121

Dysphagia
Jeffrey B. Palmer, MD, and Koichiro Matsuo, DDS, PhD

DEFINITION
Dysphagia generally refers to any difficulty with swallowing including occult or
asymptomatic impairments. It is a common problem, affecting one third to one
half of all stroke patients1 and about one sixth of elderly individuals.2 It is frequent
in head and neck cancer, traumatic brain injury, degenerative disorders of the
nervous system, gastroesophageal reflux disease, and inflammatory muscle
disease (Table 121-1). Dysphagia is classified according to the location of the
problem as oropharyngeal (localized to the oral cavity of pharynx, not just the
oropharynx) or esophageal. It may also be classified as mechanical (due to a
structural lesion of the foodway) or functional (caused by a physiologic
abnormality of foodway function).3
Sudden onset is suggestive of stroke. Concomitant limb weakness suggests a
neurologic or neuromuscular disorder. Medication-induced dysphagia is
commonly over-looked. Medications that impair level of consciousness (such as
sedatives and tranquilizers), have anticholinegic effects (tricyclics, propantheline),
or can damage mucous membranes (nonsteroidal anti-inflammatory drugs, aspirin,
quinidine) may also cause dysphagia. 4
SYMPTOMS
The most common symptoms of dysphagia are coughing or choking during
eating5 and the sensation of food sticking in the throat or chest. 3 Some of the many
symptoms and signs of dysphagia are listed in the Table 121-2. A history of
drooling, significant weight loss, or recurrent pneumonia suggests that the
dysphagia is severe. The history is most useful for identification of esophageal
dysphagia; the complaint of food sticking in the chest is usually associated with
an esophageal disorder. In contrast, the complaint of food sticking in the throat
has little localizing value and is often caused by an esophageal disorder. Coughing
and choking during swallowing suggest an oropharyngeal origin and may be
elicited by aspiration (penetration of material through the vocal folds and into the
trachea). However, some patients have impaired cough reflexes, resulting in silent
aspiration (without cough). 5,6 Silent aspiration occurs in 28% to 94%, depending

on the population of patients. 6-8 Patients with neurologic disorder have a higher
incidence of silent aspiration. Pain on swallowing (odynophagia) may occur
transiently in pharyngitis, but persistent pain is unusual and is suggestive
neoplasia. Heart burn is a nonspecific complaint that is usually not associated with
swallowing but occurs after meals. Heart burn may occur in gastroesophageal
reflux disease, but a more specific symptom of gastroesophageal reflux disease is
regurgitation of sour or bitter-tasting material into the throat after eating.
PHYSICAL EXAMINATION
An examination of the oral cavity and neck may identify structural abnormalities,
weakness, or sensory deficits. The finding of dysarthria (abnormal articulation of
speech) or dysphonia (abnormal voice quality) is often associated with
oropharyngeal dysphagia. However, the examination is primarily useful for
finding evidence of underlying neurologic, neuromuscular, or connective tissue
disease. The examination should always include trial swallows of water. 9-11 During
the swallow, there should be prompt elevation of the hyoid bone and larynx.
Changes in voice quality or spontaneous coughing after swallowing suggest
pharyngeal dysfunction. The history and physical examination are limited in their
ability to detect and to characterize dysphagia, so instrumental studies are usually
necessary.
Neurologic examination is important in the evaluation of dysphagic individuals
because neurologic disorders commonly cause dysphagia. Disorders of either
upper or lower motor neuron may produce dysphagia. The findings of atrophy or
fasciculations of the tounge or palate suggest lower motor neuron dysfunction of
the brainstem motor nuclei. In contrast to the prevailing wisdom, the gag reflex is
not strongly predictive of the ability to swallow. It may be absent in normal
individuals and normal in individuals with severe dysphagia and aspiration.
TABLE 121-1 Selected Causes of Oral and Pharyngeal Dysphagia
Neurologic Disorders
Structural Lesions
Connective Tissue
and Stroke
Diseases
Cerebral Infarction
Thyromegaly
Polymyositis
Brainstem Infarction
Cervical Hyperostosis
Muscular Dystrophy
Intracranial Hemorrhage Congenital Web
Psychiatric Disorders
Parkinson Disease
Zenker Diverticulum
Psychogenic Dysphagia
Multiple Sclerosis
Caustic Ingestion
Amyotrophic Lateral
Neoplasm
Sclerosis (ALS)
Post-ablative Surgery
Poliomyelitis
Radiation Fibrosis
Miasthenia Gravis

