Feeding Difficulties in Adults

In this episode of BackTable ENT, Dr. Ashley Agan, Dr. Gopi Shah, and Theresa Richard, a board-certified speech language specialist (SLP) in swallowing and swallowing disorders, about diagnosing and managing adult dysphagia.

First, Richard speaks about starting Mobile Dysphagia Diagnostics, a company that provides mobile FEES studies, her experience with having a son with a swallowing disorder, and her recent career shift towards providing speech-language education for her colleagues. Then, she discusses the two primary swallowing imaging studies: the modified barium study (MBS) and fiberoptic endoscopic evaluation of swallowing (FEES). MBS, also known as video fluoroscopy, was traditionally the gold standard for swallowing imagery. It is the superior imaging technique for detecting esophageal issues and provides a better understanding of the oral phase of swallowing. Richard prefers to use FEES first because it provides a live picture of laryngeal and pharyngeal structures. It is useful in patients with secretion issues and post-head and neck cancer surgery patients. Mobile FEES is also an option, which involves an endoscope with recording capabilities and a laptop.

Next, Richard discusses how to work up a patient with dysphagia. She starts with taking a thorough history and asks the patient about their dietary routine, and their medical and surgical history. Common medications that may cause dysphagia are muscle relaxants, L-DOPA, and medications that can cause dry mouth, such as scopolamine patches. Next, she discusses eating habits, with special considerations for cultural practices, age, and disability status. She notes that functional swallowing can look different for individual patients. Patients who repetitively aspirate may have recurrent pneumonia and require further evaluation. The first basic test she performs is watching her patients swallow 3 ounces of water. If they cannot swallow the three ounces, she moves to imaging studies. If they can swallow the three ounces, she escalates the test and starts to give the patients thicker liquids and different food types.

Some patients with dysphagia may require special considerations, such as ICU patients, patients with nasogastric (NG) tubes, and head and neck cancer patients. Richard notes that the conventional rule of waiting 24 hours to give an ICU patient food is not supported by evidence. She performs swallowing studies in these patients, but is observant for issues. Richard also believes that NG tubes should only be placed and left in if absolutely necessary. She has taken care of elderly patients who have had malpositioned NG tubes or NG tubes that have been left in for too long, which has severely impacted their swallowing. For head and neck cancer patients, she emphasizes the importance of working with a specialized speech language pathologist before and after their surgeries. Additionally, they may face more problems with dysphagia due to radiation therapy and chemotherapy

Finally, Richard discusses how ENTs can help SLPs by providing a solid case history and being available for communication throughout the patient’s therapy. She also discusses a new type of therapy, adult neuromuscular stimulation, but notes that the parameters may be dangerous and not FDA approved.