Maxfacts

Difficulties with swallowing, dysphagia are common problems. In many cases, dysphagia is not a symptom of a maxillofacial condition, but a consequence of a neurological condition (for example, stroke), or it occurs as an adverse effect of some medication. In fact, in many speech and language therapy clinics maxillofacial patients are probably a small but significant minority. The range of types and severity of dysphagia associated with maxillofacial conditions differs slightly from dysphagia caused by other, non-maxillofacial conditions. So, assessment and management of dysphagia in a maxillofacial surgery context also differs slightly from the management of other dysphagia conditions. Our speech and language therapy (SALT) pages focus on dysphagia in a maxillofacial surgery context.

Irrespective of the exact nature of the condition leading to dysphagia, speech and language therapy management for dysphagia rests on two pillars:

• assessment, and
• coping with / learning alternative swallowing strategies.

The two arms have one aspect in common, to assure that swallowing is safe and comfortable (to avoid malnutrition and dehydration) and that any aspiration problems (food or drink entering the airway) are recognised early (to avoid complications from aspiration pneumonia).

Assessment of swallowing typically includes a conversation about, and a record of the subjective perception of the problem(s), type and severity; this narrative should include the consideration of any emotional impact which can be considerable. Objective assessment is an inspection of the swallowing process by fibreoptic endoscopy. This may include inspection of an ‘empty swallow’, for example to find out about residual saliva or timing of the various stages of swallowing. Usually, this assessment will include the testing of a range of food textures and consistencies. Objective assessment and subjective perception of dysphagia sometimes diverge considerably. The severity of symptoms sometimes greatly exceeds what may be expected on the basis of a physical condition. It has been suggested that this may occur as a ‘learned effect’ from previous difficulty, combined with anxiety and lack of confidence to move on. Further, people with very similar physical conditions may experience very different degrees of severity of dysphagia. The reason for this is not well understood, but this finding highlights the need for individual exploration and care for any dysphagia problems in order to give recommendations about the most suitable forms of oral food, and those to be avoided.

Advice and training for alternative swallowing strategies strongly depend on the underlying cause(s) of dysphagia. Dysphagia management may highlight the need for adaptive strategies (such as modified food textures or the use of special spoons), or compensatory strategies (tricks & tips to work around the problem, such as particular postures or swallowing techniques), or both. Neither adaptive nor compensatory strategies will treat the underlying problem or change the cause, but greatly improve on quality of life by offering ways to improve vital functions.

In addition, there are approaches with a more rehabilitative aspect, for example specific exercises aiming to strengthen muscles involved in the swallowing process (such as tongue hold or neck-muscle exercises) or to improve range of motion (such as tongue exercises, or exercises to improve mouth opening if trismus is an issue) are useful in many cases.