Around 85 percent of people with amyotrophic lateral sclerosis (ALS) — a progressive neurological condition that affects motor neurons, the nerve cells that control muscle movements —experience dysphagia, or difficulties in swallowing. These problems usually occur in the later stages of the disease.
Bulbar ALS is an exception, with the muscles involved in breathing, speaking, and swallowing usually affected first in this form of ALS.
How ALS causes difficulties in swallowing
ALS is characterized by progressive muscle weakness. This includes not only the muscles that control movement of the limbs and other parts of the body, but also the muscles required for breathing, swallowing, and speaking.
Swallowing requires the combined action of many different muscles of the lips, tongue, and throat. Muscles in the tongue help to move the food inside the mouth, and to clear the mouth when swallowing. Any of these muscles can be affected in ALS, which impairs the swallowing process.
Signs of difficulties in swallowing
Difficulties in swallowing may not always be apparent. The following signs can indicate a problem:
- Frequent coughing or choking on food while swallowing
- A gurgling-sounding voice after swallowing
- Longer mealtimes
- Need for smaller bites and sips
- Foods or liquids spilling out of the mouth
- The pooling of saliva in the mouth (may look like drooling)
- Food coming out the nose
- Regurgitation (swallowed food that comes back up into the mouth)
- Shortness of breath while eating
The patient’s health and nutrient status can be impacted by swallowing difficulties, due to reduced calorie intake.
Difficulty swallowing increases the risk of food or liquid going into the windpipe, which is called aspiration. Aspiration can cause infections and other complications. Silent aspiration, in which affected individuals do not sense when something enters into the windpipe, is especially dangerous.
A method known as the modified barium swallow study can help to detect and assess swallowing difficulties. It monitors swallowing using an x-ray, which can help identify which part of the process is being affected. The technique also can help diagnose silent aspiration.
Management of swallowing difficulties
Swallowing difficulties can be managed via a combination of different approaches. These are summarized below.
The consistency of food influences how easy it is to swallow. In general, the softer the food, the easier it is to swallow. Moistening foods with gravies or sauces can make swallowing easier. It can also help to eat food that requires minimal chewing, or to blend the food before eating.
Adding a thickening agent to liquids slows the speed with which they move down the throat, reducing the risk of aspiration.
Certain strategies can improve swallowing. For instance, taking smaller bites or sips can help. Double swallowing (swallowing twice per sip of liquid or bite of food) can help eliminate leftovers after the initial swallow. Tucking the chin down the chest while swallowing might help prevent food or liquid entering the airway.
Medications and additional options
If swallowing becomes too difficult, tube feeding may be considered. Patients can still eat normally, but tube feeding offers an additional option.
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