Do You Have Difficulty Swallowing?

Continuing the series on Swallowing Issues, the following information is taken from the ALS Manual on Swallowing and Adjusting to Swallowing Disorders. Since Kennedy's Disease (SBMA) has bulbar related issues, there could come a time when swallowing and choking becomes an issue. 

Typical Swallowing Difficulties

Swallowing difficulty can occur during any stage of the swallowing process. You
may experience one or several symptoms we discuss; however, it is important to be aware of what may develop so appropriate changes can be made to ensure safe swallowing. You may begin experiencing symptoms and find they progress quickly. For this reason, frequent monitoring by your SLP will help to identify and intervene in order to keep swallowing safe.

1. During the first stage of swallowing (medical term: oral stage), you may
experience a “heavy tongue” that makes it difficult to move and control food
and liquid inside your mouth, chew, and clear all material from your mouth
once you swallow. Due to lip weakness, food or liquid may spill out the front of
your mouth while eating.
2. Impairments in the second stage of swallowing (medical term: pharyngeal
stage) may include a sensation of food “sticking” in your throat after you
swallow, coughing frequently during the meal, or food/liquid coming out
your nose.
3. Regurgitation of food or liquid during or after the meal may be an indication
of problems with the third stage of swallowing (medical term: esophageal
stage). 

The onset of swallowing difficulty varies, so being aware of potential
difficulties is beneficial. If you are experiencing any of these symptoms,
it is important that your SLP and neurologist are aware so they can make
appropriate recommendations. These difficulties and other swallowing-related
impairments are listed in Table 1.

Table 1: Typical Swallowing Difficulties 

Stage of Swallowing	Swallowing Difficulty
Oral Preparatory/Oral Stage	• Difficulty managing saliva • Difficulty chewing/fatigue with chewing • Food/liquid spilling out through the lips • Drooling • Difficulty controlling food/liquid in the mouth • Difficulty pushing the food/liquid to the back of the mouth • Residue in the mouth and cheek
Pharyngeal Stage	• Food “sticking” in the throat • Food/liquid coming out the nose • Coughing or choking during mealtime • Shortness of breath and fatigue during mealtime • Reduced cough strength and effectiveness
Esophageal Stage	• Regurgitation of food/liquid into the throat and mouth • Food “sticking” in the throat/base of neck

Risk of Aspiration and Malnutrition

Many people with ALS have entry of saliva or food into their airway without noticing it happening. This is called silent aspiration and is something about which you need to be very aware. Therefore, it is very important to closely evaluate swallowing function with the use of the Modified Barium Swallowing study, which is the gold standard test for identifying swallowing impairment and airway invasion. During this test, you are asked to swallow different consistencies of liquids and food while the swallowing process is filmed with an X-ray machine.

Safe Swallowing Strategies

Your SLP and Registered Dietician/Nutritionist (RDN) may recommend different strategies to help compensate for specific difficulties in swallowing while maintaining nutrition. The purpose of these strategies is to make mealtime easier, more manageable, and safe. Strategies commonly recommended for swallowing and mealtime, and why they may help, are outlined in Table 2.

Table 2: Common Swallowing Strategies Recommended by Your Speech-Language Pathologist

Swallow Strategy	Description	May Help…
Effortful Swallow	Swallowing hard, squeezing all of your throat muscles as hard as you can	Reduce or eliminate “leftovers” or residue in the throat
Chin Tuck Posture	Tucking your chin down to your chest while you swallow	Help protect food or liquid from entering your airway
Small Bites/Single Sips	Taking small, single bites of food and sips of liquid	Reduce exertion and fatigue during the meal
Double Swallow	Swallowing 2x per sip of liquid or bite of solid/soft/pureed food	Help to eliminate food/liquid left over after the initial swallow

Red Flags: Signs That Indicate Trouble Swallowing

Certain symptoms indicate difficulty swallowing and can be observed during
mealtime. Symptoms that indicate a possible swallowing impairment include:

■ Coughing and/or choking on food or liquid while swallowing
■ A wet or gurgling-sounding voice immediately after swallowing food or liquid
■ Difficulty chewing
■ Food escaping out of the mouth during chewing or liquid spilling from the lips
■ Increased mealtimes
■ The need for smaller bites and/or sips
■ Drooling of saliva or liquids
■ Food coming out the nose
■ Regurgitation

■ Difficulty managing secretions (saliva) during meal and throughout the day
■ Shortness of breath during mealtimes

Previous articles on swallowing:
Understanding Swallowing
Sphincter Weakness