Dysphagia

A literature review

By
Jeerunnun Uparipak 6361092
Poonyawee Vatcharakomolpun 6361095

Capstone Project
Mahidol University International Demonstration School
2021-22
 ABSTRACT
How do you feel when there are scrumptious foods that give off a smell that shouts out
hunger from your stomach? What would you feel if there was food in front of you but you could
not eat it? Isn’t it really sad for people to be prevented from eating something they love?
Currently, there is a group of people that suffer from being unable to control their swallowing
while eating, reaching up to 13.5% of the residents around the world. (2020) Simply put, on any
given day, 1 person out of every 25 people in the world has the risk of being unable to swallow
food. This condition was discovered as the difficulty of swallowing, or in medical terms,
dysphagia, which can occur in people of every age group, from children to adolescents and the
elderly (Dysphagia - Symptoms and Causes, 2021), but mostly in the elderly and people who
have conditions of underlying disease (i.e. stroke, nervous disease, diseases relating to the upper
part of the digestive system of the body (from mouth to esophagus). This, however, was not
considered essential among the majority of people and was not a well-known disease, although it
affected a large group of people. Therefore, this research will help you have a better
understanding of the condition and benefit from the information related to daily life and
relationship statistics.

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 TABLE OF CONTENT

Page
CHAPTER 1 - Background information 4

CHAPTER 2 - Function 6

CHAPTER 3 - Factor 9

CHAPTER 4 - Preventions and treatments 15

CHAPTER 5 - Consequences from dysphagia 21

CONCLUSION 22

REFERENCES 23

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 CHAPTER 1 - Background information
In the world of medication, disease is a harmful disorder that creates a symptom of an
illness in the body, specific location, and is discovered through the physical appearance or
condition underlying inside. Additionally, there are a variety of diseases that are related to the
functions in the body such as pneumonia, lung cancer, asthma that have a link to the respiratory
system or food poisoning, diarrhea, hemorrhoid or dysphagia that are revealed in the digestive
system. Here, we are going to study specifically on one's disease in the digestive tract,
dysphagia.
What is dysphagia ?
Dysphagia is the condition of patients who are unable to swallow saliva, drinks, food or
bolus (the stage of grinded food in ball-like form being mix with saliva in the first level of
digestion) (Bolus | Biology, 2013) due to the condition of the upper part of the digestive tract
(mouth, pharynx, esophagus) that squeeze itself and close the inlet of the pathway to transfer into
the next station of digestion. In which this disease not only affects the condition of inability of
swallowing, it also affects the respiratory tract because as the food can not entry the esophagus or
the digestive tract properly, the food may enter windpipe that can cause the consequence of
infected inside the lungs, can be called as ‘pneumonia’.
How dysphagia affects the world ?
According to the accumulation of quantitative information, every 1 in 25 people have the
condition of being unable to swallow foods or drinks (2020) due to the suffering from dysphagia
which this statistic could gather up into the large number of people reaching up to approximately
8% of citizens around the world. This is not the end of the shock story, the majority of people
who have dysphagia are found to be 'elderly' due to ability of the function in the body that
shutting down little by little cause diseases to explored out from lifestyle of them in the past
(NCBI - WWW Error Blocked Diagnostic, 2013). The most famous diseases that cause dysphagia
as the following condition are stroke, parkinson, sclerosis or Acid reflux disease which majority
of them are related to the neurological system.

“Dysphagia is the medical term for not being able to swallow, and I know that there are two
kinds of dysphagia: oropharyngeal and esophageal. But maybe there is also a third kind of

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dysphagia that comes when your heart breaks into pieces. I can't swallow because I have that
kind.” - Author: Holly Goldberg Sloan

This condition cause the difficulty in lifestyle, such that patients need to have people or
the nurse to take care all the time while they having a meal and the caretakers have to be
well-qualified, as patient might spread have side effect from the condition or loosing of the
breath by choking or coughing. This can result in the mental breakdown from being unable to
live an ordinary life and unable to be self-reliant. Furthermore, 60,000 individuals in each year
are dead from the suffering of dysphagia conditions (American Speech-Language-Hearing
Association, 2022)
Nonetheless, this condition is not as well-known as it should be, considering its
essentiality and seriousness. According to the statistical information from the survey between the
ages of 15 - 54 years old. The majority of people were unaware of any information and being
mystified about the dysphagia reached up to 54.8%, around a half of participants. In addition, the
majority of participants have a risk of developing the dysphagia conditions referred to by their
behavior including the consumption of alcohol, grilled food and junk food which stated in the
percentage of 88. In contrast to the statistics of people who do physical activities and have proper
amounts of sleep that stay in the minority group. Besides, the majority of participants, 77% have
relatives that stay in the age above 60 years which highly risk being involved with the dysphagia
disease.
* Note: Nonetheless, this survey is only a part of people, the majority of which are teenagers.
Therefore, there might be interchangeably on the data collection in the future.

