Diagnosis and Treatment of Neurogenic Dysphagia – S1 Guideline of the German Society of Neurology
Neurological Research and Practice
Dziewas, R., Allescher, H. D., et al. (2021).
Neurological Research and Practice, 3(1), 23.
This is a clinical practice guideline providing recommendations on the diagnosis and treatment of neurogenic dysphagia.
German Society of Neurology (DGN)
No recommendations at this time.
<div>Recommendations on the diet modification of individuals with neurogenic dysphagia are as follows:</div>
<ul>
<li>“Texture-modified diets, thickened liquids and / or systematic modifications of bolus size should only be prescribed based on the findings of a swallow examination” (p. 15). </li>
<li>“Thickening of liquids can be used in patients with neurogenic dysphagia who show aspirations with liquids” (p. 15).</li>
<li>“To improve patient compliance, different types of thickeners should be offered and tested” (p. 15).</li>
<li>“Texture-modified diet can be used in patients with chronic dysphagia to improve their nutritional status” (p. 15).</li>
<li>“Despite the use of texture-modified food and thickened liquids, patients with neurogenic dysphagia are at increased risk of malnutrition, dehydration, and aspiration pneumonia and should, therefore, be monitored for these complications” (p. 15).</li>
</ul>
<div>Recommendations for the use of behavioral swallowing interventions on individuals with neurogenic dysphagia are as follows:</div>
<ul>
<li>“Before initiating behavioral swallowing interventions, the etiology and phenotype of dysphagia should be determined” (p. 16).</li>
<li>“The Shaker maneuver should be used in patients with pharyngeal residues and impaired opening of the [upper esophageal sphincter] UES” (p. 16). </li>
<li>“Expiratory muscle strength training (EMST) should be used to treat dysphagia in patients with motor neuron disease, stroke and … Parkinson. EMST should preferentially be applied within prospective clinical trials” (p. 16).</li>
<li>“The chin-tuck maneuver should be used to improve swallowing safety in patients with impaired oral bolus control and consecutive premature spillage with subsequent predeglutitive aspiration” (p. 16).</li>
<li>“Effortful swallowing can be used to improve tongue strength and swallowing physiology” (p. 16).</li>
</ul>
<div>"In patients with neurogenic dysphagia, good oral health should be established to reduce the risk of pneumonia and, if necessary, consistent oral hygiene should be performed" (p. 18).</div>
<div>Individuals with neurogenic dysphagia should receive an instrumental swallowing evaluation via FEES or MFSS based on a validated protocol, especially in the case of unclear patho-mechanisms and/or determination of swallowing safety and efficacy. </div>
<ul>
<li><span style="color: #333333;">FEES is recommended for individuals who are bedridden, severely motorically impaired or uncooperative and be used to assess pharyngeal secretion management and laryngeal and pharyngeal sensitivity.</span></li>
<li><span style="color: #333333;">VFSS is recommended for differential assessment of pharyngeal ad esophageal swallowing difficulties and suspected disorders of the upper esophageal sphincter. </span></li>
<li><span style="color: #333333;">Manometry is recommended as a complementary diagnostic tool to evaluate esophageal motility disorders.</span></li>
<li><span style="color: #333333;">MRI, CCT, sonography or EMGs should not be included as routine swallowing assessments and only be used in the context of scientific study. </span></li>
</ul>
<div>Instrumental evaluation should include assessment of different food consistencies and quantities and ability to swallow pills for individuals in need of oral medication.</div>
<div>A standardized swallowing screening is recommended for all neurological patients to determine risk of aspiration and need for further dysphagia assessment and should be completed as soon as possible for individuals admitted to hospital due to acute neurological disease or exacerbation of existing disease. Swallow screening may include water swallow tests or multi-consistency tests. Pulse oximetry is not recommended to screen for aspiration risk.</div>
<div>Recommendations on the use of neurostimulation (including neuromuscular electrical stimulation) in individuals with neurogenic dysphagia are as follows:</div>
<ul>
<li>Before initiating dysphagia treatment with a neurostimulation approach, the pattern of swallowing impairment should be determined as precisely as possible.</li>
<li>All neurostimulation methods should be used as a supplement to the behavioral swallowing therapy.</li>
<li>Due to limited data, neurostimulation methods in principle should be used in clinical trials or registries.</li>
<li>Pharyngeal electrical stimulation (PES) should be used to treat dysphagia in tracheotomized stroke patients with supratentorial lesion. Participation in prospective clinical registries is recommended.</li>
</ul>
<div>Individuals with tracheostomies should be managed by a multidisciplinary team. Individuals with an aim of decannulation should be evaluated regularly for dysphagia, including assessment of swallowing function, oropharyngeal secretion management, bronchial secretion, respiratory function, airway anatomy, voluntary and reflexive cough, and vigilance and ability to cooperate. Instrumental evaluation of swallowing function, secretion management, spontaneous swallowing rate and laryngeal sensitivity should be conducted with FEES.</div>
<div>For individuals with neurogenic dysphagia, swallowing assessment should include medical history focusing on general aspects (e.g., underlying disease, comorbidities, dysphagia-specific concerns (e.g., changes in eating and drinking, difficulty taking medication), and dysphagia-related complications (e.g., voice change, globus sensation). The use of specific questionnaires is recommended in addition to carefully guided interviews to obtain medical history.</div>
