The vital act of swallowing food is one of those things we seldom think about - unless something goes wrong.

According to the Canadian Association of Speech-Language Pathologists and Audiologists, "We swallow on the average, about 600 times a day. It's estimated that about one in 10 people over 50 have some type of swallowing disorder, which experts call dysphagia."

Swallowing is a complex act that involves the mouth, throat and esophagus, and there are at least 50 pairs of muscles and many nerves involved to move food from the mouth to the stomach. The disorder occurs when there is a problem with any part of the swallowing process. Swallowing is a complex act that involves the mouth, throat and esophagus. There are at least 50 pairs of muscles and many nerves involved to move food from the mouth to the stomach, and much of the swallowing process is involuntary. Problems at any point, from chewing food and moving it into the back of the mouth, to moving the food into the stomach, can result in difficulty swallowing.

Dysphagia can be caused by many diseases, including those of the central nervous system, or by a stroke or head injury, an infection or an irritation that can cause a narrowing of the esophagus. People are also born with abnormalities of the swallowing mechanism, and dysphagia can be the result of conditions such as cleft palate, various cancers of the head and encephalitis of the brain.

Treatment

The disorder affects both children and adults, and it can be serious. Someone who cannot swallow properly may not be able to eat enough of the right foods to stay well or to maintain a healthy weight, and can be in danger of choking while eating. Other symptoms of swallowing disorders include food getting stuck in the throat, regurgitating undigested food particles, and unexplained frequent bouts of pneumonia. Once the cause of the dysphagia is found, surgery or medication may help. If treating the cause does not help a patient, they may be referred to see a speech-language pathologist trained in testing and swallowing disorders.

David Beattie is a Guelph, Ont.-based speech therapist who works with both adults and children who have swallowing disorders. The adult and pediatric populations are quite different in terms of the origin of swallowing problems, as is the approach to intervention, he notes.

In adults, for example, treatments may range, "from exercises to increase strength and awareness, to compensations to make swallowing safer, to modifying food textures to make food easier to manage. Caregivers are often involved, especially for the geriatric or cognitively impaired population," Beattie says.

Michael Sausser, a 46-year-old from Palm Springs, Calif., developed dysphagia following an attack of HIV-related encephalitis in 1996. Since then, his medications, as well as the neurological affects of the attack, make it difficult for him to swallow. "I suffer from dry mouth due to the drugs. Producing saliva is a problem. In order to swallow food, I must eat slowly, chew it very well and drink plenty of fluid to wash it down. Otherwise, it can get stuck in my throat and around my gums, causing me to choke."

Dysphagia in children

Swallowing disorders in children can occur at different stages in the swallowing process:

• Oral phase: Includes the chewing of food, mixing it with saliva in order to make it the right size to swallow. Saliva softens and moistens the food to make swallowing easier. During this stage, the tongue collects the food or liquid, making it ready for swallowing.
• Pharyngeal phase: This is when the swallow begins. The tongue pushes the food or liquid to the back of the mouth, and a swallowing reflex passes the food through the pharynx, the canal that connects the mouth with the esophagus. The food is squeezed down the throat, closing off the larynx to prevent food or liquid from entering the lungs or to prevent choking.
• Esophageal phase: This is when the "feeding tube" in the throat, known as the esophagus, relaxes and tightens its openings at the top and bottom, squeezing the food through the esophagus into the stomach.

Paula Zimmer is an occupational therapist at the KidsAbility Centre for Child Development in the Wellington and Waterloo Counties in Ontario. She works with children up to five years of age and deals with a variety of swallowing disorders, including operative cleft palate and palate repairs; infants having difficulty with co-ordinating the suck, swallow and breathe pattern to effectively take a bottle or to breast feed; children who have difficulty with transitioning from a puree food to a semi solid or solid food; and kids who have difficulty with chewing or swallowing due to physical issues, such as changes in muscle tone due to cerebral palsy.

