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It is important to remember that MS is only one part of a person and not the person.
MS does not represent them, it is not their identity, they are as normal as the next person.
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Swallowing Problems
Various degrees of swallowing problems may be encountered in multiple sclerosis and all phases of the swallowing process can be affected.
The tongue and teeth work as a team to break down foodstuff into small pieces which, when mixed with saliva forms a ball of food (bolus) ready for swallowing. The ball of food is propelled upwards and backwards by the tongue, this action squeezes it against the roof of the mouth causing it to move towards the throat. All of these actions are voluntary. The act of swallowing is involuntary, considered to be controlled by the swallowing centre in the brainstem; this involves a series of complex, often simultaneous reflex actions.
This is the tricky bit!
The tongue is raised which blocks the openings to the nasal passages, it is then drawn back and the ball of food is pushed completely back into the throat.
Simultaneously the epiglottis moves to a horizontal position and closes the airway. The larynx (voice box) moves up and out which completes the airway closure.
This prevents food entering the windpipe and going down into the lungs. If the foodstuff does slip into the airway coughing and choking reflexes occur in an attempt to clear the airway.
The throat muscles contract to push the ball of food into the oesophagus while muscles running around the oesophagus alternately contract and relax creating a squeezing motion which carries the foodstuff down into the stomach; this action is called peristalsis. As the foodstuff is carried down and reaches the stomach muscles sealing the entrance relax and allow the foodstuff to enter. Immediately after the foodstuff enters, the muscle (sphincter) closes to prevent regurgitation back into the oesophagus
Dysphagia - difficulty swallowing
A symptom of brainstem dysfunction, is estimated to affect 43% o people with MS at some point, more common among the severely affected. [1] This is caused by myelin damage in the part of the brain controlling swallowing or to the nerves connected with it. Early detection and appropriate treatment, will help to reduce the problem.
Left untreated or undiagnosed, (people with MS may not realise that they have a problem with swallowing) those with swallowing difficulties may be at risk from :
- Anorexia.
- Aspiration pneumonia.
- Dehydration.
- Infection.
- Malnutrition.
Some problems encountered during swallowing
- Chewing
- Choking
- Foodstuff sticking in the throat
- Coughing and spluttering during and after eating
- Difficulty moving food back through the mouth
- Dribbling -
excessive saliva may cause dribbling and choking.
Management
A speech and language therapist will be able to assess how well someone is swallowing. Following assessment, the therapist can advise on:
- Amounts of food.
- Consistencies of food.
- Eating environment.
- Posture.
A physiotherapist may also advise on seating and a dietician can advise on food and thickening agents for drinks, both of which can make swallowing easier.
Percutaneous Endoscopic Gastrostomy -
If the swallowing problems are more advanced and eating is putting the individual at risk, nutrition may be provided through a procedure called percutaneous endoscopic gastrostomy (PEG). This involves a tube being inserted through the abdomen and directly into the stomach.
Complications with PEG
- Infection of the skin around the gastrostomy site.
- Haemorrhage
- Gastric ulcer either at the site of the button or on the opposite wall of the stomach.
- Perforation of bowel leading to peritonitis.
- Puncture of the left lobe of the liver leading to liver capsule pain.
- Gastrocolic fistula: this may be suspected if diarrhoea appears a short time after feeding. In this case, the feed goes direct from stomach to colon.
- Gastric separation
- "Buried bumper syndrome" -
the gastric part of the tube migrates into the gastric wall [2]
Liquid and foodstuff from the throat can trickle into the airways and down into the lungs something to be aware of and easily overlooked when managing MS.
Oesophagus (food pipe) is part of the digestive system. It is also sometimes called the gullet. It is the tube that carries food from your mouth to your stomach
1.Polman, C.H. et al. (2001) Multiple Sclerosis: The Guide to Treatment and Management. New York, Demos Publishing.