Mediscene - temp

An 81-year-old woman, who has always enjoyed good health and is surprisingly not on any long-term medication, suddenly feels unwell and begins to lose weight for about six weeks. She has also been experiencing an odd sensation when swallowing.

When questioned by the doctor, she admits to experiencing a feeling of food getting stuck in the gullet, when swallowing.

Such difficulty or discomfort when swallowing is called dysphagia. This condition often affects elderly people for several reasons: as chewing and swallowing muscles are weaker, there may be loss of teeth and also a reduction in the saliva produced; people with cancer of the throat (pharynx)/or gullet (oesophagus); people suffering from diseases of the brain and the nervous system like stroke, multiple sclerosis, Parkinson's disease, Alzheimer's disease, motor neurone disease or severe depression; people with chronic heartburn or internal burns associated with poisoning or radiotherapy

Swallowing takes place in stages and involves a number of different muscles and nerves.

The severity of the symptoms of dysphagia depends on whether food and drink gets stuck in the oesophagus for a short time or fully.

If food does get stuck in the throat, it may cause some discomfort or pain in the chest, as it passes down to the stomach and some people try to avoid eating altogether.

What are the signs and symptoms?
* Repeated swallowing
*Coughing and spluttering frequently
*Gaining an unusually husky voice and having the need to clear the throat
*Dribbling when attempting to eat, with the food and saliva escaping from the mouth and even the nose
*Finding it easier to eat slowly
*Keeping food in the mouth for a long time
*Being tired and losing weight

Unfortunately, as many as 70% of people who suffer from swallowing difficulties, are not aware of the extent of their problem.

If a person does not eat and drink regularly, complications arise and initially there would be dehydration and loss of weight.

This in turn can lead to malnutrition, as the intake of protein and calories to stay healthy is limited.

Meanwhile, with a low vitamin and mineral intake, the body's immune system is also under threat and as a result the person is more vulnerable to infections. Over time, the person's physical and mental abilities may begin to deteriorate.

A serious complication of swallowing difficulties could be that food and liquid leak into the airways. Called aspiration, this may lead to the development of serious chest infections or pneumonia.

What a specialist can do
When a person with swallowing difficulties seeks medical help, the doctor would initially assess whether there is any obvious problem occurring in the mouth and would also check with the coughing or swallowing reflexes.

If the problem is hidden, it is important to find out whether it is structural or functional. A structural problem means that the throat/gullet is too narrow to enable food to slip into the stomach easily. A functional problem would indicate whether the muscular mechanism that helps pass food and liquid from the mouth to the stomach is not working properly.

The investigations carried out to make the correct diagnosis may include the visual examination of the gullet and stomach with an instrument called an endoscope. This investigation could be done by either simply anaesthetizing the throat with a spray or under sedation. Endoscopy is the most useful investigation and it would specially help rule out cancer, as a cause of dysphagia.

Another test that could be useful is a barium swallow. In this test, the patient has to swallow a liquid (barium) while X-rays are taken to trace its path and thereby diagnose the problem.

How is dysphagia treated?
*Medical prescription -- There are medicines that help ease swallowing difficulties, depending on the underlying problem. However, sometimes dysphagia is triggered by a medication prescribed for another condition.

*Surgery -- The problem can at times be helped by endoscopy. But sometimes surgery is necessary. Problems that might be amenable for such therapy would include early cancer and strictures (narrowing of the gullet). For some, the presentation of symptoms could be too late and this option may not be possible. Therefore it is vital that patients seek early medical advice.

*Physical modification -- If food gets stuck for even a short time, the patient should stand, stretch the top half of the body and walk around. If the muscles in the jaw and tongue are weak, the patient can be taught exercises to strengthen them so that chewing becomes more effective. It is important to learn to take deep long breaths.

If the patient is wearing false teeth, make sure they fit properly. The last meal should be taken more than three hours before going to bed because if food gets stuck in the throat it can be very uncomfortable and also painful. Always sit up as straight as possible when eating.

*Swallow modification - separate the food into small mouthfuls. If the patient has lost the sense of smell and taste, enough saliva may not be produced to soften the food. Make sure the food looks appetizing and colourful.

Have plenty of liquid at hand to help food to pass easily. Take time when eating and don't be rushed. Try to eat without stress and without other people watching you.

* Food modification -- If the swallowing problem is due to some narrowing of the oesophagus, it may be difficult to eat solid food. In this case, the patient will need to modify the food and change the texture. With functional problems of the muscular mechanisms of swallowing, liquids need to be thickened.

Although the patient may think that water and liquids are easier to swallow, when there is little control over the flow, it could easily pass into the airways and lungs. Thickening agents are, however, not readily available in Sri Lanka. Food that is a bit sour, served with lemon, may trigger the swallowing reflex automatically. Food needs to look good to stimulate the appetite. Solid food may need to be pureed or softened, to require less chewing and propulsive force to clear them through the pharynx.

How successful the overall treatment is will depend on the person. It is important to understand the problem early which in turn might ensure prompt medical interventions and finally, to take an active role in the management.

The writer is a Consultant Physician & Gastroenterologist, Sri Lanka Police Hospital