Dementias
TABLE 121-2 Symptoms and Signs of Dysphagia
Oral or Pharyngeal Dysphagia
Coughing or choking with swallowing
Difficulty with initiation of swallowing
Food sticking in the throat
Drooling
Unexplained weight loss
Change in dietary habits
Recurrent pneumonia
Change in voice of speech
Nasal regurgitation
Dehydration
Esophageal Dysphagia
Sensation of food sticking in the chest or throat
Oral or pharyngeal regurgitation
Drooling
Unexplained weight loss
Change in dietary habits
Reccurent pneumonia
Dehydration
FUNCTIONAL LIMITATIONS
These depend on the nature and severity of the dysphagia. Many individuals
modify their diets to eliminate foods that are difficult to swallow. Some require
inordinate amounts of time to consume a meal. In severe cases, tube feeding is
necessary. These alterations in the ability to eat a meal may have profound effect
on psychological and social function.14 Interaction with family and friends often
centers on mealtime-family dinners, going out for a drink or for dinner, coming
over for a snack or for dessert. Difficulty in eating a meal may disrupt
relationships and result in social isolation. Some patients may require supervision
during meals or feel unsafe when they eat alone, causing further disruption of
social and vocational function.
DIAGNOSTIC TESTING
Because the mechanics of swallowing are largely invisible to the naked eye,
diagnostic studies are commonly needed. The sine qua non for diagnosis of
oropharyngeal swallowing disorders is the videoflourographic swallowing study
(VFSS).15 In this test, the patients eats and drinks a variety of solids and liquids

combined with barium while images are recorded with videoflourography

(radiographic video taping). The VFSS is usually performed jointly by a physician
(physiatrist or radiologist) and a speech-language pathologist. A unique benefit of
the VFSS is that therapeutic techniques (such as modification of food consistency,
body position, or respiration) can be tested and their effects on swallowing
observed during the study. A routine barium swallow study is frequently sufficient
if the problem is clearly esophageal.
If a VFSS cannot be performed because of the physical limitation of the patient,
the fiberoptic endoscopic evaluation of swallowing is useful to visualize the
anatomy of the pharynx and larynx and vocal fold function during eating with no
x-ray exposure.16 It is also highly sensitive for detection of aspiration8; but it does
not visualize essential aspects of swallowing, such as the oral and esophageal
stage of swallowing including opening of the upper esophageal sphincter,
elevation of the larynx, and contraction of the pharynx.
In case of esophageal dysphagia, esophagoscopy is frequently necessary to detect
mucosal lesion or masses. Biopsy is indicated when mucosal abnormalities are
detected. Manometry is useful for detection and characterization of motor
disorders of the esophagus. Electromyography is indicated when neuromuscular
disease is suspected and is useful for detection of lower motor neuron dysfunction
of the larynx and pharynx.
TREATMENT
Initial
The treatment of dysphagia depends on its causes and mechanism. Common
treatments are listed in Table 121-3. Whenever possible, initial treatment should
be directed at the underlying disease process; for example, levodopa for Parkinson
disease, or steroids for polymyositis. Esophageal dysphagia necessitates
evaluation and treatment by a gastroenterologist. When no therapy exist for the
underlying disease or the therapy is ineffective or contraindicated, rehabilitative
strategies are appropriate. Patients and their family members are encouraged to
learn the Heimlich manuever; this is important because airway obstruction is
potentially fatal.
Differential Diagnosis
Myocardial ischemia
Globus sensation
Heartburn due to gastroesophageal reflux disease
Indirect aspiration (aspiration of refluxed gastric content)

Rehabilitation
Many patients benefit from a structured swallowing therapy provided by a speechlanguage pathologist, including instruction and supervision about diet,
compensatory manuevers, and exercise.17 The goals of therapy are to reduce
aspiration, to improve the ability to eat and drink, and to optimize nutritional
status. Therapy is individualized according to the patients specific anatomic and
structural abnormalities and the initial responses to treatment trials observed at the
bedside or during the VFSS.18
Table 121-3 Principal Treatments of Selected Disorders Affecting Swallowing
Problems
Amvotrophic lateral sclerosis

Carcinoma of esophagus
Gastroesophageal reflux disease

Parkinson disease,
myasternia gravis

polimyositis,

Esophageal stricture or web

Stroke multiple sclerosis

Principal Treatments
Dietary modification
Compensatory manuevers
Counceling and advance directives
Esophagectomy
Dietary modification
No eating at bedtime
Pharmacologic therapy
Smoking cessation
Pharmacologic treatment of underlying disease
(dietary modification, compensatory manuevers,
and dysphagia therapy only if neccesary).
Dilatation
Dietary modification
Compensatory manuevers
Dysphagia therapy

