In mid-November, Parkinson Canada hosted speech therapist Dr. Ianessa Humbert for a webinar on swallowing and saliva challenges in Parkinson’s disease (PD). She reviewed what normal swallowing is, assessments that can be done of swallowing problems, and treatment. Dr. Humbert described the risk of aspiration (food or saliva entering the windpipe). She also discussed drooling and dry mouth.
According to the speaker, adults experience changes in swallowing, which is normal aging. Severe problems should be assessed and treated Swallowing issues are evaluated first in a physical examination to assess eating and swallowing ability. This may lead to additional testing because swallowing is hidden without instrumental examinations. The modified barium swallow (MBS) study is an x-ray video procedure used to see the hidden swallowing process. It involves eating and drinking foods mixed with barium sulfate. A fiberoptic endoscopic evaluation of swallowing (FEES) involves inserting a camera into the throat during the swallowing process, and eating and drinking foods sometimes mixed with dye.
When someone is having swallowing challenges, aspiration can occur. Aspiration is when ingested food or saliva enters the windpipe (trachea). It often leads to coughing to protect the lungs, and can be excessive and frequent in abnormal swallowing. Residue (leftover food or liquid in mouth or throat after swallowing) can also occur in abnormal swallowing. It can happen in normal swallowing, but is quickly cleared, and can be excessive in abnormal swallowing and difficult to clear. There are many treatment options to treat swallowing issues such as medication, resections, botox, and behavioral therapies. In therapy, a person might learn how to eat differently or use devices.
The speaker also discussed two saliva issues: dry mouth and drooling. Dry mouth is a lack of saliva, and is reported by 60% of PD patients, compared to 30% of the control group. Dry mouth and drooling coexist in 30% of the cases. Drool is saliva that unintentionally slips out of the mouth onto the lower lip, chin, chest or lap. Excessive drooling can impact the skin, and can lead to having marked perioral dermatitis around the mouth.
There are some treatments for saliva management. For dry mouth, a salivary rate test and a salivary composition test may reveal the true problem, which can lead to medication or other adjustments that can help reduce dry mouth. Common treatments for excessive drooling include Botox and minimizing medications that cause drooling.
For more information on swallowing, please see this Stanford Parkinson’s Community Outreach webpage:
For a recording of this webinar, please see this Parkinson Canada YouTube webpage
See my notes below of the December 9th webinar.
– Joëlle Kuehn
“Saliva and Swallowing Challenges” [in Parkinson’s] – Webinar Notes
Webinar Host: Parkinson Canada
Speaker: Ianessa Humbert, PhD, CCC-SLP, speech therapist, co-founder of STEP (Swallowing Training and Education Portal)
Webinar Date: December 9th, 2021
Summary by: Joëlle Kuehn, Stanford Parkinson’s Community Outreach
- Goal is to move food and liquid from your mouth to your stomach
- Normal swallowing:
- Is automatic
- Requires movement of many parts of mouth and throat
- Involves pushing food cleanly done without getting into the windpipe
- Involves coordinated movements of many small structures in the mouth and neck
- 2 primary goals:
- Don’t leave any food or liquid behind. How: uses tongue and throat muscles (pharynx), do pushing actions to move things down smoothly
- Keep the breathing tube clear. How: larynx and hyoid bone
- Swallowing impairment – abnormal swallowing:
- Not able to clear everything from the mouth in one swallow, takes multiple attempts
- Food may go into their trachea regularly, and may not cough as a response to keeping things clear
Normal swallowing in older individuals:
- Presbyphagia – age-related changes in swallowing. Why:
- Less muscle, loose muscle as we age – may need to swallow more because muscles can’t push it all down at once
- Changes in sensation – reduced sensation – may need to swallow more because don’t feel it
- Fewer teeth – important to have good teeth to chew up food properly so you don’t choke on the pieces
- Central-nervous system changes – important for regulating and controlling swallowing
- Changes in older people:
- Need multiple swallows
- Sometimes in age, spine protrudes forward and blocks food
- Food may go down the wrong way
- Some individuals choose to avoid foods that are difficult to go down or that stick to eat and drink more comfortably
- These changes are not disorders, are a normal part of aging
- It matters because older adults are more likely to experience diseases and disorders that cause swallowing problems
How do we assess swallowing:
- Clinical swallowing exam:
- Physical exam by a speech-language pathologist (SLP) to assess your eating and swallowing ability
- Happens during a medical record review
