Differential diagnosis
Of
Oral v/s Pharyngeal
Dysphagia
PRESENTED BY: KEERTHANA.R
Site of Lesion
Oral Dysphagia Pharyngeal Dysphagia Espharyngeal Dysphagia
Damage to cortical areas which is Lesions are often found in the Sites include the lower
responsible for voluntary swallowing brainstem. esophageal sphincter, the body of
control, particularly in the primary motor Logemann, J. A. (1998) the esophagus
cortex. Murry, T. & Carrau, R. L. (2012)
Disorders such as achalasia
involve dysfunction in the lower
esophageal sphincter.
Cook, I. (1999)
Cranial Nerves
Oral Dysphgia Pharyngeal Dysphagia Espharyngeal Dysphagia
Facial nerve Glossopharyngeal nerve (CN IX) Vagus nerve (CN X)
Hypoglossal nerve Vagus nerve (CN X) Kahrilas, P.(1999)
Murry, T. & Carrau, R. L. (2012) Hypoglossal nerve (CN XII)
Damage here disrupts the
coordination of pharyngeal
contraction and airway protection
Logemann, J. A. (1998)
Neurological cause
Oral Dysphgia Pharyngeal Dysphagia Espharyngeal Dysphagia
Amyotropic lateral sclerosis: Affects Parkinson's Disease: Causing
Stroke: Damage to brainstem or cerebral
the neuromuscular coordination dysphagia in the esophageal phase due
cortex, can disrupt motor control of the
required for pharyngeal swallowing. to bradykinesia and rigidity of
oral and pharyngeal muscles. Martino &
Rochon, P. E., Duggal, R. S., and esophageal muscles. Elia, A. E. (2015)
Foley, N. (2005)
Benatar, M. (2013)
Diabetic Neuropathy: Chronic high
Myasthenia Gravis: Leads to fluctuating
Multiple Sclerosis (MS): blood sugar can lead to neuropathy
muscle weakness, impacting oral
Demyelination in the CNS can disrupt affecting the vagus nerve, which controls
muscles and making it difficult to chew
the neural pathways involved in esophageal motility. Mohammad, S.
and initiate swallowing.
swallowing, causing coordination (2014)
Grob, D., & Simpson, D. (2008)
issues and dysphagia. Díaz, A. L.
Structural cause & Population
Oral Dysphgia Pharyngeal Dysphagia Espharyngeal Dysphagia
Reduced pharyngeal constrictor Strictures, achalasia, GERD, tumors,
Weak or damaged tongue muscles, poor
function, poor laryngeal elevation, Zenker’s diverticulum.
lip seal, neurological disorders
neurological damage. Coyle (2015)
Logemann (1998)
Martin (2000)
Elderly individuals post-stroke, patients with GERD, older adults, individuals
Elderly individuals with neurological with esophageal disorders.
with neurological conditions.
injuries Kahrilas et al. (2017)
(e.g., stroke, Parkinson's disease).
( brainstem stroke) post-head and neck
Cichero (2006)
cancer patients
Harris et al. (2000)
Instrumental evaluation & findings
Oral Dysphgia Pharyngeal Dysphagia Espharyngeal Dysphagia
Videofluoroscopic Swallow Study VFSS: Delayed or absent swallow reflex. Barium Esophagram: Identifies
(VFSS): Often reveals impaired or Reduced laryngeal elevation, leading to structural abnormalities like strictures &
incomplete bolus formation & reduced incomplete closure of the airway, webs, and also reveals motility disorders
oral propulsion. Dodds, W.J., aspiration& reduced hyoid bone (e.g. diffuse esophageal spasm) by
Logemann, J.A., & Stewart, E.T. movement. Logemann, J.A. (1998) showing abnormal narrowing. Kahrilas,
(1990) P.J., & Pandolfino, J.E. (2008)
FEES: Showed premature spillage and
Fiberoptic Endoscopic Evaluation of pooling of food or liquid in the pharynx, Manometry and VFSS
Swallowing (FEES): Shows poor aspiration, insufficient closure of the Identify esophageal phase dysphagia,
bolus control, leakage into the pharynx vocal folds & residue left in the noting that impaired peristalsis and
before the swallow. Langmore, S.E. pharyngeal area results in repeated abnormal LES pressure are common
(2001) swallows. findings. Rosen, R., et al. (2017)
Role Of SLP
Oral Dysphgia Pharyngeal Dysphagia Espharyngeal Dysphagia
Assesses swallowing safety and airway Educates on safe swallowing strategies
Evaluates oral control, oral transit, and
protection. Implements strategies such and compensatory measures such as
bolus management. Provides exercises to
as head positioning, maneuvers (e.g., positional adjustments (chin tuck, head
improve oral strength, coordination, and
supraglottic swallow), and therapy for tilt or turn), Swallow maneuvers
compensatory strategies.
pharyngeal strengthening or refers for (effortful swallow, supraglottic
Murdoch (2006)
specialized medical intervention. swallow)or refers patients for
Langmore (2001) specialized medical intervention.
