Review Article

Dysphagia in severe traumatic brain injury

Hashem H. Alhashemi, MBBS, FRCPC.

ABSTRACT D ysphagia, or swallowing difficulty, is a common

problem following severe traumatic brain injury.
The purpose of this review article is to help physicians
‫) من املضاعفات الشائعة التي‬Dysphagia( ‫يعد عسر البلع‬ taking care of traumatic brain injury patients understand
‫ و ُيصاحب هذه‬،‫حتدث بعد اإلصابات الشديدة في الدماغ‬ and manage dysphagia. Swallowing was described by
.‫املشكلة زيادة خطر اإلصابة بسوء التغذية وااللتهاب الرئوي‬ William Harvey (1578-1657), who compared the speed
‫يصعب التعامل مع املرضى املصابني بعسر البلع من جراء إصابات‬ and complexity of the swallowing motions with those
،‫الدماغ الشديدة وذلك بسبب ظهور بعض اإلعاقات في السلوك‬ of the heart.1 Hundreds of years later, this example
‫ يهدف هذه املقال إلى إطالع األطباء عن‬.‫ واإلدراك‬،‫والتواصل‬ remains accurate. Swallowing motions are rapid like
‫كيفية التعامل مع املرضى املُصابني بإصابات شديدة في الدماغ‬ the pumping of the heart, and the bolus has to travel
‫وما يحدث بعد ذلك من مضاعفات كعسر البلع وشرح هذه‬ through chambers and valves to reach the stomach
‫ ومراحل‬،‫ كما أنه يسترجع تاريخ دراسة عملية البلع‬،‫املشكلة‬ (Figure 1, Table 1).2 Swallowing impairment after severe
‫ والتحكم العصبي‬،‫ واإلعاقات التي قد تُصيب عملية البلع‬،‫البلع‬ traumatic brain injuries has been reported to be as high
‫ وكيفية تقييم املرضى املُصابني بصعوبات في‬،‫بعملية البلع‬ as 60% in adults and 68% in pediatric patients.3,4 Risk
factors for developing dysphagia following head injury
‫ ويغطي هذا املقال أيض ًا كيفية التعامل‬.‫البلع والتعامل معهم‬ include the severity of the injury on CT, lower Glasgow
‫مع املرضى الذين ُأجريت لهم عملية ثقب للقصبة الهوائية‬ Coma Scale (GCS) and Rancho Los Amigos (RLA)
.‫) بسبب عسر البلع وكيفية تغذيتهم‬tracheostomy( scores on admission, abnormal tongue control, presence
of a tracheostomy, feeding tubes and mechanical
Dysphagia, or swallowing difficulty, is a common ventilation for more than 2 weeks.3-6 In a prospective
problem following severe traumatic brain injury and
is associated with an increased risk of malnutrition cohort study, Terre et al7 found that 62% of the severe
and pneumonia. Management of patients with traumatic brain patients with dysphagia aspirate on
dysphagia following head injury is complicated by the instrumental examination, and 41% of the aspirators
presence of cognitive, communication, and behavioral were silent aspirators. Severe head injury patients
impairments. The purpose of this review article is to with swallowing impairments are at risk of developing
help physicians taking care of traumatic brain injury malnutrition and pneumonia. Malnourishment is
patients understand and manage dysphagia. The article reported to affect 68% of severe traumatic brain injury
reviews the history of the study of swallowing, stages
of swallowing, impairments of swallowing, neural patients.8 Patients with severe malnutrition suffer from
control of swallowing, and the evaluation of patients serious complications like pressure sores, infections,
with swallowing difficulties and their management. and contractures.9 The incidence of pneumonia after
In addition to the general principles of dysphagia traumatic brain injury is 44-60% in intensive care
management, this article covers the management units (ICUs), and 12% in rehabilitation wards.10 In
of dysphagic patients with tracheostomy and their addition, severe traumatic brain injury patients with
nutritional management. dysphagia have more cognitive deficits, lower functional
Neurosciences 2010; Vol. 15 (4): 231-236
independence measure (FIM) scores, and longer
hospital stay.11 Similarly, stroke literature has shown that
From the Division of Physical Medicine & Geriatrics, Department of dysphagia is associated with increased risk of mortality
Medicine, King Abdul-Aziz Medical City, Riyadh, Kingdom of Saudi and morbidity, and that patients with dysphagia have
Arabia.
more cognitive impairments and lower FIM scores on
Address correspondence and reprint request to: Dr. Hashem H. admission and discharge from rehabilitation wards.12
Alhashemi, Physical Medicine and Rehabilitation Consultant, Division Important definitions in dysphagia. i) Dysphagia:
of Physical Medicine & Geriatrics, Department of Medicine – 1443,
King Abdul-Aziz Medical City, PO Box 22490, Riyadh 11426, any difficulty in swallowing. ii) Aspiration: entry of food
Kingdom of Saudi Arabia. Tel. +966 (1) 2520088 Ext. 13056. material into the airway below the level of the true vocal
Fax. +966 (1) 2520088 Ext. 14229. E-mail: Hashemhh@[Link] cords.13 iii) Silent aspiration: aspiration without a cough