- Time for the patient to share concerns or say you don’t have any
- What will SLP do during the evaluation? The goal is to find out if there are certain foods or liquids that are more difficult to eat and drink, and why
- Dysphagia – inability to eat and drink large range of food without significant residue (food or liquid left behind) or aspiration (food going into airway)
- During exam, usually no imaging, but clinician examines:
- Soft palate
- Swallowing various foods / drinks
- Test various head and neck positions
- Tasks that involve coughing
- Remember: Swallowing is hidden – can’t see anything more than you can see
- Examination can lead to further testing with other forms of imaging such as:
- Fiberoptic endoscopic evaluation of swallowing (FEES):
- Because swallowing is hidden, need a different way to see it
- Tiny camera
- Allows a look into the throat via a flexible tube with a tiny camera and light that is inserted into your nose and passed down into your throat to see the swallowing process
- Food of various consistencies and pills that are mixed with dies
- Ex. apple sauce with green food dye being seen moved back
- Can’t see moment of swallow because the muscles close around the camera, but can see before and after
- Tested in a neural head position and with the head turned to the right or left (if we turn head to the right, this makes the larynx lean towards the right and we can see if the food passes better than the left)
- Modified barium swallowing (MBS) study:
- Fluoroscopic procedure – x-ray video
- X-ray video
- Observe anatomy in parts in the mouth and throat as they move during chewing and swallowing
- What will I do: asking if there are certain foods or liquids that are more difficult to eat or drink and if so, why?
- May swallow foods of various consistencies (inc. liquids) and pills, that are mixed with barium sulfate and is mixed with food because it shows up on contrast and is black and very visible on x-ray video
- Looking if there are different strategies that make swallowing easier. Head postures – chin up or down, head turn left or right
- Swallowing alterations – hold voice box up after swallowing – hold larynx up for a bit after and then drop it
- Radiologist, SLP, and patient
- Who will be there? Speech-language pathologist and patient
- Fiberoptic endoscopic evaluation of swallowing (FEES):
What happens when food goes the wrong way?
- When food, liquid, or saliva enters the windpipe (trachea) instead of the food tube (esophagus)
- People with normal swallowing ability can aspirate small amounts infrequently (~2% of the time)
- Coughing can occur after aspiration because its our body’s natural way to protect the airway
- People with abnormal swallowing may aspirate larger amounts and more frequently
- In some people, aspiration can cause pneumonia. Pneumonia can be prevented by:
- Clean mouth
- Coughing to eject aspirated food/liquid
- Your overall health and ability to move around
- Aspiration can occur with all types of foods:
- Thinner liquids move more quickly and can be easier to aspirate
- Some individuals choose to avoid foods that are more easily aspirated
- When food or liquid remains in the mouth or throat after the swallow
- Normally, swallows leave little to no food or liquid left behind in the mouth or the throat
- But even people without swallowing problems can have some left-over food or liquid, requiring a second or third swallow:
- Especially if there is a lot to swallow
- Or it is a difficult texture like peanut butter
- Swallowing disorders can result in residu that requires multiple swallows and more time to clear
- If it takes 6-7 swallows, it is a problem
- Residue can increase as the thickness of food or liquid increases. Becomes harder to clear
- An inefficient swallow can leave behind so much residu that people can become tired when eating a meal from swallowing so many times
- People sometimes lose a lot of weight because of all the weight that goes into swallowing
- A “liquid wash” with water can be used to wash residue down, or a hard effortful swallow
- Some individuals choose to avoid foods that are difficult to go down or that risk choking
Swallowing treatment options:
- After eating and/or swallowing problem has been found, you may be asked to participate in therapy or treatment
- Goal: help manage any problems with chewing or swallowing
- 3 domains for therapy:
- Medical (i.e. drugs)
- Surgical (i.e. resections, botox)
- Performed by speech – language pathologists
- Altering foods, ways to eat
- Adding a straw, or taking straw away
- Using specific utensils
- Head and/or neck postures or positions
- Tilt head forward or back
- Good if tongue is not able to push food back, gravity can help
- Swallowing maneuvers. Ex: Mendelsohn maneuver – swallow and hold up voice box for at least 2 seconds
- Small bites
- Cough after you swallow
- Washing food down with water
- Training devices:
- Electrical stimulation
