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Difficulty swallowing

Treatment and management of dysphagia is as varied as the wide range of underlying conditions and the severity of the resulting dysphagia symptoms. Broadly speaking, dysphagia treatment modalities include surgical and non-surgical options. The latter can be divided into adaptive strategies (such as modified food textures) and compensatory approaches (such as specialised swallowing manoeuvres).

Because of the wide range of underlying conditions and the need to prevent serious consequences such as malnutrition or pneumonia from aspiration, a range of medical disciplines are involved in dysphagia management, including oral and maxillofacial surgery, ENT (ear, nose and throat) surgery, neurology and speech and language therapy. Careful initial assessment of the type and extent of swallowing dysfunctions is essential, as is long-term monitoring in order to identify and address problems early. These conditions can be associated with the prevention and/or treatment of mental health issues, such as depression and social isolation, so the benefits may be far reaching.

Surgical interventions from a maxillofacial perspective include the removal of salivary glands or relocation of salivary gland ducts for the management of sialorrhea (severe drooling), or the placement of a percutaneous endoscopic gastrostomy (PEG) to enable enteral (tube) feeding to maintain nutrition in the presence of severe dysphagia. Acute and severe aspiration may require the placement of a tracheostomy in order to protect the airway.

The role of surgical interventions in the management of dysphagia in progressive neuromuscular conditions is not well defined and is controversial. Dysphagia as a common long-term and often severe adverse effect of radiotherapy applied to the head and neck region is often caused by strictures or stenoses (narrowing) of the upper oesophageal region and spasms of the cricopharyngeus muscle (a circular muscle in the neck that needs to relax to allow food passage), in addition to swallowing problems associated with xerostomia (dry mouth) following radiotherapy. Endoscopic dilatation and laser ablation of pharyngeal constrictions lie within the field of ENT surgery, and middle and lower oesophageal causes within the field of gastroenterology.

Nonsurgical interventions include a significant contribution by reassurance, mental health support and self-help strategies (see below). Medications play only a minor role in the management of dysphagia, with a few notable exceptions. Botulinum toxin injections into the submandibular (salivary) gland are a less invasive method to manage severe sialorrhea (submandibular saliva being ‘at rest’ saliva which pools and is more mucinous). Medications used in the management of some neuromuscular degenerative conditions, such as Parkinson’s disease or myasthenia gravis (autoimmune condition leading to muscle weakness) can also mitigate related dysphagia problems, at least temporarily.

Speech and language therapy plays a major role in the compensatory approach to dysphagia management, by assessment and monitoring, and by swallowing rehabilitation and training. This includes a number of swallowing manoeuvres that, combined with suitable food textures, can help enable safe swallowing and oral food intake, often despite significant impairments. Speech and language therapists typically are also a good source of practical information and pragmatic ways to work around difficulties. Adaptions may include individually optimised food textures and temperatures, special cutlery, and many other useful tips & tricks, alongside developing new habits such as not to talk while eating.