Stanford PD Community Blog

The Parkinson and Movement Disorder (PMD) Alliance hosted a webinar on swallowing disorders by speaker Courtney Brimm, MS, CCC-SLP, a licensed speech-language pathologist at the Yavapai Regional Medical Center in Prescott Valley, AZ. She described how normal swallowing works, potential causes of swallowing problems (dysphagia), possible impacts of dysphagia on quality of life, and recommendations for next steps and ways to manage this condition. 

We at Stanford Parkinson’s Community Outreach listened to the webinar and are sharing our notes.  

If you are looking for further information about dysphagia, check out our list of resources.

The webinar will be uploaded to PMD Alliance’s YouTube channel

If you wish to contact the speaker or have any questions about the webinar, please contact PMD Alliance at info@pmdalliance.org.

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Webinar notes – “Dysphagia (Swallowing Disorders)”

By Lauren Stroshane

Webinar presented by PMD Alliance on December 18, 2019

Contact with questions: info@pmdalliance.org

Ms. Brimm is an experienced speech pathologist who practices in the hospital and in outpatient clinics with a large Parkinson’s disease (PD) population. Swallowing is something that comes up often. Speech and voice changes are also common deficits, but she is particularly passionate about swallowing. We tend to think of eating and drinking as the main aspect of daily life that is impacted by swallowing difficulties, but Ms. Brimm pointed out this can significantly affect one’s social life as well. Most social situations involve food and drink to some extent; for those who must eat slowly, who tend to cough frequently, or who are unable to manage a normal diet, this can be isolating and can significantly impact one’s relationships and overall quality of life. In her work, she finds it very rewarding to help people be able to eat a meal or attend a social event.

The webinar will be uploaded to PMD Alliance’s YouTube channel.

Basics of swallowing

Before Ms. Brimm studied anatomy, she assumed we just had one tube going from our mouth to our stomach. Or maybe two tubes, for when food “goes down the wrong pipe!” She learned that swallowing is actually quite complicated and requires coordination of multiple processes.

During the webinar, she frequently referred to anatomical images from a computer program called Dysphagia, illustrating how we swallow. For those would like to see similar visual representation, below are some links to videos of the swallowing process.

Alila Medical Media: Swallowing and Dysphagia (with Animation)

Medline Plus: Swallowing

We actually have two tubes: the esophagus, which leads to our stomach, and the trachea, which leads to the lungs. The trachea is surrounded by the vocal cords as well. The epiglottis is a small flap that covers the entrance to the trachea, protecting our airway as food passes by in the esophagus. When we aren’t in the process of swallowing, our esophagus is closed. So we actually have to open our esophagus in order to swallow.

When you take a bite of food, your teeth and saliva break it down into a lump that is manageable for your tongue, called a bolus. Once your tongue has ahold of the bolus, the soft palate in the back of your mouth raises up, which prevents food from going up your nose. The muscles at the back of the throat and entrance to the esophagus have opened. A wave-like motion of the tongue presses the food bolus to the back of the throat and down the esophagus.

What is the airway doing during this process? The body has three levels of protection to shield your trachea from any food or liquids mistakenly going down into your lungs while swallowing:

1. The airway is pulled forward, out of the way of the esophagus.
2. The epiglottis closes over the entrance to the trachea.
3. The vocal cords close around the trachea, helping to seal it off.

The process of swallowing is complicated, requiring many different muscles to work in coordination. The tongue, soft palate, and esophagus are all made of muscle—which we know tends to be slowed in PD. If muscles are weak or slow, this timing can be thrown off, resulting in food, liquid, or even saliva, going down the trachea into the lungs.

What is dysphagia?

If these levels of protection break down, then abnormal swallowing (dysphagia) can occur. This can allow food or liquid to go down the trachea into the lungs, which is called aspiration. If the individual doesn’t have a well-functioning immune system, or if there were a lot of bacteria in the material that was aspirated, then they may develop an infection in the lung, called aspiration pneumonia, which is serious and can be life-threatening. In fact, aspiration pneumonia is the leading cause of death in those with PD. Aspiration of saliva can also lead to this type of pneumonia, particularly if oral hygiene is poor and the saliva contains a lot of bacteria.

How to know if someone is aspirating? Coughing while eating or the sensation that food has “gone down the wrong pipe” is often, but not always, indicative of aspiration. Sometimes the epiglottis has been irritated by food that almost went down the trachea but was stopped, and that can trigger coughing as well.

Aspiration by itself does not lead to death; it is particularly with the addition of other risk factors – such as a compromised immune system, or exposure to bacteria-infected aspirate – that aspiration pneumonia often develops. Therefore, an important measure to help prevent aspiration pneumonia is to keep the mouth clean.

How does dysphagia show up in the lives of those with PD?

Most commonly, dysphagia takes the following forms in PD:

• Coughing or choking, particularly during meals or while drinking
• Eating slowly / long mealtimes
• Pills or food getting stuck in the mouth or throat
• Drooling or choking on saliva 

Why does drooling occur in PD?

It may seem like those with PD are producing more saliva than normal. However, there actually isn’t evidence for this. Instead, it seems to be due to decreased swallowing of saliva. PD messes with a lot of the automatic behaviors in our bodies; we don’t normally think much about swallowing, but we do ordinarily swallow periodically, even when we aren’t eating or drinking. In PD, this automatic swallowing doesn’t occur as often, thus allowing more saliva to build up. This can cause drooling and aspiration.

