Abnormal Swallowing Part 1.

Abnormal Swallowing Part 1

Signs and Symptoms Dysphagia refers to difficulty swallowing.
Swallowing difficulty can occur from a number of causes, and is frequently associated with stroke, neurological disease, and head and neck cancer. In addition, swallowing problems sometimes occur with viral infections, bacterial and fungal infections of the upper airway, psychogenic causes, and surgeries or disease processes that do not directly involve the oral, pharyngeal, or laryngeal structures.

Adults A number of symptoms, whether in isolation or in combination, can be a sign of dysphagia in adults. Symptoms of dysphagia may be as follows: Patient has difficult initiating a swallow; Patient refuses food or avoids foods that require mastication; Food spills from the patient’s mouth during mastication; Food remains in buccal pockets Patient eats slowly (especially with solids); Patient complains that “food won’t go down” or that “food gets stuck;”

Adults Patient exhibits frequent throat clearing;
Patient coughs, gags, or chokes before, during, or after a swallow; Patient regurgitates food after meals; Patient has difficulty breathing during or immediately after meals; Patient has a hoarse voice; Patient experiences nasal or esophageal reflux; Patient has a gurgly or wet voice quality; Patient complains of heartburn; Patient has excessive secretions;

Adults Patient drools; Patient experiences excessive weight loss;
Patient’s appetite is decreased; X-ray reveals chronic lung changes; Patient has frequent or recurrent pneumonia; Patient has recurrent URIs; Infiltrates are noted on chest x-ray, indicating some fluid density has built up in the lungs (usually of the right middle or lower lung lobe); Patient has frequent or recurring low-grade fevers;

Adults Patient has foul mouth odor;
Patient has an oro- or naso-gastric tube; and Leakage of food or saliva from the tracheostomy site. Although these behaviors can be symptoms of dysphagia, they do not necessarily indicate a swallowing disturbance. Certain disease processes and neurological injuries can predispose an individual to swallowing disturbances. Individuals who exhibit confused mental state, may have difficulty with the degree of vigilance, planning, judgment, and perceptual skills required for safe eating.

Adults Individuals who exhibit characteristics of dysarthric speech production may have inherent weakness and decreased range of motion for muscles utilized in the phases of swallow. Individuals with either right- or left-hemisphere damage may experience problems with the ability to cooperate with swallowing techniques and strategies. Individuals with right hemiplegia and aphasia may become overwhelmed or confused when eating around others engaged in conversation.

Adults Individuals with right-hemisphere brain damage may have problems with the praxis of eating, and may have difficulty organizing the motor sequence to move food from plate to mouth, and with judging how much food to take in one bite and how much to chew.

Infants/Children Children’s food preferences and eating habits are highly variable over short periods of time, particularly among toddlers and pre-schoolers. Consideration must be given to whether a child’s growth and eating patterns fit within “normal” variation or suggest problematic patterns. A related consideration is recognizing feeding problems in children with chronic illnesses or developmental disabilities. Symptoms of potential feeding problems may be indicated by differences in nutritional and growth indices, developmental indices, and behavioral indices.

Infants/Children Nutritional and growth indices that are potentially indicative of feeding disorders include: Child is notably below or above normal levels on standard growth charts (i.e., weight or length/stature is below the 5th percentile, weight is above 95th percentile); Child’s rate of growth has increased or decreased dramatically without sufficient medical explanation. Child has a restricted dietary range, rejects textures, or has insufficient or excessive total food intake; Health professional has recommended that the child take high-calorie supplements (e.g., Polycose, nutritional milkshakes) for catch-up growth; and

Infants/Children Nutritional deficiency is suggested by physical signs (e.g., anemia, unusual body order). Developmental indices that are potentially indicative of feeding disorders include: Existence of oral-motor problems in sucking, swallowing, or chewing; Child’s feeding skills are below the level anticipated by developmental age (e.g., resists self-feeding or utensil use despite having sufficient motor coordination.

Infants/Children Behavioral indices that are potentially indicative of feeding disorders include: Child has bizarre food habits (e.g., pica, steals food) or maladaptive mealtime habits (e.g., eats only in front of television); Mealtimes routinely last less than 10 minutes or more than 30 minutes; Child (excluding infant) eats more than three meals and three snacks per day, or child of any age east less than three times per day;

Infants/Children Child is disruptive or has tantrums at mealtimes;
Child gags, vomits, or ruminates on food during or after meals; and Inappropriate affect is indicated around feeding (e.g., persistent lack of interest in feeding, strong fears related to food). Although these behaviors can be symptoms of feeding disturbance, they do not necessarily indicate a swallowing disturbance.

