what are the different types of dysphagia the differences between oral pharyngeal and esophageal dysphagia as an SLP we know that simply saying someone has dysphagia doesn't really give us a ton of information one of the first things we might wonder is which phase of swallowing is affected does the person have a hard time keeping food in their mouth do they struggle with food and liquid entering the airway or maybe they always feel like food is stuck in their throat not all dysphagia is the same and I'm here today to dig a little bit deeper into three different phases of dysphagia which in reality are not separate phases at all they're all interrelated and should be considered a Continuum let's Dive In I'm Theresa Richard I've been a medical speech pathologist for 15 years I'm a board-certified specialist in swallowing and swallowing disorders I'm the founder and CEO of the med SLP Collective and Med SLP education let's start with the first phase oral dysphagia oral dysphagia means that the oral phase of the swallow is impacted which could mean difficulty with the lips tongue jaw or other oral structures if we reference the modified barium swallow impairment profile mbsimp which highlights 17 swallowing components oral components of the swallow to assess include lip closure tongue control bolus preparation or mastication bolus transport or lingual motion soft palate elevation and oral residue someone with poor lip closure might experience anterior bolus loss meaning food or liquid might spill out of their mouth whereas poor lingual motion could lead to reduced stability to move food or liquid from the front of the mouth to the back of the mouth some conditions that could lead to oral dysphagia include stroke Bell's Palsy oral cancer with post-op anatomical changes of the tongue lips or palate or Parkinson's disease just to name a few the type of therapy slps might consider for oral dysphagia depends on the specific impairment and the cause of impair government for example someone with a stroke who presents with dense hemiparesis reduce labial seal and limited tongue range of motion might benefit from compensatory strategies like placing the bolus on the stronger or intact side and completing appropriate exercises in muscle training for someone with head and neck cancer with a Hemi glossectomy or part of their tongue has been surgically removed you might consider other compensatory strategies as visualized under an instrumental swallow exam like using a syringe or spoon to assist with getting the bolus to the back of the mouth while also considering strategies for keeping the oral cavity moist if they've completed radiation therapy a colleague of mine once had a patient who had cerebral palsy an extremely reduced lip and jaw coordination often leading to anterior bolus loss primarily with liquids when she did a video fluoroscopy she saw that her patient had decent tongue control however an airway protection was not compromised during the video fluoroscopy my colleague was able to lean the chair back so the patient was closer to a 45 degree angle while so often we hear the rule sit upright at 90 degrees for all po it's important to remember that this may not be the case for every patient when they provided the patient with the liquid he was able to better control the bolus while allowing gravity to assist with the anterior posterior Transit and swallow liquids more efficiently without anterior bolus loss this turned out to be a very effective compensatory strategy for this patient particularly given that coordination was the ultimate limitation as opposed to generalized weakness that exercises might be able to Target the second phase of swallowing we'll talk about is the pharyngeal phase pharyngeal phase dysphagia indicates one or several impairments related to the pharyngeal and laryngeal structures related to pharyngeal bolus Transit and Airway protection going back to the 17 swallowing components assessed during the MBS imp the pharyngeal components slps will look at include laryngeal elevation anterior hyoid motion epiglottic movement laryngeal closure pharyngeal stripping wave and pharyngeal contraction pharyngeal phase dysphagia can be caused by structural neurological or strengthen motor deficits as with anything else different impairments will contribute to different symptoms and outcomes reduce laryngeal closure could lead to aspiration reduced epiglottic movement could lead to residue in the vollecula and impaired pharyngeal stripping or contraction could result in pharyngeal residue slps also look at timing and coordination of these structures it's important to note that the only way we can really see pharyngeal dysphagia and Target appropriate dysphagia therapy is through an instrumental exam we can't really tell if laryngeal elevation is reduced by looking and feeling our patients throats at bedside even if the patient coughs during meals we can't guarantee they're always aspirating and we certainly can't tell why they're coughing during meals until we either obtain a fees or video fluoroscopy some of the most common stories we hear from medical slps are stories about patients who either look fine at the bedside but demonstrate pharyngeal dysphagia during an instrumental swallow exam or the opposite where patients who cough or frequently clear their throat at bedside don't demonstrate any