A fundamental principle of rehabilitation is that the best therapy for any activity is
the activity itself; swallowing is generally the best therapy for swallowing
disorders, so the rehabilitation evaluation is directed at identification of
circumstances for safe and effective swallowing for each individual patient.
Diet modification is a common treatment of dysphagia. 19,20 Patients vary in ability
to swallow thin and thick liquids, and that determination is usually best made by
VFSS. A patient can usually receive adequate oral hydration with either thin (e.g.,
water or apple juice) or thick liquids (e.g., apricot nectar, tomato juice). Rarely, a
patient may be limited to pudding consistency if thin and thick liquids are freely
aspirated. Most patients with significant dysphagia are unable to safely eat meats
or similarly though foods and require a mechanical soft diet. A pureed diet is

recommended for patients who exhibit oral preparatory phase difficulties, pocket
food in the buccal recesses (between the teeth and the cheek), or have significant
pharyngeal retention with chewed solid foods. Maintenance of oral feeding often
requires compensatory techniques to reduce aspiration or to improve pharyngeal
clearance. A variety of behavioral techniques are used , including modifications
of posture, head position (Fig. 121-1),21-22 and respiration, 23 as well as specific
swallow manuevers.24-26
Execise therapy for dysphagia is indicated when the problem is related to
weakness of the muscles of swalowing.27 The choice of exercises must be
individualized according to the physiologic assessment. The full range of
exercises is beyond the scope of this chapter, but several example illustrate the
principles.

Tongue weakness can be treated with lingual resistance exercise.28

Strengthening of the anterior suprahyoid muscles is useful when the upper
esophageal sphincter opens poorly. Flexing the neck against gravity while
lying supine can strengthen these muscles (Fig. 121-2).29,30
Vocal fold adduction exercises may be useful in cases of aspiration due to
weakness of these muscles. These exercises are done on a daily basis
whenever possible.

Procedures
VFSS functions as both a diagnostic and a therapeutic procedures for dysphagia,
especially otopharyngeal dysphagia, because it can be used to test the
effectiveness of modifying food consistency and other compensatory techniques. 31
Endoscopy with dilatation of the esophagus is often indicated in cases of partial
esophageal obstruction due to stricture or web. Dilatation is also appropriate in
stenosis of the upper esophageal sphincter. Endoscopy can also be used for
biofeedback, especially to demonstrate movements of the larynx during
swallowing manuevers. Electromyography is also used for biofeedback.
Activities of the infrahyoid and suprahyoid muscles are recorded with surface
electrodes during swallowing therapy. Biofeedback itself is not a dysphagia
therapy but can be a useful adjunct to therapy. Surface electrical stimulation on
the submental or anterior cervical muscles is a controversial new treatment of
dysphagia. There is little evidence for its safety and efficacy.32-34
Surgery
Surgery is rarely indicated in the care of patients with oral pharyngeal dysphagia.
The most common procedure for pharyngeal dysphagia is cricopharyngeal

myotomy, during which the upper esophageal sphincter is disrupted to reduce the
resistance of the pharyngeal outflow tract. However, the effectiveness of
myotomy is highly controversial.35 Esophagectomy may be necessary in case of
esophageal cancer or obstructive strictures. Feeding gastrotomy (usually
percutaneous endoscopic gastrotomy) is indicated when the severity of the
dysphagia makes it impossible for adequate alimentation or hydration to be
obtained orally, although intravenous hydration or nasogastric tube feeding may
be sufficient on a time-limited basis.36 Orogastric tube feedings have been used
successfully by patients who have absent gag reflexes and can tolerate intermitten
oral catheterization.

POTENTIAL DISEASE COMPLICATION

Severe dysphagia may result in aspiration pneumonia, airway obstruction,
bronchiectasis, dehydration, or starvation37 and is potentially fatal. Severe
dysphagia often causes social isolation because of the inability to consume a meal
in the usual manner. This may lead to depression, sometimes severe. Suicide has
been reported.

POTENTIAL TREATMENT COMPLICATIONS

The VFSS is safe and well tolerated. Prescription of a modified diet often means
the substition of thick for thin liquids. Some patients find these unpalatable and
reduce fluid intake to the point of dehydration and malnutrition. Failure to
reevaluate patients in a timely manner may lead to unnecessary prolongation of
dietary restrictions, increasing the risk of malnutrition and adverse psychological
effects of dysphagia. Dilatation of the esophagus or sphincters may result in
perforation, but this complication is uncommon. Percutaneous endoscopic
gastrostomy may have direct or indirect sequelae. Direct sequelae, such as pain,
infection, and obstruction of the feeding tube, are common. Percutaneous
endoscopic gastrotomy tube feeding may promote aspiration pneumonia in
individuals with severe gastroesophageal reflux disease.