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 CHAPTER 2 - Function
Swallowing is the process of moving food from the mouth to the stomach. Normal
swallowing is split anatomically into three stages: oral, pharyngeal, and esophageal. (Goyal,
2006)
The oral phase of swallowing is the initial step of deglutition and is completely voluntary.
It is sometimes referred to as the buccal phase. The tongue is contracted to force the bolus up
against the soft palate and then posteriorly into the oropharynx by both the tongue and the soft
palate. (Osika, 2022) The food bolus is eaten deliberately with the teeth controlled by the
masticatory muscles (chewing). Food is "prepared" into a smaller size that is properly lubricated
so that it may be readily transferred from the front to the rear of the mouth during this phase. The
food bolus is then transported deliberately farther into the oropharynx (upper part of the throat).
The food bolus is directed from the oropharynx into the lower pharynx via the back of the tongue
and other muscles (throat). In order to prevent food from entering the nose, this phase also
requires the deliberate elevation of the soft palate. Cranial nerves found in the brain stem activate
the muscles that govern the oral phase of swallowing. The trigeminal nerve, facial nerve, and
hypoglossal nerve are among the cranial nerves involved in coordinating this stage. (Goyal,
2006)
The pharyngeal step of swallowing comes next. The pharyngeal phase, unlike the oral
phase, is an involuntary procedure. (Osika, 2022) The swallow is initiated reflexively (i.e.
unintentionally). When the soft palate elevates, the nasal cavity is shut (this stops food/fluid from
exiting the nose). The larynx (voice box) ascends and descends. The vocal folds collapse first,
followed by the epiglottis closing across the airway (breathing stops momentarily) The bolus is
pushed down by the pharynx (by contracting in a stripping motion) The upper esophageal
sphincter relaxes, allowing the bolus to pass through. After the bolus has gone through, the
upper esophageal sphincter shuts to prevent the bolus from going back up (retrograde movement)
Swallowing (Normal Swallowing | Sydney Voice & Swallowing, n.d.)
Food enters the esophagus as it exits the pharynx, a tube-like muscular structure that
guides food into the stomach by highly coordinated muscle contractions. Food transit down the
esophagus during this phase needs the coordinated activity of the vagus nerve, the
glossopharyngeal nerve, and sympathetic nervous system nerve fibers. 2Two key muscles in the
esophagus open and shut instinctively when the food bolus is carried down during swallowing.

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These muscles, known as sphincters, enable the food bolus to travel forward while preventing it
from flowing backward (regurgitation).Both esophageal sphincters, upper and lower, open in
response to food bolus pressure and shut once the food bolus has passed. The upper esophageal
sphincter keeps food and saliva from being regurgitated back into the mouth, whereas the lower
esophageal sphincter keeps food in the stomach and prevents it from being regurgitated back into
the esophagus. The esophageal sphincters act as a physical barrier to regurgitated food. (What
Your Body Does When You Swallow Your Food, 2022)
Swallowing difficulties is the inability to easily swallow meals or liquids. When
attempting to swallow, those who have difficulty swallowing may choke on their food or drink.
The medical term for trouble swallowing is dysphagia. In the United States, around 15 million
individuals suffer with dysphagia. Dysphagia affects around 1 in every 25 persons. Swallowing
difficulties are not usually indicative of a medical issue. It might be transient and fade away on
its own. (Kahn, 2022)
There are three forms of dysphagia. The first is oral dysphagia (high dysphagia), which is
caused by tongue paralysis after a stroke, trouble chewing food, or issues conveying food from
the mouth. Second, since the issue is in the throat, Pharyngeal dysphagia. Throat problems are
often caused by a neurological condition affecting the nerves (such as Parkinson's disease,
stroke, or amyotrophic lateral sclerosis). Finally, esophageal dysphagia is an issue in the
esophagus. This is often due to a blockage or irritation. Surgical procedures are often necessary.
(Newman, 2017)
Dysphagia occurs when the brain control or structures involved in any step of the
swallowing process fail. It may be difficult to move food around in the mouth for chewing if the
tongue or cheek muscles are weak. A stroke or other nervous system illness may make it difficult
to initiate the swallowing response, which is the stimulation that permits food and liquids to pass
safely down the throat. Another issue that might arise is when weak neck muscles, such as after
cancer surgery, are unable to transport all of the food into the stomach. Dysphagia may also be
caused by esophageal diseases. (Dysphagia, 2017) Other issues include being unable to trigger
the swallowing reflex (a stim­u­lus that enables food and liquids to flow safely through the
phar­ynx) due to a stroke or other ner­vous sys­tem dis­or­der. People with these problems are unable
to initiate the mus­cle movements that enable food to pass from the mouth to the stomach.
Another com­pli­ca­tion might occur when weak throat mus­cles are unable to convey all of the

