When someone has had a stroke, the damage to speech and movement is usually obvious. But for some stroke survivors, having trouble swallowing can be an invisible -- but extremely disabling -- aftereffect.
Although there is no hard data on the number of people who have difficulty swallowing after a stroke, the American Stroke Association says the problem may occur in up to 65 percent of stroke patients.
Following a stroke, weakened muscles in the mouth or throat, a loss of sensation in the tongue, poor muscle coordination, or the inability to cough can all impair swallowing. For example, if half of the tongue is damaged, it may be difficult for a person to initiate the swallowing reflex effectively by moving food to the back of the throat. Or if certain muscles are affected, they may not close off the airway enough to prevent food or liquid from leaking into the lungs. Weakened muscles may also delay swallowing or result in an incomplete swallow. A stroke may also make it difficult for a person to communicate any trouble he's having swallowing.
Proper therapy can usually treat swallowing disorders so that people can once again eat comfortably. However, left unrecognized and untreated, difficulty swallowing (dysphagia) can be life threatening. Impaired swallowing can lead to malnourishment, dehydration, choking, or aspiration pneumonia -- a bacterial infection of the lungs.
Aspiration can be hard to detect if the stroke survivor isn't able to expel food or drink from the windpipe by coughing. Also, muscles in the upper digestive tract may no longer be strong enough to prevent stomach contents, including acid, from being aspirated, or drawn up, into the lungs.
What are typical signs of dysphagia?
If you know a stroke survivor who is experiencing any of the following problems, experts suggest you ask a doctor for a referral to a speech and language pathologist trained to recognize and treat swallowing disorders:
- Excessive drooling
- Food falling out of the mouth
- Clumsiness in getting food to the back of the mouth
- Difficulty starting or completing a swallow
- Food remaining in the mouth after swallowing
- Frequent throat clearing, coughing, or choking after eating or drinking
- Voice that sounds wet or gurgling
- Complaints of food or drink sticking in throat
How is dysphagia diagnosed?
The condition is diagnosed by a physical exam, as well as video imaging to observe the internal swallowing mechanism. A speech and language therapist or physician will watch a stroke survivor swallow to see if there's a problem or delay. "We'll look for facial droop," explains Suzanne Kowler, a speech and language pathologist at St. Mary's Medical Center Acute Rehabilitation unit in San Francisco. "If all the muscles on one side are weak or paralyzed, it's going to be difficult to chew. They'll have something sticking on the right side of their mouth."
If swallowing is delayed, it may indicate a problem. "Normally it takes about a second to swallow," says Kowler, "Even a small disruption places that person at risk for aspiration (sucking food or drink) into the lungs."
To understand what's wrong with the way a stroke patient swallows, a diagnostic tool called a modified barium test, or videofluoroscopic swallowing study (VFSS) allows the therapist to watch a video in real time of a stroke patient consuming various liquids and foods. "We can see if (the food) is going into the airway or not. And we can see when the patient coughs if they're effectively expelling food from the airway," says Kowler. The test also shows very specifically which muscles are not functioning. Ultrasound is another instrument that creates pictures of the various stages of swallowing.
How is dysphagia treated?
Often the speech pathologist will suggest ways of managing a patient's swallowing problems while observing him with VFSS technology. That way, it's possible to tell if the advice works. To avoid aspirating liquid, for example, Kowler often recommends making a simple change in head position, like turning it more to one side, or tucking in the chin. A therapist can also teach a stroke survivor ways to strengthen the muscles involved in swallowing.
A therapist will often recommend a change in diet as well. The modified barium swallow test will show what consistency of food is tolerated the best. In severe cases of dysphagia -- when a stroke patient is malnourished or dehydrated -- he will be put on a feeding tube or percutaneous endoscopic gastrostomy (PEG), which is inserted through the skin directly into the stomach.
How can I help protect my loved one from aspirating?
To help prevent aspiration, Kowler recommends the following measures:
- Make sure that the person with dysphagia sits up in a chair at a 90-degree angle while eating, and continues to sit upright for at least 30 minutes after a meal.
- Don't use straws. (They make it too easy for liquid to leak into the airway from the back of the throat.)
- Allow plenty of time for meals.
- Encourage smaller bites and sips.
- Reduce distractions like television, music, and the number of people in the room.
- Make sure the person has good oral hygiene.
For most of us, eating is one of life's simple pleasures. With proper treatment, most stroke survivors who struggle with swallowing problems will be able to enjoy eating again. Even stroke survivors who may have to stay on feeding tubes for an extended time don't have to be completely deprived of their favorite foods, says Kowler. "We can work with them so they can tolerate a small amount of the food they love," she says.
National Stroke Associationhttp://www.stroke.org
American Speech-Language-Hearing Association http://www.asha.org
National Institute on Deafness and Other Communication Disorders http://www.nidcd.nih.gov
American Stroke Association. Difficulty Swallowing After a Stroke. 2003 Jul-Aug. www.strokeassociation.org/presenter.jhtml?identifier=3031213.
Dysphagia. National Institute of Deafness and other Communication Disorders
American Gastroenterological Association, Medical Position Statement on Management of Oropharyngeal Dysphagia, Gastroenterology 1999; 116: 452-454
Palmer, Jeffrey B., Drennan, Jennifer C., "Evaluation and Treatment of Swallowing Impairments," American Family Physician, April 15, 2000
Interview with Suzanne Kowler, Speech and language pathologist at St. Mary's Medical Center Acute Rehab unit in San Francisco