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Dysphagia after trauma to the head and neck

Injuries to the head and neck region that have been caused in connection with road traffic or workplace accidents, sports injuries, falls or assault can give rise to difficulties with eating, chewing, swallowing, speaking and smiling.

Head and neck trauma

External trauma, and events that cause a temporary or long-term injury, can affect the young and old alike. Trauma – violence – to the head and neck region can cause brain damage or whiplash injury and the consequent problems can include swallowing difficulties – dysphagia, or paralysis in the face and pharynx, etc.

The UK charity, Headway, says that there were 348,934 UK admissions to hospital with acquired brain injury in 2013-14. That is 566 admissions per 100,000 of the population. ABI admissions in the UK have increased by 10 percent since 2005–2006.

There were 956 ABI admissions per day to UK hospitals in 2013–2014 – or one every 90 seconds. In 2013–14, there were 162,544 admissions for head injury. That equates to 445 every day, or one every three minutes. Men are 1.6 times more likely than women to be admitted for head injury. However, female head injury admissions have risen 24 percent since 2005–2006.

In this section we will limit ourselves to injuries to the head and neck region that have been caused in connection with road traffic or workplace accidents, sports injuries, falls or assault.

These injuries can give rise to difficulties with eating, chewing, swallowing, speaking and smiling. Later we will describe how IQoro can help those affected. IQoro is a new and unique neuromuscular treatment method that requires just 30 seconds’ exercise, three times per day.

Other reasons for injury in the head and neck region can include complications after radiation therapy or surgical operations. Read more under ”Cancer of the face, mouth, head or neck”

Common consequences

Injury from external trauma can damage muscle tissue, the skeleton and cartilage – so-called hard tissue, and cause brain and nerve damage which limit various functions. The consequences vary depending on the scope of the damage and the force of the trauma, but can include the following:

  •  Brain damage.
  •  Whiplash injury.
  •  Swallowing difficulties, dysphagia.
  •  Bite- and jaw deformities.
  •  Chewing difficulties.
  •  Difficulty in mobilising food in the mouth; and storing it in the cheeks instead.
  •  Difficulties in closing the mouth.
  •  Drooling.
  •  Paralysis in the face, pharynx or body.
  •  Poor body posture.
  •  Difficulty in showing emotions through facial expressions.
  •  Weakening of the muscles in the face, mouth, pharynx or neck.
  •  Speech difficulties.
  •  Loss of sensitivity.
  •  Over-sensitivity for being touched on the face, mouth or head.
  •  Epilepsy, cramp attacks.
  •  Dryness in the mouth during periods of medication.

Trauma to the head and neck region can result in consequences other than those shown here.

Brain damage – a common cause of disablement amongst young adults

Young men, and older people of both sexes, are over-represented among victims of traumatic brain injury, where the the most common reasons are traffic- or fall-related accidents, and assault. Brain injury is the most common cause of death and disablement amongst young adults. [1] 

Even a small amount of bleeding in the brain can cause life-threatening injuries, and swift medical intervention is essential. An unfortunate twist however, is that the symptoms: headache, giddiness, nausea, etc. usually don’t appear until a couple of hours after the injury. [2]

Nerves are injured or die – crucial functions are affected

When the head suffers external violence the pressure on, or rupturing of, the brain tissue can cause injuries to blood vessels and cause bleeding in various parts of the brain. The bleeding causes a haemorrhage and increases the pressure in the brain; at the same time it leads to a lack of oxygen which eventually injures or kills the nerves in the affected area. [1, 2]

A bleeding in the brain is called a stroke – irrespective of the reason for the bleeding.

Many muscle- and nerve functions are affected by such a stroke, and this gives rise to a total- or partial paralysis of the body, with varying degrees of function impairments. Common effects are problems with vital functions; such as being able to eat, chew, swallow (dysphagia), speak and smile – with the resultant effects on quality of life.

Serious, long-standing dysphagia is experienced by approximately 30 percent to 50 percent of those affected by stroke [4–6]. It’s not uncommon that the victims initially must be fed via the nose, or directly to the stomach via a PEG (Percutaneous Endoscopic Gastrostomy).

Facial paralysis (central facialis pares)

Facial paralysis, central facialis pares, affects all with stroke-related dysphagia

100 percent of those affected by stroke-related dysphagia have a central facial paralysis or central facialis pares in the lower quadrant of the face on the opposite side to the brain hemisphere that is injured. One can often see that one corner of the patient’s mouth hangs slackly and does not rise as the other does when smiling.

According to research: 74 percent also have reduced muscle function in one of the face’s other quadrants, and 52 percent have reduced function in all four quadrants of the face [7–10] These are new research findings of importance in selecting the correct treatment.

External trauma to the neck region – swallowing, voice and breathing problems

The neck is an especially vulnerable area for serious injuries because of the lack of a protective skeleton. Only soft components like skin, muscles, sinews and cartilage converge in the neck’s inner area. In this region there are large, important blood vessels and nerves, the thyroid gland and the windpipe.