Infants/Children Medical abnormalities affecting neuromuscular functioning may interfere with eating responses. Congenital anomalies, inherited conditions, chronic illnesses, constitutional factors, and medications can also affect feeding. Previous illnesses, hospitalizations, and accidents (e.g., choking, swallowing poisonous substances) may affect feeding by providing an aversive conditioning history. Moreover, these experiences may have prevented the child from progressing through the normal feeding stages because development of proper eating was considered less important in light of the medical condition.

Infants/Children Mealtime problems have been estimated to occur in roughly 1/3 of children with developmental disabilities. A child’s feeding-related behaviors may be reflective of overall developmental delays or the problems may be specific to feeding. SLPs who treat children with feeding disorders work primarily with children who have: difficulty consuming enough nutrition to gain weight and grow; difficulty with oral motor skill acquisition; and aspiration risk and/or disorders of oropharyngeal swallowing.

Infants/Children However, based on the diverse nature of feeding problems, referrals to SLPs also may be prompted by concerns related to: Oral defensiveness; Gagging/vomiting with meals; Difficult mealtime behavior; Failure to thrive or under nutrition/inadequate intake; Food refusal; Picky eating Dependence on alternative means of nutrition; and Food “stuffing” or pocketing in the oral cavity.

Infants/Children It is important that the SLP consider swallowing physiology when determining the reason for the feeding disorder. A child who refuses to eat enough to gain weight adequately may be experiencing slow gastric motility or constipation. A child who refuses to transition to textures may be experiencing gastroesophageal reflux (GER) or other gastrointestinal impairments. Severe GER can cause eating to be painful. Early experiences with pain during oral intake can cause the child to stop eating and develop behavior problems (e.g., batting the spoon) that make it difficult, if not impossible for the parent to feed the child.

Infants/Children Limited experiences with oral intake often result in failure of the child’s oral sensorimotor response to develop normally. These children often do not demonstrate hunger and often struggle with parents for control during feeding in an attempt to demonstrate their aversion to or avoidance of sensory stimulation. It is important to remember that often the presenting signs, e.g., weak suck, gagging, oral defensiveness, are related to underlying medical, motor/sensory, and behavioral issues, but these signs are not the cause of the problem.

Aspiration Aspiration refers to nasal, oral, pharyngeal, laryngeal, or gastric contents (secretions, food, liquid) that are drawn into the trachea by inspiration. Glottal aspiration occurs when any of these contents fall below the level of the true vocal folds. Pulmonary aspiration occurs when any of these contents are drawn into the pulmonary bronchi. Most SLPs do not differentiate between glottal and pulmonary aspiration, although they should. Not all glottal aspiration becomes pulmonary aspiration.

Aspiration Penetration is defined as the entry of material into the pharynx and/or the vestibule of the larynx in the absence of the swallow. Penetration leading to aspiration may occur before the swallow response, when the airway is still open-- preprandial penetration. Preprandial penetration is the most common type in neurological disease. It is typically the result of loss of bolus control (oral containment) during the oral phase.

Aspiration Penetration leading to aspiration may occur during the swallow response—prandial penetration--if the laryngeal valves are not functioning properly. Prandial penetration is the least common type of penetration. However, it can occur in individuals with vocal palsy or paresis, or incoordination. Penetration leading to aspiration may occur after the swallow response—postprandial penetration--when the larynx lowers and opens for inhalation.

Aspiration Uncleared residue at the laryngeal inlet can be pulled into the airway. Aspiration may be prevented if the material is expectorated from the larynx/trachea back into the pharynx and swallowed. Aspiration is usually thought to be “silent” if the individual does not immediately cough or throat clear in response to the aspirate.

Aspiration Because of aging or various diseases of the CNS, a cough often does not occur when material reaches the area of the vocal cords; it occurs later. Often times there is a delay of several minutes for the aspirate to make its way into trachea or bronchi. The "delayed cough" often reported, occurs when aspirate passes through the glottis, often with no cough, and trickles down until it reaches the receptors in the lower trachea or bronchi that trigger a cough.

