Swallowing and Feeding Disorders (Dysphagia)
Anatomy and phases
Know the four phases: oral preparatory, oral, pharyngeal, and esophageal. Understand the swallow mechanism: hyolaryngeal elevation, epiglottic inversion, vocal fold closure, and upper esophageal sphincter relaxation. Know that aspiration occurs when material enters below the true vocal folds; penetration is entry into the laryngeal vestibule above the folds. Recognize signs: coughing, wet voice, throat clearing, and silent aspiration (no cough).
Assessment and management
Understand bedside screening versus instrumental assessment (VFSS and FEES). Know compensatory strategies (chin tuck, head turn, effortful swallow, texture modification) and rehabilitative exercises (Mendelsohn maneuver, Shaker exercise, Masako). Know the IDDSI texture framework conceptually. For pediatric feeding, consider oral-motor, sensory, and behavioral factors.
Traps in questions
A common trap is assuming absence of coughing means no aspiration-silent aspiration is real. Another is confusing penetration with aspiration. Do not recommend NPO (nothing by mouth) reflexively; least-restrictive safe diet is preferred. Distinguish compensatory (immediate safety) from rehabilitative (long-term change) strategies.
Rule of thumb
Penetration = above the folds; aspiration = below the folds. Instrumental assessment is needed when silent aspiration is suspected.
Worked example: A stroke patient with a wet voice after thin liquids should receive a VFSS or FEES before diet decisions; a bedside screen alone cannot rule out silent aspiration.