supervision.

🧑‍⚕️ Clinical Cases