Aspiration While observing a meal or during a bedside examination, one has to wait, for up to a couple of minutes after the patient has finished swallowing, for a possible cough. If the cough occurs, it varies from very slight (usually in the elderly) or loud and hacking, indicating the aspirate has reached either the lower trachea or the bronchi. If you hear a cough at bedside after the patient has swallowed, and you have had to wait, it is almost certainly aspiration.

Aspiration During the 4-5 minutes it takes to complete a videofluoroscopic examination, aspiration, in the form of the “delayed cough" is frequently missed. Delayed cough may not occur on every swallow, and may therefore be intermittent so it is important to look for other signs of aspiration besides sound, e.g., cough or throat clearing. Indeed, cough is not the only, nor actually the most reliable sign of aspiration. Other signs of aspiration include gurgly/wet voice quality, and respiratory changes, including rapid respiratory rate and wheezing.

Aspiration “Silent” aspiration of saliva occurs commonly in normal adults during sleep or unconsciousness without any obvious health effects if their immune systems are operating satisfactorily (Huxley, 1976). However, constant, chronic “silent” aspiration of bacteria- laden saliva in dehydrated patients, in those with periodontal disease, and in those NPO patients receiving tube-feeding has the potential to result in pulmonary problems. Too much emphasis has been placed on the fact of aspiration and too little on its nature and content.

Aspiration Respiratory physiology of the normal lung, as well as evidence from near-drowning victims, makes it clear that the lungs have a remarkable ability to withstand several types of insult and to clear itself of invaders. When the host is malnourished, in extremely ill health, or otherwise immuno-compromised, the risk of aspiration becomes an issue. The fundamental issue with aspiration and whether it is potentially problematic is the nature and volume of the aspirate and the patient’s defense system.

Aspiration The majority of large volume and particulate aspirations are comprised of vegetable matter and can result in the inert-nontoxic syndrome. The clinical response to this form of aspiration ranges from chronic respiratory complaints, such as cough and wheezing, to atelectasis (stagnation of secretions), or if the aspiration is massive, sudden death. Acidic aspirates, such as gastric contents and foods with low pH, such as lemon and other fruit juices, can potentially injure delicate lung tissue, rendering the mucosal barrier of the lower respiratory tract incompetent.

Aspiration The resulting irritant-toxic syndrome may result in acute pneumonitis or acute respiratory distress syndrome (ARDS). In addition, particulate-matter aspiration can be contaminated by anaerobic flora of the oropharyngeal cavity. Anaerobes predominate in the oral flora of patients with periodontal disease and xerostomia. Oropharyngeal flora can achieve extremely high concentrations, especially in the presence of periodontal disease.

Aspiration While normal saliva has 108 organisms/mL, saliva from a patient with gingivitis may contain 1011 organisms/mL. Aspiration of pathogens from a previously colonized oropharynx is the primary route by which organisms gain entrance to the lungs and produce infectious aspiration syndromes. While pneumonia is part of the infectious aspiration syndrome, other infectious syndromes can result, including lung abscess.

Aspiration The microbiology of aspiration pneumonia is intimately tied to the flora of the oropharyngeal cavity. Like other respiratory tract infections, aspiration pneumonia most commonly manifests in patients with underlying disease that predisposes to host defense impairment. Conditions which compromise host immunity to aspirates include diabetes mellitus, congestive heart failure, COPD, malnutrition, renal failure, and malignancy. However, only 25% to 50% of all aspirations progress to pneumonia.

Aspiration Summary The clinical response to aspirated material is dependent on the interplay between the characteristics of the aspirate and those of the host. If the aspirate is small in volume, but highly contaminated with bacteria, then even relatively strong host defenses may be overwhelmed and pneumonia can result. If the aspirate is large in volume, but small in contagion, then pneumonia will result only if the aspirated organisms are highly virulent or the host defenses severely compromised.

Aspiration Summary Aspiration pneumonia, like other respiratory tract infections, usually occurs in patients with underlying disease. It most commonly occurs in post-stroke or post-gastrectomy patients, and in those with dysphagia, GER, xerostomia, periodontal disease, dementia, or underlying serious illness. Even patients who aspirate noninfectious material may progress to pneumonia as a result of lung injury caused by noxious aspirate material, a condition known as aspiration pneumonitis. Aspiration pneumonitis in someone with oropharyngeal dysphagia is caused by reflux, regurgitation, and/or vomition.