- Lingual strengthening if you have weakness
- Don’t work for everyone, and not everyone needs it
- Note: each of these have many many possibilities, and is tailored to swallowing problems
- Important to practice eating. Just like you would practice walking or sitting
Saliva – Drooling:
- Saliva that slips out of the mouth onto the lower lip, chin, chest, lap, etc
- Excessive drooling can impact the skin, can have marked perioral dermatitis around mouth. Botox into the salivary glands can help
- Why do people drool:
- Normally we swallow a liter of saliva each day
- Helps us to manage normal flow of saliva that we create
- We swallow approximately once per minute during the day
- Saliva helps with gut, and helps with cavities, keep mouth moist
- We swallow less frequently at night:
- We may have an open mouth while sleeping
- This is why we are more likely to drool while sleeping
- Drooling in PD – can be more because:
- Swallow less frequently
- Head is tilted down (gravity)
- Masked face (open mouth posture)
- May produce more saliva (sialorrhea, hyper salivation)
- Sensation changes (close mouth and swallow – may not realize mouth is open, or feel saliva on lip)
- Medications (more or less saliva)
Saliva – Dry mouth:
- Sometimes people with PD may also have dry mouth symptoms
- Study showed:
- Dry mouth was reported by 60% of PD patients, compared to 30% of control
- Dry mouth and drooling coexisted in 30% of cases
Saliva management – treatment options:
- Talk to a movement disorders team
- For excessive drooling:
- Medications that are causing drooling or can minimize it
- Phone or watch timer to prompt frequent swallowing
- For dry mouth:
- Salivary rate test
- Salivary composition test
- Medications causing dry mouth
Question & Answer:
Question: Are there foods to eat or avoid that can affect drooling or swallowing?
Answer: Dairy generally gives you a more lubricated feeling in the mouth, and some people who have a cold actually avoid dairy because they feel like their phlegm is thicker. There can be foods that help you feel more lubricated if you have a dry mouth. In terms of drooling, it’s important to ensure that your salivary rate is within normal limits. If the salivary rate or composition is the problem, diet will have little to no effect on salivation in general.
Question: Is there any medication to help with trouble with swallowing or choking?
Answer: Medications to help with trouble with swallowing or choking would target the underlying reason for your swallowing impairment. There aren’t many medications that target swallowing in isolation (only swallowing), because swallowing doesn’t happen in a vacuum. Swallowing disorders are almost always a consequence of an underlying disease or disorder. If you target the disease or disorder, you often target the swallowing problem.
Question: How can you manage swallowing pills if you feel like the throat is swollen or sore, or if you have a bad taste in the mouth?
Answer: Patients can take pills with certain kinds of foods that move down quickly. If you are able to swallow something like apple sauce, adding a pill to that can distract you from thinking about the pill. A big problem with pills is that people are fearful of pills.
Question: Are all botulinum toxins the same for the treatment of hypersalivation?
Answer: They aren’t. The one that swallowing experts talk about specifically is Type A. You’d talk to an ENT (ear nose and throat), also known as otolaryngologists. They’d be able to tell you more details on frequency, if you’re a candidate, and what the type is. Botox lasts 4-6 months, so know that if it’s problematic, you can’t take it out. That is why the evaluation is thorough, so that they don’t leave you with a 4-6 month problem.
Question: Are there exercises to help prevent swallowing challenges?
Answer: The swallowing challenge itself is the one that needs to be figured out first. That’s why it’s important to get tests done to figure out the specific problem. It’s important to get evaluated by a speech pathologist who can do imaging to find out what the problem is.
Question: Is using straws for drinking helpful?
Answer: A straw delivers food deeper into your mouth. A cup is right at your lips, which gives your mouth more time to prepare to push the food back. Sometimes straws lead to people aspirating food or liquids because they don’t have enough time to deal with the liquid that’s delivered too far back to their mouths. Sometimes we don’t recommend straws for people who allow the food or liquid to fall back too quickly. In those cases, we might even ask them to put their chin down, so they have gravity against getting the food back too quickly. On the other hand, straws are helpful for people who need help getting the food back. If they can’t get it back properly with their tongue, if we deliver it farther back, then they have less work to do to get it into their throat. The problem determines whether the strategy is effective or ineffective.