The medical term for swallowing difficulties is Dysphagia. It is caused by myelin damage in the part of the brain controlling swallowing or to the nerves connected with it.

It is estimated that perhaps 30%-50% of people with MS have swallowing difficulties. Often, people are unaware they may have a problem, therefore it is essential to increase awareness amongst people with MS, their families, carers and GPs that swallowing problems are not limited to more advanced MS. With early detection and appropriate treatment, much can be achieved and the chances of successfully reducing the problems are improved.

What are the main problems encountered during swallowing?

The main swallowing problems encountered include:

• problems chewing
• food sticking in the throat
• sluggish movement and/or difficulty moving food back through the mouth
• coughing and spluttering during and after eating
• excessive saliva causing ‘dribbling’
• choking

How do we swallow?

After food enters the mouth it is moved backwards by the tongue to the premolars and molars which, through a mixture of crushing and grinding, break the food into small pieces. The tongue also helps to mix the chewed and softened food with saliva to form a bolus (cohesive ball of food) prior to swallowing; the initial stage of which is a voluntary action.

The tongue pushes the bolus upwards and backwards and, by squeezing it against the roof of the mouth causes it to slide towards the throat.

From this point, swallowing becomes entirely involuntary and is considered to be controlled by the swallowing centre in the brainstem, the stalk at the base of the brain that links it with the spinal cord. It involves a series of complex, often simultaneous reflex actions, noted for their speed and power.

There are two parts to this involuntary phase:

1. The tongue is raised so that the openings to the nasal passages are blocked. It is then drawn back and the bolus pushed completely into the throat. At this moment the epiglottis moves to a horizontal position to close over the airway and the larynx (voice box) moves up and out to complete airway closure. This prevents food entering the windpipe and going down into the lungs. If the bolus does slip into the airway by mistake, coughing and choking reflexes clear the passage - often described as ‘going down the wrong way’.

2. The second involuntary stage begins as the throat muscles contract and push the bolus into the oesophagus. The muscles running around the oesophagus alternately contract and relax creating ‘waves’ that transport the bolus to the stomach; this process is called peristalsis. As this wave reaches the stomach, the muscles sealing the entrance relax and allow the bolus to enter. Immediately after the food enters, the sphincter closes to prevent regurgitation back into the oesophagus.

If left untreated or undiagnosed, people with swallowing difficulties can be at risk from malnutrition, dehydration or even anorexia. They may also experience aspiration, where liquid and food from the throat trickles into the airways and down into the lungs. This can lead to infection or a type of pneumonia and is an area of MS management that is often overlooked by GPs through lack of awareness.

How can swallowing problems be treated?

Once a swallowing problem is suspected, diagnosis and treatment becomes a team effort involving a radiologist, speech therapist, dietician, the person with MS, their family and carers.

a) Radiologist.

A person with MS may be referred to a radiologist for a video-fluroscopy. This is a moving x-ray of the swallow which tracks the bolus from the mouth into the oesophagus and can verify the exact nature and location of the swallowing problem.

b) Speech Therapist

A Speech Therapist will observe the MS patient eating and drinking and can determine any alterations to the normal pattern of swallowing.

c) Dietician

A dietician can advise as to which kinds of food are easier to swallow although a Speech Therapist is also able to advise on this.

d) Family, friends and carers.

These people need to be aware of the difficulties encountered by a person with MS and it’s advisable that they should learn some strategies to help deal with problems as they arise.

How to swallow with minimum discomfort

• Tuck in the chin during swallowing only by a matter of a centimetre to help close the airways.
• Change to a softer diet by using puréed or liquidised food; this will often ease swallowing difficulties and reduce both the sensation of food being stuck in the throat and the likelihood of choking. 
• Thicken drinks by the addition of a corn starch-based preparation as advised by a dietician.

Other strategies that can minimise discomfort include:

• good posture
• eat in a relaxed atmosphere
• avoid rushing a meal
• take time to chew well, allowing time between swallows
• alternate liquid with solid food moisten drier foods, e.g. by adding gravy
• avoid speaking whilst eating
• drink a small amount of water at the end of a meal to remove any lingering food in the throat, then clearing the mouth by deliberate coughing
• remain upright for at least 30 minutes after the meal.

It is recommended that the Heimlich manoeuvre (a first aid treatment for choking) should be learned by carers and people with MS 

• The Heimlich manoeuvre
o Stand behind the person who is choking.
o Place your arms around their waist and bend them well forward.
o Clench your fist and place it right above the person's navel (belly button).
o Place your other hand on top, then thrust both hands backwards into the stomach with a hard, upward movement.
o Repeat this until the object stuck in the throat is expelled through their mouth.

If you need to carry out this manoeuvre on yourself, place a clenched hand above your navel (belly button) and your other hand on top. Then thrust your fist hard into your stomach. Repeat this until the object stuck in the throat is expelled through the mouth.

If the swallowing problems are more advanced and eating is putting the individual at risk, nutrition can be provided through a procedure called percutaneous endoscopic gastrostomy (PEG). This involves a tube being inserted through the abdomen and directly into the stomach.

Personal Experiences.

• “My experience is one of progressive difficulty in swallowing. Despite having followed advice from speech therapists and peers, I choke and splutter over the smallest amount of food in my mouth and often have to have someone 'pat' my back to encourage swallowing. Sometimes I have to force myself to breath and taking an intake of breath when you've got something in your mouth isn't easy. Later in the evening seems to be worst. My 9.30 p.m. medication has become a nightmare. I am frequently having to get someone to bring a bowl because I am going to regurgitate the tablets I have just swallowed. Then it's a vicious circle, because the tablets wont work and other symptoms get worse.”

• “I find that liquid, especially water, will slip down my throat without my brain consciously telling it to. This results in much coughing and spluttering. On two occasions, my throat and chest have been so sore after it that my GP has sent me for a chest X-Ray to check in case it’s gone down into my lungs. The X-rays have always been clear but I’m grateful that my GP see the potential danger here.”

• “I was referred to a Speech Therapist who explained that the reason I get trouble swallowing tablets and supplements is that water will quickly find it’s own course, leaving the pill stuck in the throat, so I was advised to mash any supplements with my food.”

© Multiple Sclerosis Resource Centre (MSRC)