Coyle (2015)
Intervention
Oral Dysphgia Pharyngeal Dysphagia Espharyngeal Dysphagia
Mendelsohn Maneuver: Help to Botox injections: Into the lower
Tongue and lip strengthening exercises
improve pharyngeal constriction and esophageal sphincter for achalasia to
Help improve bolus control and oral
laryngeal elevation (Huckabee & reduce sphincter pressure (Pasricha et
transit (Clark et al., 2009
Steele, 2006 al., 1995).
Chin-tuck maneuver can help prevent
Neuromuscular Electrical Stimulation Diet and Lifestyle Modifications: Avoid
premature spillage into the pharynx
(NMES): To stimulate the pharyngeal frequent meals can be beneficial in
(Kahrilas et al., 1988).
muscles, aiding in swallowing managing symptoms (Katz et al., 2013).
rehabilitation (Ludlow et al., 2007).
Diet Modification: Pureed foods to
improve ease of oral intake (Logemann,
1998).
Non Oral
Management
Nasogastric tube (NG-tube)
A nasogastric tube (NG tube) is a flexible tube inserted through
the nose, down the esophagus, and into the stomach. NG tubes are
used to provide temporary nutritional support. This type of tube is
commonly used for patients who are unable to eat or drink by
mouth but do not require long-term feeding support.
[Link]
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10
PERCUTANEOUS ENDOSCOPIC GASTROSTOMY TUBE
A gastrostomy feeding tube (G-tube) insertion is the placement of a feeding tube through the skin and
the stomach wall. It goes directly into the stomach.
[Link]
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PERCUTANEOUS ENDOSCOPIC JEJUNOSTOMY TUBE
A J-tube, is a feeding tube inserted directly into the jejunum, the middle
portion of the small intestine.
[Link]
PARENTERAL NUTRITION (PN)
Parenteral nutrition is a unique sterile intravenous (IV) solution that is given directly into the
bloodstream via a catheter that is inserted into a vein. Parenteral nutrition is often given to those with
moderate to severe GI diseases and those individuals who cannot properly digest or absorb food, such
as short bowel syndrome, GI fistulas, or bowel obstruction.
TOTAL PARENTERAL NUTRITION (TPN)
TPN is a mixture of separate components which contain lipid emulsions, dextrose, amino acids,
vitamins, electrolytes, minerals, and trace elements. Clinicians should adjust TPN composition to
fulfill individual patients' needs. The main three macronutrients are lipids emulsions, proteins, and
dextrose.( Mohandas KM, Shastri YM 2003).
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PERIPERHERAL PARENTERAL NUTRITION (TPN)
Peripheral parenteral nutrition (PPN) is delivered through a smaller, peripheral vein, in one of your
arm. PPN is used to provide partial parenteral nutrition temporarily, using the quicker and easier
access of the peripheral vein. PPN should be used to provide short term nutritional support (ideally 5 –
7 days) for appropriate patients, who have adequate peripheral venous access, and where central
access is unavailable.( CAROL J. ROLLINS 2003)
PPN solutions contain 20% dextrose and must be supplemented with fat emulsions .
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ENTERAL NUTRITION
Enteral feeding may mean nutrition taken through the mouth or through a tube that goes directly to the
stomach or small intestine. It can be used when a person is unable to eat or drink enough to get the
nutrients they need. This can refer to oral, gastric
Types Nasogastric tube
ORAL
MANAGEMENT
ORAL MANAGEMENT
Oral management techniques focus on Oral management techniques focus
on improving the patient's ability to swallow by strengthening the muscles
involved and modifying food and drink to make swallowing
[Link] the patient's ability to swallow by strengthening the
muscles involved an modifying food and drink to make swallowing safer.
INTERNATIONAL DYSPHAGIA DIET
STANDARDISATION INITIATIVE ( IDDSI)
Dysphagia diets are recommended for individuals with temporary or
permanent swallowing issues. The goal of the diet is to find the safest and
most enjoyable foods for you to eat.
Foods and drinks are divided into 8 levels depending on their thickness and texture. Most people will receive a
food modification IDDSI level and a drink modification IDDSI level where drinks are measured from
Levels 0 – 4, while foods are measured from Levels 3 – 7.