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diagnosis, and pulmonary complications. Stroke 2005; 36: 2756-2763.
2. Achem SR, Devault KR. Dysphagia in aging. J Clin Gastroenterol 2005; 39:
357-371.
3. Palmer JB, Drennan JC, Baba M. Evaluation and treatment of swalowing
impairments.Am Fam Physician 2000; 61: 2453-2462.
4. Buchholz DW. Oropharyngeal dysphagia due to iatrogenic neurological
dysfunction. Dysphagia 1995; 10: 248-254.
5. Smith Hammond CA, Goldstein LB. Cough and aspiration of food and
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practice guidelines. Chest 2006; 129: 154S-168S.
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8. Leder SB, Sasaki CT, Burrell MI. Fibreoptic endoscopic evaluation of
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9. dePippo KL, Holas MA, Reding MJ. Validation of the 3-oz water swallow
test for aspiration following stroke [see comments]. Arch Neurol 1992; 49:
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10. Tohara H, Saitoh E, Mays KA, et al. Three tests for predicting aspiration
without videofluorography. Dysphagia 2003; 18: 126-134.
11. Wu MC, Chang YC, Wang TG, et al. Evaluating swallowing dysfunction
using a 100-ml water swallowing test. Dysphagia 2004; 19:43-47.
12. Palmer JB. Evaluation of swallowing disorders. In Grabois M, ed. Physical
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Blackwell Science, 1999:277-290.
13. Leder SB. Gag reflex and dysphagia. Head Neck 1996; 18: 138-141.
14. Kumlien S, Axelsson K. Stroke patients in nursing homes: eating, feeding,
nutrition and related care. J Clin Nurs 2002; 11: 498-509.
15. Palmer JB, Kuhlemeier KV, Tippett DC, et al. A protocol for the
videofluorographic swallowing study. Dysphagia 1993; 8:209-214.
16. Langmore SE. Endoscopic Evaluation and Treatment of Swallowing
Disorders. New York, Thieme, 2001.
17. Carnaby G, Hankey GJ, Pizzi J. Behavioural intervention for dysphagia in
acute stroke: a randomised controlled trial. Lancet Neurol 2006; 5:31-37.
18. Ott DJ, Hodge RG, Pikna LA, et al. Modified barium swallow; clinical and
radiographic correlation and relation to feeding recommendations. Dysphagia
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19. Bisch EM, Logemann JA, Rademaker AW, et al. Pharyngeal effects of bolus
volume, viscosity, and temperature in patients with dysphagia resulting from

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1041-1059.
20. McCallum SL. The National Dysphagia Diet: implementation at regional
rehabilitation center and hospital system. J Am Diet Assoc 2003; 103:381-384
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dimensions effected by chin tuck. Arch Phys Med Rehabil 1993;74: 178-181.
22. Ohmae Y, Ogura M, Kitahara S, et al. Effects of head rotation on pharyngeal
function during normal swallow. Ann Otol Rhinol Laryngol 1998;107:344-348.
23. Bullow M, Olsson R, Erkberg O. Videomanometric analysis of supraglottic
swallow, effortful swallow, and chin tuck in patients with pharyngeal
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24. Hind JA, Nicosia MA, Roecker EB, et al. Comparison of effortful and
noneffortful swallows in healthy middle-aed and older aduls. Arch Phys Med
Rehabil 2001;82:1661-1665.
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26. Longemann JA. Behavioral management for oropharyngeal dysphagia. Folia
Phoniatr Logop 1999;51:199-212
27. Longemann JA. The role of exercise programs for dysphagia patients.
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swallowing in older adults. J Am Geriatri Soc 2005;53:1483-1489
29. ShakerR, Kern M, Bardan E, et al. Augmentation of deglutitive upper
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abnormal UES opening. Gastroenterology 2002;122:1314-1321
31. Palmer JB, Carden EA. The role of radiology in rehabilitation of swallowing.
In Jones B, ed. Normal and Abnormal Swallowing: Imaging in Diagnosis and
Theraphy, 2nd ed. New York, SpringerVelag, 2003:261-273
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33. Ludlow CL, Humbert I, Saxon K, et al. Effects of surface electrical
stimulation both at rest and during swallowing in chronic pharyngeal
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34. Suiter Dm, Leder SB, ruark JL. Efects of neuromuscular electrical stimulation
on submental muscle activity. Dysphagia 2006;21:56-60
35. Jacobs JR, Logemann J, Pajak TF, et al. Failure of cricopharyngeal myotomy
to improve dysphagia following head and neck cancer surgery. Arch
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37. Finestone HM, Greene-Finestone LS, Wilson ES, et al. Malnutrition in stroke
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predictors. Arch Phys Med Rehabil 1995;76:310-316.