231

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 Dysphagia in TBI ... Alhashemi

or other signs of distress or difficulty. Investigative tools, Cortical control of swallowing. Cortical control
such as videofluoroscopy (VFS) or fiberoptic endoscopic can start, inhibit, and modulate swallowing. Cortical
evaluation of swallowing (FEES), are needed to diagnose involvement in swallowing has been studied using
silent aspiration.14 iv) Penetration: a sign observed PET, and fMRI scans. Multiple and bilateral
during instrumental investigation of swallowing (VFS, cortical/subcortical structures appear to be involved
or FEES). Penetration means that food material went in the control of swallowing (sensorimotor cortex,
into the larynx but remained above the level of the vocal posterior parietal, anterior insula, temporal cortex,
cords.15 anterior cingulate cortex, basal ganglia, thalamus and
Stages (mechanics) of swallowing. To François cerebellum). This diffuse representation explains why
Magendie (1783-1855), we owe the classical division any cortical or sub-cortical insult can potentially cause
of swallowing to 3 stages: oral, pharyngeal, and dysphagia. In addition, it proves that swallowing is not
esophageal.16 In the oral phase, with the help of the a simple reflex; instead, it requires the interaction of
saliva, the teeth and tongue transform the food into many cortical and sub-cortical structures like any higher
a homogenous bolus that can be swallowed easily. mental function.18,19,21
Next, the tongue pushes the bolus backward toward Dysphagia in relation to impairment. Oral and
the pharynx, and the pharyngeal stage starts. In the pharyngeal stage abnormalities are common in dysphagia
pharyngeal stage, the soft palate seals the nasal cavity secondary to traumatic brain injury.
to prevent regurgitation of the food through the nose, Oral stage abnormalities.2 i) Impairment of the
the tongue base, and the pharyngeal muscles contract sensations of the oral mucosa causes a prolonged oral
toward each other to push the bolus down, the larynx phase and delays the initiation of swallowing. ii) Facial
is pulled anterior and superior to avoid the coming
bolus, and the upper esophageal sphincter relaxes. After
that, the esophageal stage starts, and the bolus moves Table 1 - Chambers, and valves in relation to swallowing.2
down via the concentric contractions of the esophageal
smooth muscles and gravity until it reaches the lower Chambers Valves
esophageal sphincter and, finally, the stomach.2,17
Mouth Lips & soft palate
Neural control of swallowing. Brain stem
control.18,19 i) Afferent: solitary nucleus (7, 9 & 10th Nose Soft palate
cranial nerves). ii) Efferent: nucleus ambiguus (9, 10
Pharynx Base of the tongue
& 11th cranial nerves). iii) Central pattern generator
(CPG): interneuronal (premotor) reticular formation Trachea Larynx
to coordinate different cranial nerves and synchronize Esophagus Upper esophageal sphincter
both sides. Table 2 demonstrates the function of the 6
cranial nerves involved in swallowing.20
Table 2 - Cranial nerves involvement in swallowing.20

Cranial nerve Swallowing involvement

Trigeminal Motor to the muscles of mastication, and sensory to

the face and oral mucosa.

Facial Motor to the muscles of facial expression, taste from

the anterior 2/3 of the tongue, and parasympathetic
supply to all salivary glands excluding the parotid.

Glossopharyngeal Taste from the posterior 1/3 of the tongue, sensory

to the pharynx, motor to the stylopharyngeus
muscle and parasympathetic supply to the parotid
gland.

Vagus Taste from the epiglottis & pharynx, sensory to the

larynx & pharynx, and motor to the pharyngeal &
laryngeal muscles.

Accessory Joins the vagus nerve (functionally considered as a

part of the vagus nerve).

Hypoglossal Motor to the intrinsic muscles of the tongue.

Figure 1 - The nasopharynx.
Note that 10 cranial nerves are located in the brain stem, and 6 of them
are involved in swallowing (olfactory & optic nerves are in the brain).