External trauma against the neck area can therefore give rise to nerve, muscle or tissue damage that causes swallowing difficulties related to the mouth and pharynx – so-called oral- or pharyngeal dysphagia.

Tissue damage and scar tissue in the esophagus can cause constant esophageal dysphagia which will always result in food portions above a certain size becoming stuck in the chest. Liquid foodstuffs are sometimes the only way that a person thus injured can swallow. The trauma can also give rise to voice or breathing problems. [2]

Reduced quality of life – and high costs

In summary, external trauma usually causes reduced bodily function and great suffering: often with life-threatening consequences. Many victims continue to have long-term brain injury despite conventional rehabilitation.

The injuries do not only affect the victim himself – with social exclusion and reduced quality of life as non-medical consequences – but also his nearest and dearest. In addition, society is burdened with the high costs of long-term medical care, treatment and absence from work. [1]

Care interventions

To treat injuries, and to be able to offer effective trauma care is important from both the patient’s and society’s perspective. Health authorities, through their various organisational departments; and in cooperation with other agents in society, have a responsibility for selecting and executing the optimal intervention.

Victims of trauma to the head and neck region may be treated by a range of different professions depending upon the exact area of damage and its scope: doctors, nurses, physiotherapists, dentists, dental hygienists, speech therapists, work therapists, as well as officials representing the state’s insurance and financial support services, may all be involved. [1]

Those affected by such trauma will have their lives directly altered by their various reduced functions. A well-functioning care chain with rehabilitation and the correct resources and services are essential preconditions for the victim to be able to live as good a life as possible. [1]

Definition of rehabilitation, compared with treating the condition

Rehabilitation 
To be supported in recovering the best possible functional ability, and the conditions for the best possible quality of life.

Treating the condition
To try to reduce those difficulties which various lifelong functional impairments bring to everyday life.

Treatment with IQoro

IQoro is a new and unique neuromuscular treatment method that takes just 30 seconds’ exercise, three times per day. After external trauma to the head and neck region, training with IQoro can improve muscle strength and coordination for a surer and more effective swallowing function, and improve the ability to use the face’s expressive musculature, and to form sounds.

In cases of central brain injury, training with IQoro shows results of 97 percent having improved the swallowing function, and 71 percent having achieved a completely normal swallowing ability. At the same time, the training improves the conditions caused by paralysis in the face and pharynx.

All treatment results have lasting, enduring effect.The exercising reaches the muscles in the face, oral cavity, pharynx, esophagus, and down to the diaphragm, and in this way can improve a range of various functions.

Training with IQoro for 5 to 13 weeks* shows improvements with lasting effect for problems including:

*The exact training time can vary depending on the degree of severity of the trauma -a total training period of six months or more can be required.

IQoro stimulates the sensory nerves in the mouth, and by doing this reaches the brain’s control system for the swallowing process, which is closely linked to the control systems for other bodily functions [16], including breathing, the ability to form sounds (speech), facial expression, postural control [13], stomach and intestine functions, and more. This explains why exercising with IQoro can have a positive effect on so many different functions.

Long-term, lasting, improvement in swallowing ability and facial paralysis

Treatment with IQoro after stroke, a central brain injury, has an lasting positive effect on swallowing difficulties and paralysis in the face and pharynx. The effectiveness of the treatment is shown to be equally good whether the training was initiated early (1–3 weeks), or a long time after (1–10 years), the brain injury occurred. [9–13]

Research shows that 97 percent are improved and that 71percent attain a normal swallowing capacity with an enduring effect after 5 to 13 weeks’ training. [11-12] Exercising with IQoroshows statistically significant (***) long-term improvements of paralysis in all four quadrants of the face [9]. In the best cases the paralysis disappears completely, or alternatively is improved – giving a more symmetrical face with increased control.

Tissue damage and the building of scar tissue in the esophagus, can cause constant esophageal dysphagia – where food portions above a certain size always become stuck in the chest.

There is not yet any research results available to prove that IQoro has a positive effect on this condition, however IQoro has been shown to have a positive effect on hiatus hernia [14,15] – a typical intermittent esophageal dysphagia, where swallowing difficulties come and go – and therefore it is probable that IQoro will be of help in these cases too, where the muscle function has been affected by external trauma.

An alternative to PEG

Research, and long clinical experience, have shown that feeding directly into the stomach through a PEG (Percutaneous Endoscopic Gastrostomy) does not always have to be a solution for life.

The study ”Effect of IQoro training on impaired postural control and oropharyngeal motor function in patients with dysphagia after stroke” included five individuals with PEGs, of which all five could eat and drink via the mouth when the 13 weeks IQoro training came to an end.

Further, four of the five PEGs could be removed at this point, the other being removed at a later date. At a long-term follow-up visit 18 months later, without continued training in the interim, it could be concluded that the cure was still in effect. [13]

Even in those cases where the PEG cannot be replaced for different reasons, it is still of great importance to maintain the muscle functions which are involved in the entire swallowing process: from mouth to stomach. This is to optimise the stomach’s ability to receive normal amounts of nutrient and to avoid long, drawn-out mealtimes – which can take longer than 30 minutes via a PEG.