Aspiration Summary It goes like this:
Patient has diabetes, Parkinson’s disease, COPD, or other disease involving GER or is nauseated for other reasons. The patient may also be someone with an oropharyngeal swallowing impairment causing delay in swallow, spillage over tongue, discoordination or a combination of these and other problems. The patient may be asleep, sedated, obtunded, comatose and lying supine and otherwise unable to sit up quickly and produce an appropriate, fast swallow. The patient refluxes/regurgitates/vomits.

Aspiration Summary Emesis or vomition occurs when gastric and often small intestinal contents are propelled up to and out of the mouth. It results from a highly coordinated series of events as the follows: A deep breath is taken, then the glottis closes and the hyoid moves anteriorly to open the upper esophageal sphincter. Also, the soft palate elevates to close off the posterior nares.

Aspiration Summary The diaphragm contracts sharply downward to create negative pressure in the thorax, which facilitates opening of the esophagus and distal esophageal sphincter. Simultaneously with downward movement of the diaphragm, the muscles of the abdominal walls are vigorously contracted, squeezing the stomach and thus elevating intragastric pressure. With the pylorus closed and the esophagus relatively open, vomiting/reflux/regurgitation occur. In a patient who is not alert or able to become alert quickly and, at the same time coordinate a pharyngeal swallow quickly, aspiration is almost inevitable.

Aspiration Summary Returning yet again to the four essential factors to consider with aspiration, ask yourself: How much is aspirated? What is aspirated? Over how long a period? and How adequate is the patient's defense system? A large amount of aspirate of stomach contents is usually lethal, while chronic, smaller amounts are missed until a bacterial infection occurs several days later or chronic bronchiolitis develops.

Aspiration Summary This is the reason that (bacterial) aspiration pneumonia is over-identified in children and adults alike and pneumonitis missed. Specific issues to consider when evaluating ICU patients for aspiration risk, include patient position, site of enteral feeding, volume of gastric contents (higher volume has greater risk), and size of any feeding tube. Studies have suggested a reduced risk of aspirating gastric contents in semi-erect patients, in those whose feeding tubes are in the small bowel, and in those with small-bore feeding tubes.

Aspiration Summary Patients with prolonged hospitalization and underlying illness may become colonized by enteric gram-negative bacilli. The gram-negative pneumonias of the elderly, both in nursing homes and at home, have been well researched and identified as being related to the aspiration of saliva. The elderly in nursing home are at greater risk from aspiration of reflux and oral bacteria than from aspiration of foodstuffs. Oral hygiene and the aspiration of bacteria-filled saliva, which cannot be prevented, are the most important first level risk factors to be considered.

Aspiration Summary In addition to oral hygiene, the patient's immune response determines the risk of developing pneumonia. Therefore, oral care becomes much more important in the aspirating patient than small amounts of water to drink. Because the elderly do not complain of the usual symptoms of pneumonia, high fever, disturbing cough, and chest pain, it is often difficult to diagnose. Pneumonia is the fifth leading cause of death in the elderly (over 65) in the U.S. It is probably the most common primary cause of death in all progressive diseases.

Aspiration Summary Aspiration of certain foods presents more danger than others. One of the reasons that ice cream is favored in LTC by older residents its because it is sweet and sweet is the one taste sensation that remains at a normal threshold in the aged. The problem with ice cream, is the high fat content of the cream and aspiration of fat or oils in the lungs is very hazardous.

Aspiration in Infants/Children
In vulnerable infants and children, recurrent aspiration of even small volumes has been found to be a significant cause of morbidity, with complications including pneumonia, respiratory disease, and growth compromise or failure to thrive (Mercado-Deane et al., 2001; Newman et al., 2001;Radford, Stillwell, Blue, & Hertel,1995). Development of interstitial lung disease and fibrosis has been linked with chronic aspiration in children(Ahrens, Weimer, & Hofmann,1999).

Children and adolescents with histories of prematurity, low birth weights, and chronic lung disease (CLD) frequently exhibit recurrent respiratory problems and lung function abnormalities (Greenough, 2000). Repeated aspiration can worsen underlying lung injury, particularly in children with underlying CLD or neurogenic dysphagia (e.g., cerebral palsy). In older children and adults with neurogenic dysphagia, respiratory distress and hypoxemia during mealtimes have been associated with aspiration events (Rogers, Arvedson, Buck, Smart, & Msall, 1994; St Cyr, Ferrara, Thompson, Johnson, & Foker, 1989).