LEVEL 0 (THIN)
▪ Flows like water
▪ Flow fast
▪ Can drink through any type of teat/nipple, cup or
straw as appropriate for age and skills
Examples
Plain Water
Fruit Juices (lemon, orange)
LEVEL 1 (Slightly Thin)
▪ Thicker than water
▪ Requires a little more effort to drink thin liquids.
▪ Flows through a straw, syringe, nipple
Examples:
Light Fruit juice (apple, muskmelon)
Thin Buttermilk
LEVEL 1 Rationale
▪ A thickened drink is a special type of liquid used in
babies, to help them swallow safely. It flows more
slowly than regular liquids, making it easier for the
child to control when drinking. Even though it is
thicker, it can still be sipped through a baby bottle’s
teat (nipple). This is often used for babies who have
trouble swallowing or are at risk of choking
LEVEL 2 (Mildly Thick)
▪ Flows off a spoon
▪ Sippable, pours quickly from a spoon, but slower
than thin drinks
▪ Effort is required to drink this thickness through
standard bore straw (5.3 mm diameter)
Examples:
Thin Mango Lassi
Porridge water
LEVEL 2 Rationale
▪ If thin drinks flow too fast to be controlled safety,
these mildly thick liquids will flow at a slightly
slower rate.
▪ May be suitable if tongue control is slightly
reduced
LEVEL 3 (Moderately
Thick)
▪ Can be drunk from a cup or spoon
▪ Some effort is required to suck by straw
▪ Food or substance can't be shaped or spread
smoothly on a plate
▪ No oral processing or chewing required – can be
swallowed directly
▪ Smooth texture with no lumps
Examples
Honey
Ragi malt
Thick milkshakes
LEVEL 3 Rationale
▪ If tongue control is insufficient to manage Mildly
Thick drinks (Level 2), this Liquidised/ Moderately
thick level may be suitable
▪ Allows more time for oral control
▪ Needs some tongue propulsion effort
▪ Pain on swallowing
LEVEL 4 (Pureed
Extremely Thick)
▪ No lumps
▪ Not Sticky
▪ Cannot be drunk from the cup/ by straw
▪ Falls off from the single spoonful when tilted & continuous
to hold the shape on the plate.
▪ Shows some very slow movement under gravity but cannot
be poured.
Examples:
Mango pulp
Smashed dal
LEVEL 4 Rationale
▪ Biting & chewing not required
▪ Who has pain/ fatigue on chewing can be used
▪ Who has missing teeth, poorly fitting dentures can be
used
▪ Increased residue is risk if too sticky
LEVEL 5 (Minced &
Moist)
▪ Can be eaten with fork/spoon
▪ Can be scooped & shaped on the plate
▪ Soft & moist with no separate thin liquid
▪ Small lumps visible & size are:
Paediatrics: 2mm lump size
Adult: 4mm lump size
Examples:
Minced vegetables
Mashed sabudana khichdi
LEVEL 5 Rationale
▪ Biting is not required
▪ Minimal chewing required
▪ Tongue force is required to move the bolus.
▪ Who has fatigue on chewing can be used
▪ Who has missing teeth, poorly fitting dentures can be
used
LEVEL 6 (Soft & Bite
Sized)
▪ Can be eaten with a fork, spoon or chopsticks.
▪ Can be smashed with pressure from the fork/spoon
▪ Chewing is required before swallowing
▪ Soft, tender & moist food without no separate thin
liquid.
▪ Food piece sizes should be no bigger than 1.5cm x
1.5cm
Examples:
Aloo subzi (soft potato curry cut into small chunks)
Idli with small pieces
LEVEL 6 Rationale
▪ Chewing is required
▪ Tongue force is required to move the bolus for
swallowing.
▪ Who has pain/ fatigue on chewing hard food can be
used
LEVEL 7 (Regular /
Easy to chew)
▪ Everyday foods that are soft and tender in texture
▪ Includes food that are hard, tough, sticky, crunchy.
▪ Have no restrictions textures
▪ Can be easily bit or chewed (without tiring) before
swallowing
▪ Includes mixed consistency (both thin and thick foods
and liquids together)
Examples:
Idiyappam with coconut milk
Chapati dipped in dal or softened with ghee
LEVEL 7 Rationale
▪ Ability to bite hard / soft foods & chew them for long
enough that they form soft ball/bolus that is swallow
ready.
▪ Ability to chew all food texture without tiring easily.
▪ Ability to remove the bones that cannot be swallowed
safely.
“Helping someone with
dysphagia is a reminder that
even the smallest victories—
like a sip of water—can be
monumental.”
SLP Practitioner
THANK YOU