| Ch 15 | Page 4 / 13 Paragraph 3 / 8 |
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| Palliative care | Dysphagia | |
Dysphagia can be defined as the difficulty in transferring the alimentary bolus (liquid or solid) from the mouth to the stomach.
In a palliative care unit (like St Christopher), dysphagia is observed in approximately 10% of patients (however, the unit also welcomes patients with lateral sclerosis for which dysphagia is an evolutive phase of the disease).
Four steps are necessary for correct swallowing:
endobuccal preparation of the alimentary bolus (mastication, salivation),
oral swallowing phase, with closed lips and anterior tongue retraction pushing the bolus towards the oropharynx,
pharyngeal phase: partial occlusion of the nasal fossa, complete occlusion of larynx, stopped breathing,
esophageal phase: peristalsis pushes the bolus towards stomach.
The first two phases are voluntary; the latter two are reflexive.
A tumour mass in the mouth or the superior pharynx will rapidly lead to swallowing difficulties, whereas a low pharynx tumour or an oesophageal tumour will be troublesome only when voluminous.
Treatment of the tumour also provokes major swallowing side-effects:
surgery,
radiotherapy: post-radiotherapy sclerosis, mouth dryness, candidiasis,
chemotherapy, not onlyvia chemotherapy alone, but also through the increased risk of candidiasis complicating dry irradiated mucosa,
other potential mouth infections: herpes zoster, cytomegalovirus.
Depending of the location, patients may suffer from:
mouth leakage (the patient slavers): lip sensation disorders, abnormal tongue movement, reduced swallowing reflex,
frequent nasal regurgitations poor palatal function (often after surgery or radiotherapy),
swallowing difficulty: the patients pushes his head backwards in order to swallow,
coughing when swallowing may occur
- before deglutition (poor deglutition reflex),
- during deglutition (poor laryngeal occlusion),
- after deglution (difficulty in emptying the pharynx, poor functionning of cricco-pharyngeal muscles, tracheo-esophageal fistula).
Should enteral alimentation (feeding) or parenteral alimentation (hydration) be proposed to the patient?
The following table summarises enteral and parenteral feeding indications:
| General indications |
Parenteral route |
Nasogastric tube, gastrostomy |
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Indications Swallowing time greater than 10 seconds No improvement after rehabilitation or nutritional support Radical treatment proposed (surgery, radiotherapy) |
Indications Complete pharyngeal or oesophageal obstruction Short use (a few weeks), Other intestinal or gastric problems |
Indications Prolonged use (more than two weeks) |
| Contraindications Rapid terminal deterioration Other major difficulties |
Contraindications Presence of sepsis Difficulties at home No access to biochemical monitoring No access to nutritional team Superior vena cava compression |
Contraindications For the tube: oesophageal obstruction, fistula For gastrostomy: gastric tumour, occlusion |
Some simple advice may help a dysphagic patient to eat normally by mouth:
- (if possible) always eat while comfortably seated, head upright, relaxed,
- do not talk while eating or drinking, largely yawn before eating to ease any constriction,
- eat small amounts, with closed lips, and try to slowly chew and volontarily swallow small quantities,
- take a break between each deglutition, eat slowly, do not mix solid and liquid food,
- drink a small amount of water after each meal to rinse your mouth and clear your throat,
- remain seated a good while after eating or drinking.
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