Dysphagia

Assessment of respiratory function can reveal impairments in voice and phonation, as well as indicate potential swallowing difficulties. Difficulty swallowing is known as dysphagia and it indicates a risk of aspiration.

Following an acute, high-level SCI, the risk of dysphagia and aspiration increases—particularly when airway protection is compromised. This may result from altered consciousness, restricted neck mobility, or an impaired ability to cough as well as swallow effectively.

The cause of dysphagia can be multifactorial and include:

  • rigid cervical collars and Halo braces which immobilise or restrict neck mobility, limiting the natural flexion-extension movement needed for swallowing
  • focal throat (pharyngeal) swelling
  • temporary nerve dysfunction (neuropraxia) of the pharyngeal plexus impairing motor and sensory function, and recurrent laryngeal nerve palsy (RLNP) as a complication of anterior cervical discectomy and fusion
  • prolonged periods of intubation, including tracheostomy tubes with cuff inflation, which can alter normal airway dynamics and protective reflexes
  • insertion of nasogastric feeding tubes, especially large bore rigid types which can also alter normal airway dynamics and protective reflexes.

Assessment

Including a speech pathologist as part of the multidisciplinary team is essential for effective respiratory management. Early detection of dysphagia is necessary to ensure sufficient nutrition and reduce the risk of aspiration pneumonia. Following high-level SCI, dysphagia is often poorly identified, partly due to a reduced ability to cough for airway protection. This leads to a high incidence of silent aspiration. Instead of a typical sign of coughing during meals, the first symptomatic signs may be elevated body temperature, chest infection or diagnosis of pneumonia.​

Key features

Signs and symptoms that may indicate dysphagia and aspiration include:

  • large volume of secretions: often cleared from above the cuff line of a tracheostomy tube and indicates poor secretion management
  • wet or gurgly voice quality: especially after swallowing, which may indicate pooling of secretions or aspiration 
  • sensation of food sticking in the throat: which may suggest pharyngeal residue or impaired clearance
  • coughing or choking during or after eating/drinking: which is a classic sign of aspiration or impaired airway protection
  • fatigue during eating/drinking: as swallowing may require more effort, especially when there is respiratory compromise
  • suspected silent aspiration: where aspiration occurs without overt signs like coughing and is instead evidenced by elevated temperature, increased respiratory rate, reduced and altered breath sounds on auscultation, or decreased oxygen saturation on pulse oximetry
  • recurrent chest infections or pneumonia: which are often secondary signs of undiagnosed aspiration.
  • radiological imaging confirming suspected aspiration.

Management

Best practice recommendations for the acute management of dysphagia and associated complications following cervical SCI include:

  • completing an early multidisciplinary screen for dysphagia risk factors and symptoms
  • referring for a formal assessment by a speech pathologist when risks or symptoms are identified, especially when tracheostomy and ventilation is required
  • avoiding the use of thickened fluids without speech pathology assessment
  • introducing early nasogastric feeding for high-level cervical SCI to ensure consistent and adequate nutrition and hydration for recovery
  • considering early gastrostomy tube feeding if dysphagia persists, with removal once safe oral intake resumes
  • performing routine twice daily mouth care to reduce the risk of ventilator-associated pneumonia.

References

Chaw, E., Shem, K., Castillo, K., Wong, S. L., & Chang, J. (2012). Dysphagia and associated respiratory considerations in cervical spinal cord injury. Topics in Spinal Cord Injury Rehabilitation, 18(4), 291–299. https://doi.org/10.1310/sci1804-291

McRae, J., Smith, C., Beeke, S., Emmanuel, A., & Members of the Delphi expert panel group. (2022). Development of a swallowing risk screening tool and best practice recommendations for the management of oropharyngeal dysphagia following acute cervical spinal cord injury: An international multi-professional Delphi consensus. Disability and Rehabilitation, 44(26), 8311–8324. https://doi.org/10.1080/09638288.2021.2012607

Oh, L., Dibas, M., Ghozy, S., Mobbs, R., Phan, K., & Faulkner, H. (2020). Recurrent laryngeal nerve injury following single- and multiple-level anterior cervical discectomy and fusion: A meta-analysis. Journal of Spine Surgery, 6(3), 541–548. https://doi.org/10.21037/jss-20-508