121
Disfagia
Jeffrey B. Palmer, MD, and Koichiro Matsuo, DDS, PhD

DEFINISI
Secara umum disfagia merujuk pada suatu kondisi kesulitan menelan, termasuk
gangguan yang bersifat asimptomatik atau tanpa gejala. Disfagia merupakan
masalah umum yang dijumpai pada sepertiga sampai setengah dari pasien stroke
dan seperenam pada manula. Kondisi ini juga sering dijumpai pada keganasan
kepala dan leher, cedera otak, penyakit degeneratif sistem saraf, penyakit refluk
gastro esofagus dan penyakit inflamasi otot (Tabel 121-1). Berdasarkan letak
kelainannya, disfagia digolongkan menjadi dua yaitu orofaring (termasuk
oral/mulut dan faring, tidak hanya orofaring) atau esofagus. Disfagia juga dapat
diklasifikasikan sebagai kelainan mekanik (karena lesi struktural pada jalur
makanan) atau fungsional (karena ganguang fisiologi dari jalur makanan).
Bila terjadi secara mendadak, kemungkinan merupakan stroke. Bila disertai
dengan kelemahan anggota tubuh kemungkinan merupakan gangguan neurologi
atau neuromuskular. Disfagia yang diinduksi oleh penggunaan obat sering
terabaikan. Obat-obatan yang menggangu kesadaran (seperti sedatif dan obat
penenang), obat dengan efek antikolinergik (trisiklik, propanteline) atau obatobatan yang merusak membran mukosa (anti inflamasi non steroid, aspirin,
quinidin) juga dapat menginduksi disfagia.
GEJALA
Gejala yang paling umum dari disfagia adalah batuk atau tersedak saat makan
serta perasaan adanya makanan yang melekat di ke tenggorokan atau dada.
Beberapa gejala dan tanda disfagia dapat dilihat pada tabel 121-2. Riwayat
pengeluaran air liur berlebihan, penurunan berat badan yang drastis, atau
pneumonia berulang menunjukkan kondisi disfagia yang berat. Riwayat pasien
sangat penting untuk mengidentifikasi disfagia esophagus; keluhan seperti rasa
makanan melekat di dada biasanya berhubungan dengan kelainan esophagus.

Bertentangan dengan hal tesebut, keluhan rasa makanan melekat di tenggorokan

hampir tidak berarti dan hal ini biasanya berhubungan dengan kelainan esophagus.
Batuk dan tersedak saat menelan menunjukkan asal gangguan yang berada pada
orofaring dan dapat menyebabkan apirasi (masuknya material ke pita suara dan
trakea). Beberapa pasien mempunya refleks batuk yang buruk yang akan
menyebabkan terjadinya aspirasi (tanpa batuk). Aspirasi yang tanpa diketahui
(silent aspiration) terjadi pada 28%-94% tergantung populasi pasien. Pasien
dengan ganguan neurologi mempunyai angka kejadian yang lebih tinggi untuk
silent aspiration. Nyeri saat menelan (odinofagia) dapat terjadi pada pasien
dengan faringitis, tetapi bila nyeri menelan yang menetap meskipun hal ini jarang
terjadi, mengindikasikan adanya keganasan. Heart burn merupakan keluhan yang
tidak khas, hal ini biasanya tidak berhubungan dengan proses menelan, tetapi
biasanya terjadi setelah makan. Heart burn merupakan gejala dari penyakit refluk
gastro-esofagus, tetapi gejala khas pada penyakit refluk gastro-esofagus adalah
regurgitasi material asam dan pahit di tengorokan setelah makan.
PEMERIKSAAN FISIK
Melalui pemeriksaan rongga mulut dan leher, dapat dilakukan identifikasi
kelainan struktural, kelemahan, atau defisit sensorik. Disartria (abnormalitas
artikulasi) atau disfonia (abnormalitas kualitas suara) sering memiliki hubungan
dengan disfagia orofaring. Bagaimanapun juga, pemeriksaan menjadi sangat
penting untuk mengetahui penyebab kelainan seperti ganggaun neurologi,
neuromuskular, atau penyakit jaringan ikat. Pemeriksaan harus mencakup
percobaan menelan air. Pada saat menelan, harus dilakukan elevasi tulang hyoid
dan laring secara tepat. Perubahan kualitas suara atau batuk spontan menunjukkan
disfungsi faring. Anamnesis dan pemeriksaan fisik memiliki keterbatasan dalam
mendeteksi dan menggambarkan disfagia, oleh karena itu diperlukan studi
instrumental.
Pemeriksaan neurologi penting dilakukan dalam mengevaluasi individu dengan
disfagia karena kelainan neurologi menjadi penyebab disfagia yang cukup sering.
Kelainan pada UMN dan LMN menyebabkan disfagia. Adanya atrofi dan
fasikulasi lidah atau palatum menunjukkan disfungsi LMN nukleus motorik
batang otak. Berlawanan dengan hal tersebut, refleks gag tidak cukup kuat untuk
memprediksi individu dengan ketidakmampuan menelan. Refleks ini mungkin
tidak ditemukan pada individu normal dan ditemukan normal pada individu
dengan disfagia berat dan aspirasi.

