Swallowing difficulty, medically known as dysphagia, falls within the scope of practice for Speech-Language Pathologists (SLPs). These professionals are trained experts in the mechanics and coordination of the oral, pharyngeal, and laryngeal structures necessary for safe eating and drinking. SLPs diagnose the precise nature of the swallowing impairment and implement targeted interventions to restore function or establish safer eating strategies. The goal of this therapy is to ensure patients maintain adequate nutrition and hydration while reducing the risk of complications like aspiration pneumonia.
Defining Swallowing Difficulty
Swallowing is a highly coordinated process broken down into three main phases: oral, pharyngeal, and esophageal. The voluntary oral phase involves chewing food into a swallowable mass (bolus) and moving it to the back of the throat. This triggers the involuntary pharyngeal phase, where the airway closes and muscles propel the bolus down. Finally, the bolus enters the esophagus for transport to the stomach.
Dysphagia occurs when a problem disrupts this sequence, causing difficulty moving food or liquid from the mouth to the stomach. If protective mechanisms fail, material can pass below the vocal folds and enter the lungs, an event called aspiration. Unmanaged dysphagia can lead to aspiration pneumonia, severe dehydration, and malnutrition. Common underlying causes include acute events like stroke or traumatic brain injury, or progressive conditions such as Parkinson’s disease, dementia, or head and neck cancer.
Diagnostic Assessment by the SLP
The process of pinpointing the swallowing problem begins with a clinical bedside examination. During this initial assessment, the SLP observes the patient’s oral motor function, including lip and tongue strength, and watches for signs of difficulty, such as coughing or a “wet” vocal quality after swallowing. This is followed by instrumental assessments, which provide an internal view of the swallowing mechanism.
The Modified Barium Swallow Study (MBSS), also known as videofluoroscopy, is a dynamic X-ray procedure conducted in a radiology suite. The patient swallows foods and liquids mixed with barium, a contrast material, allowing the SLP and a radiologist to visualize the entire swallow in real-time. This study identifies where and why the swallow is failing, and whether material is entering the airway.
The Fiberoptic Endoscopic Evaluation of Swallowing (FEES) involves passing a thin, flexible scope through the nose to view the throat structures. The SLP observes the larynx and pharynx directly as the patient swallows dyed food and liquid. FEES is portable, provides visualization of residue remaining in the throat after the swallow, and can be used for biofeedback during therapy. Both instrumental assessments are necessary for developing an individualized treatment plan.
Specific Treatment Techniques
Swallowing therapy involves a combination of three main intervention types: compensatory strategies, swallowing maneuvers, and rehabilitative exercises. Compensatory strategies are temporary adjustments used during a meal to immediately improve swallow safety. A common example is the chin tuck posture, where the patient swallows with their chin lowered toward their chest, narrowing the airway entrance. Another posture is the head turn, which redirects the bolus down the stronger side of the throat by turning the head toward the weaker side.
Swallowing maneuvers require the patient to voluntarily alter the physiology of the swallow with each bite or sip. The effortful swallow involves squeezing throat muscles as hard as possible during the swallow to increase pressure and clear residue. The Mendelsohn maneuver teaches the patient to manually hold the larynx up at the peak of the swallow for several seconds, keeping the upper esophageal sphincter open longer. The supraglottic swallow involves holding one’s breath before and during the swallow, followed by an immediate cough to clear any material that may have entered the airway.
Rehabilitative exercises are designed to strengthen the underlying musculature for long-term functional improvement. Examples include tongue resistance exercises, where the patient pushes their tongue against a device or the roof of the mouth to build strength for bolus propulsion. The Shaker exercise, or head-lift, is performed while lying flat and involves repeatedly lifting the head to strengthen the muscles that elevate the voice box during swallowing. The SLP may also recommend diet modification, adjusting the texture of food and the thickness of liquids according to the International Dysphagia Diet Standardisation Initiative (IDDSI) framework to ensure safe consumption.
Long Term Management
Long-term management of dysphagia focuses on maintaining skills gained in therapy, adapting to chronic conditions, and ensuring quality of life. This phase involves the patient’s adherence to a home exercise program, performing rehabilitative exercises multiple times a day to maintain muscle strength and endurance. Consistency is necessary to prevent regression of swallowing function.
Caregiver and family training is a central component, teaching them safe feeding techniques, appropriate diet preparation, and how to recognize signs of aspiration or decline. Swallowing difficulty carries psychosocial aspects, as the fear of choking or the need for a modified diet can lead to social isolation and anxiety around mealtimes. The SLP addresses these concerns by maximizing the patient’s ability to participate in social eating and drinking events safely.
In cases where swallowing function is severely compromised and the risk of aspiration remains high, non-oral feeding options like a feeding tube may be necessary for adequate nutrition and hydration. The SLP is involved in the discussion about the need for a nasogastric (NG) tube or gastrostomy (G) tube, which provide a temporary or long-term alternative route for nutrition. Many patients who use a feeding tube temporarily, particularly after a stroke, are eventually able to transition back to eating by mouth with continued swallowing therapy.