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food into the stomach. Food particles may fall or be pushed into the windpipe (trachea), causing
lung infection. (- Ent et al., 2020)

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 CHAPTER 3 - Factor
Dysphagia was reported as the most popular disease in the elderly as the function and
ability of the muscular tissue has regression following the age at which the majority of people
consider this condition as related development from the chronic disease such as the side-effects
from the patients who suffer from the neurological and digestive sickness. Nonetheless,
numerous factors can also influence the occurrence of this condition too depending on the health
of specific people.

1. Neurological disorder
The neurological disorder is the condition that occurs from the disorder in the function of the
brain which includes nerves and spinal cords. However, there are several diseases resulting from
the neurological disorder such as stroke, Parkinson's disease, multiple sclerosis, dementia and
many more. The majority of the time, patients who have dysphagia as a side effect from the
neurological disorder will have the disorder in the central or the peripheral part of the nervous
system (Sherrell, 2021) which results in the muscle and neuromuscular junction disorders or
dysphagia.

2. Congenital and developmental condition

a. Cleft lip and palate

Figure 1 : Cleft lip and palate

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 People with cleft lip and palate will face the swallow issue as the opening of the lip
causes the difficulty of sucking liquid food especially, during a new born baby as the air inside
the mouth of the baby can not create a vacuum to be able to suck the mother's milk properly
(Feeding - Common Problems and Solutions, 2021). Most of the time, air will be the most
consumed instead of food. The problem in sucking food might cause choking and flatulence.
* This condition is nowadays rarely seen in society due to the development of
technologies in the medical fields, causing lower financial costs.

b. Learning disability
The majority of people with learning disabilities will have learning issues on
understanding the function of swallow, they might not know how to swallow properly in order to
prevent the food from entering the windpipe. This group of people will have a high risk of
choking or in some cases can lead to death.

3. The lower esophagus related section

a. Achalasia

Figure 2 : dysfunction of sphincter

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 Achalasia is the rare condition that occurs from the dysfunction of the lower part
esophagus sphincter that is responsible for preventing food from traveling back after falling into
the next part, failing to open properly. This condition prevents the entry of bolus which causes
the occurrence of dysphagia (NHS website, 2021).

b. GERD or Gastroesophageal reflux disease

Gastroesophageal reflux disease (GERD) is caused by a malfunction of the lower
esophageal sphincter, which allows acid and food to back up into the stomach. Because the acid
affects the lining of the esophagus, it can cause further abnormal tightening in the esophagus,
which is known as esophageal stricture. The esophageal stricture may either limit and prevent
food from progressing to the next stage (Esophageal Strictures: Symptoms, Causes & Treatment,
2022), or it will induce unpleasant swallows that may trap food in large pieces in the esophagus,
resulting in vomiting. Furthermore, GERD can result in the formation of tumors that block the
esophageal route, producing pain while swallowing causing the condition of dysphagia.

c. Scleroderma
This condition occurs from the connective tissue disorder that causes the barrier between
the esophageal walls causing the block of the food from passing through the pathway
(Scleroderma Esophagus, 1990). This barrier will be in the form of white tissue and elastic.
However, this condition also causes the dysfunction of the esophagus muscle and the lower part
of the esophagus or sphincter to lose the ability to work.

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 4. Food allergy or Eosinophilic esophagitis

Figure 3 : ring-like structure that blocks pathway of swallow in esophagus

Food allergy or Eosinophilic esophagitis is take places from the muscle of the esophagus
inability to contract properly due to the food allergy cause the inflamed that affect the function of
esophagus by the reaction of the immune system that react to the allergens causing white blood
cells process the work against the trigger (Eosinophilic Esophagitis, 2022). This, however, can
result in the further development of the abscesses and the narrowing of the esophagus in ring-like
structure to block the pathway of swallow.

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 5. Radiation therapy

Figure 4 : Radiation therapy

Radiation therapy is a medical technique of using radiation which can separate into 2
types of using, lower radiation for scanning of the organ within the body and another type is to
use high amounts of radiation which is normally used for treating the patients who suffer from
cancer or tumor conditions. However, using a high rate of radiation, approximately in the amount
of HR (hazard ratio) 5.846 can cause side effects in cheat swelling and soreness of the throat and
food pipe which often result in difficulty of swallowing (Difficulty Swallowing | Radiotherapy |
Cancer Research UK, 2020).