pharyngeal dysphasia during an instrumental swallow exam I've been surprised a lot of times during Feast studies especially if I see the patient aspirate but it's not from a primary pharyngeal dysphagia it's important to understand that if the dysphagia you're observing is the primary dysphagia or secondary to something else like esophageal dysphagia which we'll discuss next I'll be posting other videos just like this one that you won't want to miss so make sure to hit that like And subscribe button and turn on the notification Bell also do you have any specific questions about the different phases of swallowing leave a comment below and tell me about it we'll be sure to get your questions answered as soon as possible now let's move on to the esophageal phase esophageal dysphagia indicates an impairment or disruption anywhere along the esophagus between the upper esophageal sphincter and lower esophageal sphincter that results in difficulty with swallowing sensations of food getting stuck in your throat or chest sometimes an impaired ability to keep undigested food down many slps who work with dysphagia will encounter esophageal dysphagia the most common cause being acid reflux show at all 2015 estimated that around 18 percent of people with gerd have infrequent symptoms of dysphagia while 31.6 percent have frequent symptoms of dysphagia it's important to note that while slps do not directly diagnose esophageal dysphagia Asha recognizes that the scope of our practice for dysphagia includes the oral pharyngeal and cervical esophageal regions for assessment and treatment of dysphagia one crucial role slps can help navigate is whether or not oral pharyngeal symptoms of dysphagia are being caused by a primary esophageal dysphagia for example a patient might report the sensation of food getting stuck in their throat or a lump in their throat this is also known as Globus sensation and can be caused by chronic gastroesophageal reflux disease so while the symptom is in the pharynx the etiology or root cause might be in the esophagus thus when a patient complains of swallowing trouble it's critical that slps use their assessment tools and critical thinking to help discern whether or not it appears to be a primary oral dysphagia a primary pharyngeal dysphagia or a primary esophageal dysphagia with secondary changes in the oral pharynx leading to oral pharyngeal dysphagia symptoms some examples of esophageal related etiologies include gerd esophageal diverticulum upper esophageal sphincter dysfunction esophagitis shotsky's ring or other obstructive immotility disorders so if the SLP is among the first to catch or suspect a primary esophageal impairment what would the next step be slps cannot directly diagnose entry esophageal disorders so it's important that we directly communicate our findings with the medical team slps can suggest a referral to a GI specialist who will conduct a more thorough assessment of the esophagus once the diagnosis is established the SLP could still have a role with dysphagia symptoms for example if the patient's diagnosis is GERD the SLP can educate the patient and their caregivers on strategies to reduce episodes of reflux and mitigate the risk of aspirating reflux if you'd like to dig deeper into what the slp's role in reflux management is make sure to check out a previous video on this topic as well one of the greatest challenges for slps who complete video fluoroscopy is capturing an esophageal sweep this is a barrier between slps and Radiologists and for reasons that make sense when you hear what the concerns of some Radiologists are while slps know that the esophageal phase is part of the entire swallowing Continuum and we need to get the full picture Radiologists might be pressured to avoid completing an esophageal sweep because there is a separate study specifically meant to assess the esophagus known as the esophagram some Radiologists might raise concerns around billing and what the full scope of the video fluoroscopy is and whether or not this is blurring the lines I've heard several slps share stories about taking time to write emails or share literature that not only shows the importance of an esophageal sweep but shows them that the esophageal sweep is actually a part of the standardized video fluoroscopy protocol the other important piece of the discussion was to emphasize that this is simply a screening tool not a diagnostic tool and can help improve our referral process for patients who would benefit from a formal esophageal assessment while we still have a ways to go before all Radiologists and slps can agree to an esophageal sweep slps have slowly been gaining traction and implementing changes in the fluoroscopy suite to allow us to finally see the whole swallowing picture during our video fluoroscopy assessments I've got a free gift for you over at medslpcollective.com you'll get instant access to our free medislp Collective clipboard kit this is a robust packet of resources you can save print and use directly at work to assist with assessments and treatment planning across a variety of populations including specific resources on esophageal dysphagia we also have a Vibrant Community of slps and mentors to help you out with your toughest clinical cases head over to medslpcollective.com now to get your hands on this the link will be in the description below [Music]