Training with IQoro before being fed via a PEG, and stimulating the taste function – perhaps with a net of varying tastes and consistencies in the mouth – during the PEG session, contribute to stimulating and maintaining the muscle functions that are involved in the swallowing process. Taken together, these actions can improve the conditions for PEG continuing to work.

Text by: Mary Hägg

Associate Professor of Experimental Research in Ear, Nose and Throat diseases at Uppsala University, and Hospital Dental Surgeon specializing in orofacial medicine.

Mary has worked for 12 years as a hospital dentist and for 31 years as Head of the Speech & Swallowing Centre, Department of Otorhinolaryngology, Hudiksvall Hospital, Sweden.

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Reference sources

  1. Landstinget Uppsala län, (2010), Trauma – Uppdragsbeskrivning om åtgärder kring skador uppkomna genom olycksfall eller annat yttre våld.
    PDF – no longer available.
    (English translation: ”Trauma – Description of required actions after injury resulting from accident or other external violence”).
     
  2. Vårdomsorg.se (2016), Så skadar våld kroppen, hämtad: 2016-10-26http://xn--vrdomsorg-52a.se/tema/alkohol/alkohol-och-vald/sa-skadar-vald-kroppen-1189
    (English translation: ”How violence injures the body”).
     
  3. SOSFS 2008:20, Socialstyrelsens föreskrifter om ändring i föreskrifterna och allmänna råden (SOSFS, 2007:10) om samordning av insatser för habilitering och rehabilitering. Västerås 2008.(English translation: ”The health authorities’ directions on changes in the regulations and general advice (SOSFS, 2007:10) on the coordination of efforts for habilitation and rehabilitation”).
     
  4. Stockholms läns landsting, Fokusrapport dysfagi, 2005, ISBN 91-85211-00-1(English translation: ”Focus report: dysphagia”).
     
  5. S. Broadley, A. Cheek, S. Salonikis et al., Predicting prolonged dysphagia in acute stroke: the Royal Adelaide Prognostic Index for Dysphagic Stroke (RAPIDS), Dysphagia, vol. 20, no. 4, pp. 303–310, 2005.
     
  6. R. T. Sorensen, R. S. Rasmussen, K. Overgaard, A. Lerche, A. M. Johansen, and T. Lindhardt, Dysphagia screening and intensified oral hygiene reduce pneumonia after stroke, Journal of Neuroscience Nursing, vol. 45, pp. 139–146, 2013.
     
  7. Hägg M. Tibbling L. Four-quadrant Facial Function in Dysphagic Patients after Stroke and in Healthy Controls. Neurology Research International Volume 2014, Article ID 672685, 5 pages, https://www.hindawi.com/journals/nri/2014/672685/
     
  8. Cumhur E., Gaye E., et al. Orbicularis oculi muscle activation during swallowing in humans. Exp Brain Res (2013) 224:79–91 , DOI 10.1007/s00221-012-3290-6
     
  9. Hägg M., Tibbling L. Effect of oral IQoro® and palatal plate training in post-stroke, four-quadrant facial dysfunction and dysphagia: A comparison study. Acta Otolaryngol. 2015 Sep;135(9):962-8. doi:10.3109/00016489.2015.1042043. Epub 2015 May 7. PMID: 25947252
     
  10. Hägg MK., Tibbling LI. Effects on facial dysfunction and swallowing capacity of intraoral stimulation early and late after stroke. NeuroRehabilitation. 2015;36(1):101-6. doi: 10.3233/NRE-141197. PMID: 25547771
     
  11. Hägg M, Tibbling L. Longstanding effect and outcome differences of palatal plate and oral screen training on stroke-related dysphagia. The Open Rehabilitation Journal, 2013, 6, pp 26-33.
     
  12. Hägg M, Anniko M. Lip muscle training in stroke patients with dysphagia. ActaOto-Laryngologica, 128 (9): pp1027-1033, 2008.
     
  13. Hägg M., Tibbling L. Effect of IQoro® training on impaired postural control and oropharyngeal motor function in patients with dysphagia after stroke. Acta Otolaryngol 2016; 136 (7):742-748. DOI:10.3109/00016489.2016.1145797 https://www.tandfonline.com/doi/full/10.3109/00016489.2016.1145797
     
  14. Hägg M, Tibbling L, Franzén T. Esophageal dysphagia and reflux symptoms before and after oral IQoro® training. World J Gastroenterol 2015; 21(24): 7558-7562.
     
  15. Hägg M, Tibbling L, Franzén T. Effect of IQoro® training in hiatal hernia patients with misdirected swallowing and esophageal retention symptoms. Acta Otolaryngol. 2015 Jul; 135 (7):635-9.
     
  16. Ekberg O, (2011), Röntgendiagnostiska avdelningen, Universitetssjukhuset MAS, Malmö, Normal sväljning inclusive anatomi och fysiologi, (pdf). Hämtad 2015-12-05,
    (English translation:” Normal swallowing including anatomy and physiology”).