Approaches to management of disordered swallowing.

Management of disordered oropharyngeal swallowing begins with careful assessment of the patient's oropharyngeal anatomy and physiology, medical status and cognitive, language and behavioural characteristics. More often, videofluoroscopic studies are performed which enable observation of bolus movement and movements of the oral cavity, pharynx and larynx throughout the swallow. Treatment for oropharyngeal dysphagia may take the form of compensatory strategies, direct therapy or indirect therapy. Compensatory strategies include postural changes and modification of bolus volume and consistency as well as rate of food presentation. These strategies are designed to eliminate the symptoms of the swallowing problem but may not directly change swallow physiology. Direct therapy techniques are designed to change swallow physiology and consist of oral sensory stimulation techniques and swallow manoeuvres, as well as maxillofacial prosthetics, medication and surgical procedures. Indirect therapy procedures are designed to improve the neuromuscular controls necessary for the swallow without actually producing a swallow. Specific swallowing treatment strategies within each category are described. In addition to assessing the patient's swallow physiology, the videofluoroscopic study of the swallow can be used as a treatment efficacy trial in which selected compensatory strategies or direct therapy techniques are used by the patient to improve their swallow safety and efficiency. Factors to be considered in the design of an overall treatment plan for a patient with disordered swallowing are defined.