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 6. Foreign bodies

Figure 5 : Foreign body

The phrase "Chew carefully and thoroughly, or you may choke or become unable to
breathe" refers to the presence of foreign bodies. According to the human body, teeth are
responsible for chewing the food before swallowing in order to prevent the food getting stuck in
the esophagus. The result of having forgign bodies in the esophagus might cause pain and the
blocking of the pathway of breathing if the meal is too big to pass through the esophagus as the
food might press over the pathway of the windpipe.

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 CHAPTER 4 - Preventions and treatments

Preventions
Referring to the occurrence of a variety of factors (i.e. food allergy) that cause dysphagia
as the consequence condition to occur causing the difficulty and degrades the quality of life.
However, if the appropriate action is taken into consideration in order to fix those trickers,
dysphagia can be prevented.

1. Surgery
a. Peroral endoscopic myotomy (POEM)

Figure 6 : procedure of Peroral Endoscopic Myotomy (POEM)

The relatively new endoscopic technology is used to adapt with the surgery procedure in
order to remove tumors, tissues or the blockage part that prevent food from entering the stomach
properly causing the difficulty of consuming, which the most common condition that is being
treated by this procedure is Achalasia (POEM: Treatment Procedure For Achalasia, 2022).

2. Take good care of oral

a. Teeth
Teeth is the organ located in the mouth which consist of 32 teeth (incisors, canines,
premolars, molars and wisdom teeth) (The Teeth (Human Anatomy): Diagram, Names, Number,
and Conditions, 2009). Each tooth serves a specific purpose. Nonetheless, the aim of combining
them is to grind, cut, and reduce the size of food in order to generate the proper shape and size of
teeth that can be swallowed comfortably. However, without teeth, food (including liquor and

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liquid diet) will be difficult to swallow, due to the stickiness of the diet and a variety of other
variables; also, this might result in diet obstruction within the esophagus (including the
windpipe), which can result in death.

b. Tongue
The tongue is located on the floor of the mouth and is anchored to the hyoid bone (The
Tongue (Human Anatomy): Picture, Function, Definition, Problems, and More, 2009). The
tongue's function is to assist the mouth in controlling swallowing by manipulating the order and
location of food to prevent it from entering the windpipe, as well as to aid mastication, speech,
and taste (taste buds). This organ is essential to swallowing as its function is the creation of the
pressure to drive the bolus (ground food + saliva) down to the esophagus. Furthermore, the
correctness of using the tongue to swallow can help to prevent choking symptoms and coughing.

Treatments
1. Change eating habit
As the majority of the occurrence of dysphagia condition occurs from the obstruction that
blocks the esophagus pathway resulting in the inability of swallowing which to change style of
eating might be one of the effective ways for preventing the happening of dysphagia (Dysphagia
- Diagnosis and Treatment - Mayo Clinic, 2021). In terms of changing habits is to eat more
thoroughly and precisely by trying to eat food in smaller pieces and chew more often.
Furthermore, in the case of patients who also suffer from the difficulty in swallowing liquid food,
there are products that can respond to the needs of patients such as the product from Nestlé or
from brand Thick-it, in order to have more ability to control the swallow function more precisely.

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 Figure 7 : thickened drink

2. Speech–language pathology or speech-language therapy

Treatment of speech-language therapy will be led by the speech-language pathologists
(SLPs) who will observe the posture, environment and the behavior of patients who undergo the
condition that is related to speaking, including pronunciation, and consuming. For example, in
the case of children during the development years that undergo the issue of speaking and
dysphagia will be treat by adapting speech pathologist’s suggestion on using proper gesture and
technique will directly help them to speak or adapt to the case of adult who have hard time in
speaking and consuming due to the illness condition (Slew, 2021).

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 As the majority of the factors that lead to the occurrence of the dysphagia come from the
weakness of the muscles around the throat area. This technique will help patients strengthen
mobility, and control of these muscles will assist the ability of controlling swallow while
consuming food, helping people from struggling to swallow.

3. Surgery
Surgery can be used in any of the applications with all the conditions of people who
suffered from dysphagia as the dangerous part of having dysphagia is that it can lead to the side
effects from having food in lungs or airway of patients that can lead to the death of people or the
condition called pneumonia.

a. Esophageal stent
The technique of the stent procedure will be taken into consideration when the patient
faces the illness from the cancer, ulcer, radiation treatment or a hole (Esophageal Stent
Procedure, 2019). However, this procedure can be one of the options apart from taking medicine
or in the case of having cancer, healthcare may advise the chemotherapy instead. This procedure
will be in the process of closed surgery: the insertion of a stent through the mouth in order to
open the path from blocked esophagus. Interestingly, this technique is similar to the application
of widening the area from blood clotting in the vein.