Unfortunately, there is no tool or procedure for predicting how well an individual is able to tolerate aspiration. We have no answer to the question, "How much aspiration is too much?" before a child develops respiratory consequences. Many factors can shift an individual's threshold of aspiration tolerance. Influences include, but are not limited to: the underlying diagnosis and prognosis; overall medical, health, and nutritional status; and the extent of the dysphagia.

Ultimately, the impact of the dysfunction is determined by the balance between severity of the swallowing impairment and the child's compensatory mechanisms (Loughlin & Lefton-Greif, 1994). The variability in clinical presentations associated with swallowing dysfunction and recurrent aspiration complicate evaluation and management efforts. Some children may present with chronic symptoms, such as pneumonia or persistent coughing. Others demonstrate episodic difficulties, such as coughing or increased congestion while feeding.

Responses to aspiration may differ according to age or the degree of maturity. Whereas younger infants may present with apnea or bradycardia, older children may cough or choke (Heuschkel et al., 2003; Thach, 2001). Another factor complicating the clinical identification of aspiration is that children may demonstrate similar respiratory presentations (e.g., wheezing or apnea), regardless of whether the response is triggered reflexively by vagally mediated receptors in the nasopharynx or larynx, or by direct aspiration.

It is well known that children with histories of younger gestational ages and low birth weights, neurogenic conditions, and congenital malformations of the upper aerodigestive tract are at increased risk for dysphagia. In fact, approximately 50% of children under one year of age who are diagnosed with swallowing dysfunction carry diagnoses of neurologic impairment or congenital syndromes (Newman et al., 2001). However, clinicians need to be aware that other groups of children may also be at risk for chronic or transient dysphagia with concomitant aspiration.

Recent studies have identified children with isolated neonatal dysphagia (Heuschkel et al., 2003; Sheikh et al., 2001). It has also been shown that previously asymptomatic infants may develop symptomatic swallowing dysfunction and aspiration following a viral infection (e.g., respiratory synctial virus [RSV]; Hernandez, Khoshoo, Thoppil, Edell, & Ross, 2002; Khoshoo, Ross, Kelly, Edell, & Brown, 2001; Khoshoo & Edell,1999).

Children with CLD, particularly those requiring supplemental oxygen therapy, are at greatest risk for severe responses to RSV. Therefore, it is reasonable to suspect that this group of children is at substantial risk for swallowing related difficulties following infection.

Cough and Airway Clearance
The cough is the primary lower airway protective response after aspiration. It is triggered by irritation of the trigeminal nerve endings of the upper respiratory passages, including the lower trachea and bronchi. Cough can also be triggered by pressure on the trachea or on the laryngeal nerves, irritation of the external auditory canal, tracheal obstruction, irritation of the gastric mucous membrane, and diseased or malformed teeth.

Because of ageing or various diseases of the CNS, a cough often does not appear when material reaches the area of the vocal cords, it occurs later. The so-called "delayed cough" occurs when aspirate passes through the glottis and trickles down until it reaches the receptors in the lower trachea or bronchi. Silent aspiration is generally defined as the absence of a cough response following an aspiration event. In infants and children, silent aspiration may predispose infants and children to lung injury.

Silent aspiration is common in children with dysphagia with estimates ranging from 70-97% depending upon age and the underlying etiology of the dysphagia (Arvedson, Rogers, Buck, Smart, & Marshall, 1994; Lefton-Greif et al., 2000; Newman et al., 2001; Sheikh et al.,2001). Although the reasons for the high incidence of silent aspiration in young children are unknown, one hypothesis is that silent aspiration may result from a blunting of airway defense mechanisms (e.g., cough; Loughlin & Lefton- Greif,1994).

A possible explanation for this blunting may be related to the maturation and transformation of laryngeal chemoreflex responses (LCRs). LCRs are comprised of several airway protective reflexes: rapid swallowing, laryngeal constriction, and apnea. These LCRs are though to emerge during fetal development as a protective mechanism against potential aspiration of amniotic fluid (Thach, 2001). Others, such as coughing, may become more important during post natal life.