Suggestions to help with drooling:

• Keep a water bottle handy and take frequent sips of water throughout the day. This serves two purposes: it thins the oral secretions, making saliva less sticky and easier to swallow; it also reminds you to swallow frequently.
• Be aware of mouth posture. Sometimes we start to let our jaw hang open, which can allow the saliva to escape as it builds up in our mouth.
• Explore treatment options with your neurologist. Botox injections can sometimes be helpful to reduce saliva production. However, this can sometimes cause dry mouth, so it is not an option for everyone.

What can I do for dysphagia?

Everyone is different, and it’s important to be evaluated professionally if you or your loved one feel that you are having difficulty swallowing. Here are some tips and strategies that can be applied to most individuals trying to avoid choking and aspiration:

1. Be upright when eating or drinking, unless you have been instructed by a physician not to sit upright for another condition that you have. We have to temporarily stop breathing while we eat, which can be exhausting. It helps our body to coordinate eating and breathing if we sit up.
2. Avoid distractions while eating or drinking, such as talking, watching TV, etc. Pay attention to what you’re eating.
3. Take breaks between swallows. Repeated gulps can increase the likelihood of aspiration or choking. 
4. Chew your food well and take smaller bites.
5. Try swallowing an extra time, even if you don’t feel like you need to. This can help clear out residue or remaining bits of food in the throat.
6. Use a straw (WITH CAUTION, and only if this works for you). There is more about straws in the Q&A below.
7. For those who are bothered by slow eating / lengthy mealtimes, consider the timing of your medications and try to eat once your meds have kicked in so you can move better.
8. If you feel food getting stuck in the throat while swallowing, this is due to the movement of the muscles getting uncoordinated. She recommends that you see a speech pathologist or ENT and get a formal swallow evaluation.
9. Practice good oral hygiene. Brush the teeth or cleanse the mouth (if dentures or no teeth) with a soft bristle brush, 2 to 3 times a day. It is best to use a non-alcohol—based mouthwash, as alcohol can irritate the oral tissues and cause dry mouth.
10. Make sure you are getting adequate nutrition. Movements like dyskinesia and tremor can burn a lot of calories, and weight loss is common in PD. Coupled with dysphagia, it can become difficult to take in sufficient calories each day to meet your body’s needs.  Are you losing weight unintentionally? If so, see your doctor, and consider asking for a consult with a dietician to see how you can increase nutrient intake.
11. Remember that eating can take a lot of energy. Allow adequate time for meals and breaks if need be. If a person is malnourished, fatigued, or weak, it can become a vicious cycle of not eating enough because eating takes so much effort.
12. Cognition plays a big role in swallowing; if there is cognitive impairment, try to have someone around during mealtime to help keep the person on track.

Q&A Session

Q: How does dry mouth affect the process of swallowing?

A: Dry mouth makes swallowing more difficult in two ways:

1. Lack of saliva lubrication makes it more difficult for the muscles in the mouth to contract and push the food down into the esophagus, which can be uncomfortable and ineffective.
2. Mouth sensation is impaired without saliva, so it may be difficult to even feel where the food or liquid are in your mouth if it is dry.

Q: Is it bad to drink from a straw?

A: It depends on the person – it is not good or bad, it just depends on the individual and if they have other concurrent diagnoses. If you are going to use a straw, try to keep the straw towards the front of your mouth. Just put the very tip of the straw in your mouth, so that when you take in a mouthful of liquid, it’s towards the front of your mouth and you have time to complete the normal swallowing process. If you put the straw farther back in your mouth, the liquid will come shooting into the back of your mouth and you may not be ready for it.

Q: Is it bad to take pills with a straw?

A: Again, it depends on the person. In PD, people often lack the flexibility and speed of the tongue to respond to liquid and hard pills that are in the mouth. The tongue has a lot to do when managing both water and pills! Sometimes it is better to put the pill farther back on the tongue, then take a swallow of water to wash it back. But again, this is very individual. Make sure to get a formal swallow evaluation to see what your particular challenges are!

Q: Can you get aspiration from acid reflux?

A: Yes. If you wake up in the morning with a sour, acidic taste in your mouth, that might be a sign that you’re having acid reflux overnight, which can spill over and cause aspiration into the lungs. Stomach acid is a very high risk for causing aspiration pneumonia, because it’s so harsh.

Q: Why is my saliva often thick and stringy, like a spiderweb?

A: Without knowing more about your medical history, it’s hard to know. But having thick secretions is a common complaint in PD. Think about your fluid intake – if you’re a little dehydrated, that can cause thicker secretions such as you described. It’s hard to swallow such thick secretions too. Drinking more water may help.

Q: What should I do if a person I know is frequently coughing and choking?  

A: Coughing indicates that our body is trying to protect our airway. It’s not bad in and of itself, but it can be a warning sign. In PD, muscle rigidity is one of the most common causes – the esophagus can become stiff and respond too slowly when we swallow. Involuntary movements of the tongue can also contribute, such as dystonia or dyskinesias. A formal swallow study by an ENT or speech pathologist is a good idea, particularly with radiology imaging or a scope down your nose, to visualize the exact swallowing issues that are happening.

For further resources about swallowing issues, see the APDA’s webpage on this topic.

A video of the webinar will post to PMD Alliance’s Youtube channel.

Contact info@pmdalliance.org with any questions about the webinar.