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 Figure 8 : Esophageal stent procedure

The following side effects may occur after the procedure

● Bleeding
● Pain in the esophagus
● The gastroesophageal reflux
● Growth of tumor
● The movement of stent

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 b. Laparoscopic Heller myotomy

Figure 9 : procedure of Laparoscopic Heller myotomy surgery

Laparoscopic Heller myotomy is the procedure that cutting the tighten part that mostly
occurs in the lower esophageal sphincter as the occurrence of underlying symptoms that cause
dysphagia such as GERD, the condition that acid from stomach reflux itself into the lower part of
esophagus causing the abnormal tightening of sphincter (Nissen Fundoplication: What Is It,
Procedure Details & Recovery, 2022). This procedure is the use of endoscopic technology
causing the fasten of recovery and healing.

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 CHAPTER 5 - Consequences from dysphagia

Feeding is one of the first and most important complex actions to arise in all animals. It
should come as no surprise that disrupting this behavior has serious, and in some instances
life-threatening, repercussions. This crucial activity in most vertebrates starts in utero with the
swallowing of amniotic fluid and becomes critical for life within hours after birth. Thus, the
developmental processes required for eating and swallowing must be active throughout
embryonic and fetal development in order to prepare the baby for these vital tasks.
Dysphagia may be caused by developmental disturbance of the face and oropharyngeal
cartilages, bones, and muscles (together referred to as the "pharyngeal apparatus"), which are
essential for eating and swallowing, without a significant input from the growing nervous
system. (NCBI - WWW Error Blocked Diagnostic, n.d.)
Learning difficulties, which make learning, comprehending, and communicating difficult,
are examples of congenital or developmental problems that may induce dysphagia. Cerebral
palsy is a term used to describe a set of neurological diseases that impede mobility and
coordination. A cleft lip and palate is a common birth abnormality that produces a gap or split in
the top lip or roof of the mouth. (NHS website, 2021)
Cerebral palsy (CP) is a series of conditions that impact a person's ability to move,
balance, and maintain posture. The most prevalent motor impairment in children is cerebral
palsy. Cerebral refers to having anything to do with the brain. Palsy refers to muscular weakness
or difficulty with movement. CP is caused by aberrant brain development or brain injury that
impairs a person's ability to regulate his or her muscles. (What Is Cerebral Palsy? | CDC, 2021)
Furthermore, A cleft is a split or gap in the top lip and/or the roof of the mouth (palate). It exists
from birth. The gap exists because components of the baby's face did not correctly connect
together during growth in the womb. Cleft lip and palate is the most common facial birth
abnormality in the United Kingdom, affecting around one in every 700 infants. (NHS website,
2021b)

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 CONCLUSION
This project's objective is to share information on Dysphagia, a disease in which patients
are unable to swallow due to a problem with the upper digestive tract. For this literature review,
we gather credible information from several sources. It has been condensed into five chapters for
simple comprehension: background information, function, factor, prevention and treatment, and
consequences of dysphagia. In order for this report to be as comprehensive as possible, we ran a
survey before starting this project in order to determine the knowledge of the intended audience.
According to the background information, every 1 in 25 persons have the condition of
being unable to swallow meals or liquids (2020) owing to dysphagia, whereby this figure might
aggregate into a huge number of people reaching up to around 8% of residents globally. The
distressing story does not finish there; the majority of people with dysphagia are determined to
be 'elderly' due to the capability of the function in the body that progressively closes down,
leading illnesses to develop from their previous lifestyle (NCBI - WWW Error Blocked
Diagnostic, 2013).
The most common conditions that cause dysphagia include stroke, Parkinson's disease,
multiple sclerosis, and acid reflux disease, the majority of which are neurological in origin.
Swallowing is separated into three phases for the function: The voluntary passage of the bolus
from the oral cavity into the oropharynx is referred to as the oral phase. The bolus moves
involuntarily from the oropharynx into the esophagus during the pharyngeal phase. The bolus
moves involuntarily through the esophagus and into the stomach during the esophageal phase.
Dysphagia has also been reported as the most common disease in the elderly, as the
function and ability of the muscular tissue deteriorates with age, and the majority of people
regard this condition as a result of a chronic disease, such as the side-effects of patients suffering
from neurological and digestive illnesses. Nonetheless, a variety of factors, including a person's
health, might impact the incidence of this disorder.

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2033

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