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 Dysphagia in TBI ... Alhashemi

muscles weakness leads to leakage of food and drooling, medically stable and cognitively able to cooperate. It is
as well as pocketing of food inside the mouth. iii) the last and most functional part of the exam. During
Tongue weakness leads to difficulty in the formation the trial the patient is given different fluid and food
and transportation of the bolus. iv) Loss of teeth causes consistencies, and is observed for cognitive/behavioral
difficulty in eating a regular diet. deficits, oropharyngeal coordination, change of voice
Pharyngeal phase abnormalities.17,22 i) Inability of (wet voice), and spontaneous cough during or after
the soft palate to seal the nasal cavity due to weakness feeding.26,27 At the end of the trial, recommendations
results in regurgitation of food through the nose. ii) Food can be given regarding safe fluid and food consistencies,
residue tends to accumulate in the vallecula in cases of use of specific rehab strategies, or the need for further
tongue base weakness. iii) Lack of normal sensation in instrumental examination of swallowing using VFS or
the pharynx and larynx leads to delayed swallowing, FEES.
pooling of food residue, and loss of the protective cough Investigations. i) Videofluoroscopy, also known
as, MBS (modified barium swallow) is considered a
reflex. iv) Pharyngeal muscles weakness cause pooling of
gold standard test for studying swallowing disorders.
food residue. v) When the upper esophageal sphincter In 1898, Cannon28 was the first to use fluoroscopy to
fails to relax, food residue accumulates in the pyriformis study swallowing. Over the last century, several other
sinus. vi) Incomplete epiglottic closure and vocal cord pioneers continued to work on this test,29-31 however,
paralysis increase the risk of aspiration. vii) Weakness the way we administer and interpret the test today is
of the submandibular/suprahyoid group of muscles based on the work of Professor Logemann.32,33 The
leads to decreased laryngeal protective movement VFS is performed in the radiology department using a
(superior/anterior). Note that accumulation of residue fluoroscopy machine and radiopaque material (barium).
anywhere in the mouth or pharynx increases the risk of During the exam, the patient is given food of different
aspiration. consistencies with the addition of barium. The patient
Patient evaluation. History. The patient’s age, medical should be cooperative to be able to undergo the exam.
problems, and medications are essential components of The details of how to administer and interpret the
the history. Severe traumatic brain injury patients with exam can be found in other articles.32,33 The VFS is a
dysphagia are usually not able to communicate due to diagnostic and therapeutic tool that can diagnose silent
the decreased level of consciousness and/or the presence aspiration and document the efficacy of compensatory
of tracheostomy. Information about the mechanism of strategies used to manage dysphagia.5,34 ii) Fiberoptic
trauma, extent of the injury(ies), feeding difficulties endoscopic evaluation of swallowing was originally
and change in weight can be obtained from the medical described by Professor Langmore in 1988.35 Since
chart and care givers. Symptoms suggestive of dysphagia then, a great number of studies and reviews have been
include a history of chocking/coughing during or after published documenting the benefits of FEES.36,37 The
eating, tube feeding, weight loss, recurrent pneumonia, test is conducted using a flexible fiberoptic laryngoscope
drooling and need for suction.23,24 and a food coloring material. The FEES is a diagnostic
Examination. At the bedside, patients are observed and therapeutic tool that can diagnose silent aspiration
for the presence of skull deformities, O2 supplement, and document the efficacy of compensatory strategies
drooling, tracheostomy, feeding tube and physical used to manage dysphagia.37 iii) Both the VFS and FEES
restraints. Patient’s vital parameters and GCS score need are complementary to each other. Table 3 illustrates
to be documented. In the presence of a tracheostomy, important clinical differences between the 2 tests.34,37
iv) If the patient is coughing, tachypneic, tachycardic,
the frequency of suction and color of secretions are also
febrile, on oxygen or in need of frequent suction, a chest
documented. Patients are examined for cognitive and
x-ray is performed to rule out aspiration pneumonia.
cranial nerves abnormalities. In addition, the oral cavity
is examined for lack of hygiene, loss of sensation, loss
of teeth and presence of fixation (jaw wires). A blue dye Table 3 - Important clinical differences between videofluoroscopy
test,23 can be performed for tracheostomized patients. (VFS) and fibro-optic endoscopic evaluation of swallowing
(FEES).34,37
It is a sensitive, but not a specific test. Patients are
given a fluid colored with an inert blue dye through
FEES VFS
the mouth. If the colored material comes out of the
trachea during suction, then this test is diagnostic for 1. Direct sensory and anatomical 1. Detect aspiration before, during
aspiration.25 If the test is negative, the patient may exam. and after swallowing.
still be aspirating. In that case, the physician may 2. No radiation risk (repeatable). 2. Oral phase abnormalities are
need to order VFS or FEES to rule out aspiration. A demonstrated.
feeding trial is performed by a trained clinician (speech 3. Portable to bed side.
pathologist, nurse or a physician), if the patient is

