Dr Girish Nair, Neurologist, Fortis Hospital

He learnt to swallow all over again

A road accident left Mahesh Khatre unable to swallow. Here's how he learnt to, all over again

Mahesh Khatre, a 53-year-old bank employee was a victim of a hit-and-run accident in June. He sustained a brain haemorrhage for which he was operated. But, Khatre lost his ability to swallow, an action that a healthy adult performs 600 times a day. His condition was called oropharyngeal dysphagia. Those struck by it are unable to chew, swallow, or transfer food to the oesophagus, the food pipe.

The deceptively simple act of swallowing is one of the most complicated tasks performed by the central nervous system. It requires precise co-ordination between the brain and 50 pairs of muscles and nerves in the neck so as to allow the food to reach the stomach, and not to, say, the lungs, every time you eat.

Here's Khatre's story about how he learnt to swallow again. It's something I didn't know, but learnt — the slightest miscoordination in the act of swallowing can turn life-threatening — you could asphyxiate on your saliva, or the fluids could go down your wind pipe. Like breathing, swallowing too, is an involuntary action and is controlled by the brain. But, in case of brain injuries or neurological conditions such as Parkinson's and Alzheimer's, the crucial nerve links between the brain and the neck are severed. Patients then have to depend on feeding tubes to stay alive.

I have had a lot of time to think about swallowing.

The accident
Early in June, a biker hit me and sped away when I was crossing a road in Mulund. I fell down and hurt the right side of my head. Although I got up immediately, I felt dizzy, and decided to check into a hospital. The doctors found that I had sustained a brain haemorrhage and operated on me immediately. I remained unconscious for two weeks, and was put on a ventilator. When I regained consciousness, my throat was dry and I realised that I was unable to swallow anything, including my saliva. You could say, I forgot how to.

I was suffering from oropharyngeal dysphagia, and my doctors said that I must learn how to swallow again.

My brain went into a hyper catabolic state because of stress. I began burning 2,000-2,400 calories every day despite doing nothing but lie on the hospital bed. Though I was fed supplements, my nutritional intake couldn't keep up. I lost 15 kilos in two months.

Any number of things could have happened — malnutrition, severe dehydration, aspiration pneumonia (inflammation of the lungs that comes from breathing unfiltered air). I needed to teach myself how to swallow, and fast. ENT surgeon Dr Sanjay Bhatia stepped in.

Smart brain, smart me
Our brain is capable of reassigning functions of damaged areas to healthy regions, if taught to do so. Dr Bhatia taught me five important swallowing strategies. Suck-swallow technique: Sucking is one of the first reflex actions humans learn, and that's how I had to start, too. I was advised to suck on a lollipop twice a day. A vertical back tongue motion pushed the saliva to the back of my mouth, and helped trigger my taste buds.

Tongue click: I would fold my tongue and produce a clicking sound. Then I'd stick it out and keep it hanging for five seconds, after which I would roll it back to touch the roof of my mouth with the tip.
Cheek exercise: I would fill my mouth with air and pass it from one cheek to the other. It strengthened the tongue and the cheek muscles and taught me to keep my lips shut. Chin tuck: I would tuck my chin to my chest to constrict the airway and elevate the larynx manually. This taught my brain to take control over the neck muscles.
Toothbrush gag: Putting a toothbrush at the back of the tongue initiates the gag reflex which pushes the larynx upwards and blocks the airway. I practised it to exercise the open and close movement of the wind pipe.

Within a month, I was able to eat semi-solid foods like mashed potatoes and yoghurt. Now, after spending 10 weeks in the hospital, I am able to eat solid food.

Munch on this
Neurologist Dr Girish Nair of Fortis Hospital says swallowing centres are located in different regions of the brain, including the medulla oblongata, the cerebral cortex (responsible for memory, language and consciousness), and the cranial nerve nuclei located in the brain stem.There are three phases of swallowing:

Oral: Food is chewed and mixed with saliva. The tongue pushes the food into the pharynx, the passage that connects the mouth to the oesophagus, or food pipe, located below the larynx (see figure 1).
Pharyngeal: As soon as the food enters the pharyngeal passage, nerves signal the brain to trigger a swallowing reflex. The neck muscles elevate the larynx and seal the windpipe. The food passes through the pharynx into the esophagus (see figure 2).
Oesophageal: Till food enters the oesophagus, breathing is suspended. Once the food is in the oesophagus, nerves signal the brain to lower the larynx and open the air passage. The food moves to the stomach and the process is repeated.