The hypothesis of LCR maturation may be consistent with observations of prolonged apnea, bradycardia, and rapid swallowing in preterm infants who have trouble coordinating breathing and swallowing. Unlike normal adults who cough after aspirating, silent aspiration is particularly problematic in children under two years of age because the protective cough mechanism is absent during the period of greatest lung growth (Thurlbeck, 1982). Furthermore, caregivers and clinicians may underestimate the presence of swallowing dysfunction in this population because silent aspiration, by definition, does not provide overt evidence of airway contamination.

GER and LPR Many adults and children with swallowing disorders will also have other upper airway disorders that are often exacerbated or caused by gastroesophageal reflux (GER) into the upper airway. Extraesophagel reflux (EER) or laryngopharyngeal reflux (LPR) has been implicated in such disorders as asthma, chronic cough, and hoarseness in adults. Along with "asthma," another red flag for GER is chronic sinusitis in children and adults.

GER and LPR In children, it has been additionally implicated in apnea, recurrent croup, subglottic stenosis and chronic upper airway infections. However, unlike GER, the symptoms of LPR are often silent or non-episodic, as in the case of hoarseness in adults and chronic upper airway infections in children, causing it to be underdiagnosed. Individuals with GER are frequently prescribed proton pump inhibitors (PPIs) such as Prilosec, Prevacid, Aciphex, and Protonix.

GER and LPR PPIs don't stop reflux, they just stop the production of gastric acid although about 30% of people get breakthrough acid during sleep, the very worst time. Indeed, McGlashan, Johnstone, Sykes, Strugala, and Dettmar (2009) investigated whether any improvement in LPR-related symptoms, using the Reflux Symptom Index (RSI), and clinical findings, using the Reflux Finding Score (RFS), could be achieved with treatment with a liquid alginate suspension (Gaviscon) compared to control (no treatment).

GER and LPR Twenty-four patients were randomized to receive 10 ml liquid alginate suspension (Gaviscon(R) Advance) four times daily after meals and at bedtime, and another 25 patients were randomized into the control group (no treatment). Patients were assessed pretreatment and at two, four, and six months post treatment. Significant differences between treatment and control were observed for RSI at the two-month and six-month assessments and for RFS at the six-month assessment.

GER and LPR The researchers concluded that significant improvement in symptom scores and clinical findings were achieved with liquid alginate suspension (Gaviscon(R) Advance) compared to control and further evaluation for the management of patients presenting with LPR is warranted. Another case of the problems with PPIs and pneumonitis was personally reported on the dysphagia listserv by Suzanne Morris (2/21/09). She states that like many people she started on Prevacid for reflux that had been escalating with non-PPI drugs for years.

GER and LPR At first, she thought the most wonderful medication in the world because for the first time things didn't hurt and she could sleep well at night. However over a 2.5 year period, both the frequency and the amount of the medication were gradually increased. In spite of the changes, she ended up with several bouts of pneumonitis and finally a whole series of what she thought was the "stomach flu".

GER and LPR The flu symptoms, which were intense and usually lasted for several days, were puzzling because she had never had any tendency toward this type of influenza and was experiencing it at least once a month. Although totally familiar with all of the literature on GERD because of her work with kids with feeding and GI issues, she didn’t relate much of it to her personal situation. One day she started questioning whether the flu/gastritis and the pneumonitis could actually be directly related to the high levels of PPIs and low levels of stomach acid.

GER and LPR She hypothesized that the lack of gastric acid over nearly three years had strongly interfered with her body's first line of defense for food-borne bacteria since there was little or no acid in the stomach to kill these bugs. Additionally, the lack of acid reduces the body's ability to absorb Vitamin B-12, zinc, calcium, etc., which could result in at least subclinical malnutrition and reduce the power of her immune system.

GER and LPR In consultation with Irene Campbell-Taylor, she began to wean herself from the Prevacid (PPI) and take Gaviscon after each meal and before bed. She has been off of all pharmaceutical reflux medications for more than 5 years. She takes Gaviscon after meals (as needed). The episodes of painful heartburn are almost nonexistent and the flu-like episodes have stopped.

GER and LPR When she intermittently experiences reflux that is identified by an accumulation of mucous and throat clearing and emerging esophagitis, she takes a 2-week course of Prilosec (PPI) to temporarily reduce the amount of acid in order to enable the tissues to heal more rapidly. This short term course doesn't bother her in other ways and that is actually how the PPIs were designed to be used (short term rather than long-term acid suppression).

Abnormal Swallowing Part 1.

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