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 Dysphagia in TBI ... Alhashemi

Rehabilitation management. General principles. Table 4 - Criteria to attempt weaning from tracheostomy.42,43
Functional improvement after an injury can occur
due to a structural change that regains function, or a M C Ø F A M O S
behavioral change that compensates for the function.
M Good Mental state *
This improvement is achieved in rehabilitation of
swallowing disorders by using compensatory strategies C Good Cough
and rehabilitation exercises. The compensatory Ø Absence of the following (null set)
strategies aim to change eating behaviors by modifying
bolus volume, texture, and head/body posture. On the F Respiratory Failure
other hand, rehab exercises aim to induce structural A Aspiration (his own secretions)
change by intensifying motor and sensory input to
M Medical problems (fever, pneumonia, low BP)
the damaged area.3,38 Pharyngeal muscular stimulation
is an emerging modality in the field of swallowing O Obstruction (vocal cord paralysis, tracheomalacia, granuloma, clot,
mucous plug)
exercises. Pharyngeal muscular stimulation, whether
it is superficial (VitalStim), deep on pharyngeal walls S Suction (more than twice/shift)
or surgically implanted, requires further research *Comatose patients may tolerate weaning, if all remaining criteria are
before it can be generally applied in the management fulfilled.
of dysphagic patients.23,39 Swallowing is much more
complex than a simple motor task. In addition to the
motor part, swallowing has cognitive, sensory, and co-
ordination components. This complexity of swallowing isolation. It may also increase the risk of aspiration due
may interfere with the efficacy of the pharyngeal to the impairment of laryngeal mobility, sensitivity,
muscular stimulation. Finally, dysphagia following and the loss of the subglottic pressure.41 In addition,
severe traumatic brain injury is complicated by the prolonged tracheostomy can cause an anterior fistula
presence of cognitive, communication, and behavioral to the innominate artery and a posterior fistula to
impairments.40 The best way to minimize the effects the esophagus. An anterior fistula can result in a fatal
of these complications is to use a multidisciplinary bleed, and a posterior fistula can result in recurrent
(Dysphagia/Tracheostomy) team that consists of (ENT pneumonia.42 Due to these risks and complications,
specialist, Respiratory therapist, Speech & Language patients with tracheostomy need to be weaned off
Pathologist and a Dietitian) when managing severe tracheostomy as soon as they are ready for the weaning
traumatic brain injury patients with dysphagia. process. Table 4 presents criteria to attempt weaning
Management of patients with tracheostomy. Up from tracheostomy.42,43 If a patient cannot produce a
to 50% of patients undergo tracheotomy following voice when his tracheostomy opening is closed for a
short period, he may have an obstruction at or below
severe traumatic brain injury (Figure 2).5 Tracheostomy
the level of the vocal cords. In such cases, a scope must
decreases the patient’s ability to communicate with
be performed by ENT to rule out vocal cord paralysis
others, which may lead to depression and social
due to recurrent laryngeal nerve injury at the time of
tracheotomy. If the vocal cords are mobile, the scope
has to pass below the level of the vocal cords to rule
out an obstruction caused by clot, granuloma, or mucus
plug. An obstruction at or below the level of the vocal
cords may cause failure of the tracheostomy weaning
process. The process of weaning from tracheostomy
differs between centers. Safe decannulation is the
ultimate goal of all weaning protocols. There is no
evidence to suggest that one method is superior to the
other.42 The use of multidisciplinary Tracheostomy/
Dysphagia teams leads to fast and safe decannulation of
patients, with a significant reduction in the number of
tracheostomy related complications.44-46 Tracheostomy
teams in each hospital have their own protocols that
should be followed to ensure the delivery of needed care
Figure 2 - Tracheostomy tube. for tracheostomy patients. Table 5 illustrates steps that
can be taken during the weaning process.42,43

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 Dysphagia in TBI ... Alhashemi

Table 5 - Steps that can be taken during the weaning process.42,43 with increased morbidity. A multidisciplinary team
approach is essential for the management of dysphagic
Steps to follow during weaning from tracheostomy patients. More teaching and research is needed in this
area to increase our clinical knowledge and to improve
1. Consider the criteria to attempt weaning.
patients’ outcomes.
2. May downsize the tracheostomy for more use of the upper airways.
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