Oropharyngeal dysphagia in the acute post-stroke phase – is there a role for risk factors?

Abstract

Introduction: Stroke is one of the main causes of morbimortality in developed countries. Oropharyngeal dysphagia (OPD) is the second most frequent complication in the acute post-stroke phase and it is an independent predictor of unfavorable outcome and institutionalization, being associated with longer hospital stays and a huge economic impact. There is a documented association between the presence of certain sociodemographic and clinical characteristics and the incidence of post-stroke OPD, namely: advanced age, presence of cognitive impairment, higher degree of dependence, National Institute of Health Stroke Scale (NIHSS) at admission greater than four and brainstem involvement.

Objectives: This study aimed to characterize, from a sociodemographic and clinical point of view, patients in the acute post-stroke phase in a tertiary hospital who underwent functional endoscopic evaluation of swallowing (FEES) due to suspected dysphagia and to correlate the results obtained in FEES suggestive of OPD with each of the variables.

Methods: A retrospective analysis of 68 patients who underwent FEES in the acute post-stroke phase at our hospital from 2018 to 2023 was conducted, with description of their sociodemographic profile, event characteristics and FEES findings.

Results: Regarding sociodemographic characteristics: 73.53% were at least 70 years old, 60.29% were male, 36.76% had some degree of dependence and 13.24% had dementia. When it comes to stroke’s features: 83.83% were of ischemic etiology, 80.88% had involvement of the cerebral hemispheres, 16.18% of the brainstem and 7.35% of the cerebellum, and 85.29% had an NIHSS at admission greater than 4. Concerning FEES’ findings: 42.65% of patients showed significant salivary stasis, 60.29% had delayed swallowing reflex, 48.53% had residue after swallowing, 10% had vocal chords paralysis and 57.59% had penetration or aspiration, of which 12% were silent aspirations. After a comparative analysis of all sociodemographic and clinical variables with the presence of OPD, a statistically significant relationship was only obtained for the presence of NIHSS at admission greater than 4 (p=0.015).

Discussion: Although the presence of some of these risk factors may signal an increased risk of OPD in patients in the acute post-stroke phase, it does not replace an instrumental assessment of swallowing. Moreover, FEES has the ability to identify salivary stasis or a delay in the swallowing reflex and to detect silent aspirations. Aspiration pneumonia is the most common complication of OPD in the acute post-stroke phase and is the leading cause of hospital admission and death, with silent aspirations being the main risk factor.

Conclusion: Although the clinical assessment of swallowing plays an important role in the evaluation of oropharyngeal competence, it lacks sensitivity in screening OPD in the acute post-stroke phase, not only in cases of altered state of consciousness, but also in the presence of silent aspirations. In these situations, FEES is a more reliable tool to assess airway protection, with the otolaryngologists playing a primary role in post-stroke patients’ evaluation.