Tabel 121-1 Beberapa Penyebab Disfagia Oral dan Faring

Kelainan Neurologis
dan Stroke
Infark Serebri
Infark Batang Otak
Perdarahan Intrakranial
Penyakit Parkinson
Multiple Sclerosis
Amyotrophic Lateral
Sclerosis (ALS)
Poliomyelitis
Miasthenia Gravis
Demensia

Lesi Struktural
Tiromegali
Hiperostosis servikal
Congenital Web
Divertikulum Zenker
Ingesti Kaustik
Neoplasma
Bedah Post-ablative
Fibrosis Radiasi

Tabel 121-2 Gejala dan Tanda Disfagia

Disfagia Oral dan Faring
Batuk dan tersedak saat menelan
Kesulitan saat memulai menelan
Rasa makanan melekat ditenggorokan
Pengeluaran air liur yang berlebihan
Kehilangan berat badan yang tidak dapat dijelaskan
Perubahan pola makan
Pneumonia berulang
Perubahan suara
Regurgitasi hidung
Dehidrasi
Disfagia Esofagus
Rasa makanan melekat di tenggorokan
Regurgitasi Oral atau Faring
Pengeluaran air liur yang berlebihan
Kehilangan berat badan yang tidak dapat dijelaskan
Perubahan pola makan
Pneumonia berulang
Dehidrasi
KETERBATASAN FUNGSIONAL

Penyakit Jaringan Ikat

Polimiositis
Distropi Muskular
Penyakit Psikiarik
Disfagia Psikogenik

Keterbatasan fungsional pada individu dengan disfagia tergantung pada tingkat

keparah disfagia seseorang. Bayak individu yang melakukan modifikasi makan
untuk menghindari makanan yang sulit ditelan. Beberapa orang membutuhkan
waktu yang lama untuk makan. Pada beberapa kasus, dibutukan selang makan.
Ketidakmampuan dalam makan ini akan berefek pada kondisi psikologis dan
sosial. Interkasi antara keluarga dan teman biasanya terjadi disaat waktu makan
malam keluarga, bersantai untuk minum atau makan malam, menikmati makanan
ringan atau makanan penutup. Kesulitan makan dapat menyebabkan terganggunya
hubungan ini dan mengakibatkan terjadinya isolasi sosial. Beberapa pasien
mungkin membutuhkan pegawasan saat makan atau merasa tidak nyaman saat
makan sendirian, yang mengakibatkan gangguan fungsi sosial.
TES DIAGNOSTIK
Mekanisme menelan tidak dapat dilihat secara kasat mata, oleh karena itu
dibutuhkan studi diagnosis. Videoflourographic swallowing studi (VFSS) sangat
diperlukan untuk diagnosis kelainan menelan pada lokasi orofaring. Dalam tes ini,
pasien diinstruksikan untuk makan dan minum beberapa jenis sediaan padat dan
cair yang telah dikombinasikan dengan barium, sementara gambar akan direkam
menggunakan videoflourographic (perekam video radiografi). VSFF biasanya
dilakukan oleh dokter dan ahli kelainan bahasa dan bicara. Manfaat dari VFSS
adalah teknik terapeutik (seperti modifikasi konsistensi makanan, posisi tubuh,
atau respirasi) dapat di uji dan efeknya dalam proses menelan dapat diobservasi
selagi pemeriksaan. Pemeriksaan barium rutin sering kali sudah cukup jika
kelainannya jelas berada pada esofagus.
Jika VFSS tidak dapat dilakukan karena keterbatasan fisik pasien, evaluasi
menggunakan endoskopi serat optik akan berguna untuk melihat anatomi faring
dan laring dan fungsi pita suara saat makan tanpa menggunakan sinar x. ini juga
sensitif untuk mendeteksi aspirasi, namun tidak dapat memvisualisasikan aspek
penting dalam proses menelan seperti oral (mulut) dan proses menelan di
esofagus, atau kejadian penting dari proses menelan di faring termasuk
pembukaan spingter esofagus atas, peninggian laring, dan kontraksi faring.
Pada kasus disfagia esophagus, esofagoskopi sering kali dibutuhkan untuk
mendeteksi lesi pada membran mukosa atau masa. Biopsi diindikasikan bila
ditemukan abnormalitas mukosa. Manometri berguna untuk mendeteksi dan
menggambarkan kelainan motorik pada esofagus. Elektromiografi diindikasikan
bila curiga kelainan pada neuromuskular dan berguna untuk mendeteksi disfungsi
LMN dari laring dan faring.