"In order to help these children, we see them for an assessment and ask a number of questions to look at their birth history, medical history and feeding history," she says. "We then do a physical assessment to look at the mechanics of feeding — lips, jaws, cheeks, tongue, various textures of foods, liquids and solids, various tools for feeding including modified spoons and forks, changing a bottle's nipple sizes for better fit for the abilities of the child's mouth and skill level, adapted plates — [and] assess if a different position for feeding may be more effective for the swallow.

"Feeding and swallowing is a very complicated skill and is very stressful for families, especially if there are already special needs associated with a child," Zimmer adds. "We strive on minimizing the stress and promoting the success for families."

Dysphagia in adults

According to the Canadian Stroke Network it is estimated that as many as 55 per cent of all stroke patients suffer from neurological damage that causes dysphagia. This puts the patient at risk of choking, developing pneumonia or suffering from malnutrition.

Someone who cannot swallow properly may not be able to eat enough of the right foods to stay well or to maintain a healthy weight, and can be in danger of choking while eating. Other symptoms include food getting stuck in the throat, regurgitating undigested food particles, and unexplained frequent bouts of pneumonia. "Patients with dysphagia are more likely to die in the first 90 days post-stroke, which is why it is so important that people are screened and treated early for this condition," says Dr. Rosemary Martino, assistant professor in the Department of Speech Language Pathology at the University of Toronto, and an affiliated scientist at the University Health Network. Martino was the lead researcher who developed The Toronto-Bedside Swallowing Screening Test, or TOR-BSST©. It was presented at the International Stroke Conference 2007 as a state-of-the-art tool to screen patients for dysphagia or swallowing problems. In December 2007, the Canadian Stroke Strategy, a joint initiative of the CSN and the Heart and Stroke Foundation, recommended the screening of all stroke patients before they are given food, fluids, or oral medication.

The TOR-BSST© involves evaluating patients for alertness, participation in the test, oral motor function, and the presence of a cough. Small amounts of water are administered using a preset protocol and the patient is monitored for signs of impaired swallowing.

"Coughing during and for up to one minute after completion of the test, and a 'wet' or hoarse voice, suggest that there is an abnormal swallow," Martino said.

There is a huge international interest in this test, with implementation at more than 60 hospitals in the year that the tool has been available. Many stroke survivors do not recover to a normal swallow by six months post-stroke. Martino said that, "In stroke, approximately 55 per cent have dysphagia in the acute phase. In 50 per cent of these, the dysphagia recovers to near normal in approximately one month. Those who remain with dysphagia at one month continue to have dysphagia for several months, even years, thereafter - it becomes a chronic problem."

Beverly Clayton, 32-year-old from Toronto, had a major stroke in 2001. "I suffered from right-side paralysis, and when I came to in ICU [the intensive care unit], I had a feeding tube. After it was removed I was given applesauce to eat. I remember getting it to the back of my tongue and then literally forgetting how to swallow it."

Clayton worked with an occupational therapist for several months following the stroke. "That was a difficult time for me in my life. I don't remember a lot of what happened to me, I was only 26." She eventually re-learned how to swallow while eating a special diet consisting of yogurt and cottage cheese. The cottage cheese has a more definitive texture than applesauce, so it was more stimulating on her tongue surface. "I could only swallow it if it were at room temperature."

While therapy can help, many dysphagia sufferers still have to come to terms with the long-term effects of their disorder.

"I still experience some problems regarding swallowing," says Clayton, even though it has been six years since her stroke.

Sausser said that even after treatment, dysphagia still has an impact on his daily activities. "Having a swallowing disorder has made my life much harder, because I frequently choke. I fear choking to death, which leads to anxiety when I eat. I have to try to drink more fluids in order to swallow easier. It's tough not being able to eat some of my favourite foods. Sometimes I have felt isolated from not being able to socialize around meals and drinks like I used to."

The author is a freelance writer based in Guelph, Ont.