TATALAKSANA
Inisial
Pengobatan disfagia bergantung pada penyebab dan mekanismenya. Berbagai
pengobatan yang umum dilakukan terlampir pada Tabel 121-3. Bila
memungkinkan, pengobatan awal seharusnya diarahkan pada proses penyakit
yang mendasari, misalnya levodopa untuk penyakit Parkinson, atau steroid untuk
polimiositis. Disfagia esofagus membutuhkan evaluasi dan pengobatan oleh
seorang gastroenterologis. Ketika tidak ada terapi yang tersedia berdasarkan
penyakit yang mendasari atau terapi tidak efektif atau dikontraindikasikan, maka
pendekatan rehabilitatif adalah pilihan yang tepat. Pasien dan anggota
keluarganya didorong untuk mempelajari manuver Heimlich; hal ini penting
karena obstruksi jalan napas berpotensi menimbulkan kematian.
Diagnosis Banding
Iskemia miokardium
Sensasi globus
Heartburn dikarenakan penyakit refluks gastroesofagus
Aspirasi tidak langsung (aspirasi refluks isi lambung)
Rehabilitasi
Banyak pasien mendapatkan manfaat dari terapi menelan terstruktur yang
diberikan oleh ahli patologi bahasa-wicara, termasuk instruksi dan pengawasan
mengenai makanan, manuver kompensasi, dan latihan.17 Tujuan dari terapi
tersebut adalah untuk mengurangi aspirasi, meningkatkan kemampuan makan dan
minum, dan mengoptimalkan status nutrisi. Terapi tersebut diterapkan individual
berdasarkan pada anatomi spesifik pasien dan kelainan-kelainan struktural dan
respon awal terhadap uji coba pengobatan selama perawatan di tempat tidur atau
VFSS.18 Prinsip dasar rehabilitasi adalah bahwa terapi terbaik untuk setiap
aktifitas adalah aktifitas itu sendiri; menelan secara umum merupakan terapi
terbaik untuk gangguan menelan, sehingga evaluasi rehabilitasi diarahkan pada
identifikasi keadaan untuk menelan aman dan efektif pada setiap pasien.
Tabel 121-3 Prinsip Pengobatan Gangguan yang Berhubungan Proses Menelan
Gangguan
Sklerosis lateral amiotropik

Karsinoma esofagus
Penyakit refluks esofagus

Prinsip Pengobatan
Modifikasi makanan
Manuver kompensasi
Konseling dan arahan
Esofagektomi
Modifikasi makanan
Tidak makan menjelang waktu tidur

Penyakit Parkinson,
miasternia gravis

Striktur esofagus
Sklerosis multipel stroke

polimiositis,

Terapi farmakologis
Berhenti merokok
Pengobatan farmakologis berdasarkan penyakit
yang mendasari (modifikasi makanan,
manuver kompensasi, dan terapi disfagia bila
diperlukan).
Dilatasi
Modifikasi makanan
Manuver kompensasi
Terapi disfagia

Modifikasi makanan adalah pengobatan umum disfagia.19,20 Para pasien bervariasi

dalam kemampuan menelan cairan encer dan kental, dan penentuan tersebut
biasanya dilakukan sangat baik dengan VFSS. Seorang pasien biasanya dapat
menerima hidrasi oral adekuat baik dengan cairan encer (misal, air atau jus apel)
atau kental (misal, nektar aprikot, jus tomat). Walaupun jarang, seorang pasien
mungkin terkendala pada konsistensi pudding apabila cairan encer dan kental
diambil. Kebanyakan pasien dengan disfagia yang berarti tidak mampu makan
daging atau makanan keras yang serupa dengan aman dan membutuhkan makanan
yang lunak. Diet bubur direkomendasikan untuk pasien yang memperlihatkan
kesulitan-kesulitan pada tahap persiapan oral, makanan tersisa dalam kantung
bukal (antara gigi dan pipi), atau tersangkutnya makanan yang telah dikunyah
pada rongga faring. Pemeliharaan dari pemberian makan secara oral sering
membutuhkan teknik kompensasi untuk mengurangi aspirasi atau untuk
meningkatkan pembersihan rongga faring. Berbagai teknik perilaku digunakan,
termasuk modifikasi sikap tubuh, posisi kepala (Fig.121-1), 21-22 dan pernapasan,23
serta manuver menelan tertentu.24-26
Terapi latihan untuk disfagia diindikasikan ketika gangguan yang terkait dengan
kelemahan otot-otot menelan.27 Pilihan latihan harus individual berdasarkan pada
penilaian fisiologis. Berbagai bentuk latihan tidak dijelaskan pada bab ini, tetapi
beberapa contoh mengilustrasikan prinsip-prinsip tersebut.

Kelemahan lidah dapat diterapi dengan latihan daya tahan lidah.26

Penguatan otot-otot suprahioid anterior berguna ketika sfingter esofagus atas
sulit membuka. Memfleksikan leher melawan gravitasi saat berbaring
terlentang dapat menguatkan otot-otot tersebut (Fig.121-2).29,30
Latihan aduksi pita suara mungkin berguna pada kasus aspirasi dikarenakan
kelemahan otot-otot tersebut. Latihan ini dilakukan setiap hari apabila
memungkinkan.

Prosedur

VFSS berfungsi sebagai prosedur diagnostik dan terapeutik pada disfagia,

khususnya disfagia orofaring, karena prosedur ini dapat digunakan untuk menguji
efektivitas modifikasi konsistensi makanan dan teknik kompensasi lainnya.31
Endoskopi dengan dilatasi esofagus sering diindikasikan pada kasus obstruksi
esofagus parsial dikarenakan striktur atau tertutupi. Dilatasi juga cocok pada
kasus stenosis sfingter esofagus atas. Dilatasi juga dapat digunakan untuk
biofeedback, khususnya menunjukkan pergerakan laring selama manuver
menelan. Elektromiografi juga digunakan untuk biofeedback. Aktifitas otot-otot
suprahioid dan infrahioid dicatat dengan elektrode selama terapi menelan.
Biofeedback sendiri bukan suatu terapi disfagia tetapi dapat menjadi tambahan
yang berguna untuk terapi. Stimulasi elektrik pada otot-otot servikal anterior dan
submental merupakan suatu pengobatan baru yang masih kontroversial untuk
disfagia.
Namun, masih sedikit bukti yang ada untuk keamanan dan
keberhasilannya.
Pembedahan
Pembedahan jarang diindikasikan pada perawatan pasien dengan disfagia oral atau
faring.
Prosedur yang paling umum untuk disfagia faring adalah
krikofaringomiotomi, dimana sfingter esofagus atas dikacaukan untuk
menurunkan tahanan saluran keluar rongga faring. Bagaimanapun, efektifitas
miotomi masih sangat kontroversial.35 Esofagektomi mungkin diperlukan pada
kasus kanker esofagus atau striktur obstruktif. Gastrostomi sebagai cara
pemberian makan (biasanya gastrostomi endoskopi perkutaneus) diindikasikan
ketika keparahan disfagia tidak memungkinkan untuk masuknya asupan makanan
secara adekuat atau hidrasi cairan dicapai secara oral, walaupun hidrasi intravena
atau pemberian makan melalui selang nasogastrik mungkin mencukupi dalam
batas waktu tertentu.36 Pemberian makan melalui selang orogastrik telah
digunakan dengan baik pada pasien yang kehilangan refleks muntah dan tahan
terhadap kateterisasi oral.

POTENSI KOMPLIKASI PENYAKIT

Disfagia berat mungkin menyebabkan pneumonia aspirasi,obstruksi jalan napas,
bronkiektasis, dehidrasi, atau kelaparan37 dan berpotensi menimbulkan kematian.
Disfagia berat sering menyebabkan isolasi sosial dikarenakan ketidakmampuan
untuk mengkonsumsi makanan sesuai tata cara biasanya. Hal ini mungkin
menyebabkan timbulnya depresi, yang terkadang menjadi berat. Kasus bunuh diri
juga telah dilaporkan.

POTENSI KOMPLIKASI PENGOBATAN

VFSS dinilai aman dan ditoleransi dengan baik. Rekomendasi tentang modifikasi
pola makan berarti mengganti makanan yang kental menjadi cair. Beberapa
pasien merasakan pengobatan ini tidak menyenangkan dan mengurangi asupan
cairan berujung pada dehidrasi dan malnutrisi. Kegagalan untuk mengevaluasi
kembali pasien-pasien pada waktu yang tepat mungkin menyebabkan
perpanjangan yang tidak perlu dari restriksi makanan, meningkatnya risiko
malnutrisi dan efek psikologis yang merugikan dari disfagia. Dilatasi esofagus
atau sfingter mungkin menyebabkan perforasi, tetapi komplikasi ini tidak umum
terjadi. Gastrostomi endoskopi perkutaneus mungkin menimbulkan sequele baik
secara langsung maupun tidak langsung. Sequele langsung, seperti nyeri, infeksi,
dan obstruksi saluran makan, umum terjadi pada pasien. Gastrostomi endoskopi
perkutaneus saluran makan mungkin mendorong terjadinya pneumonia aspirasi
pada individu dengan penyakit refluks gastroesofagus berat.

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