Ms Michelle Kwan, senior speech therapist at Alexandra Hospital, feeding a patient during a swallow assessment.PHOTO: ALEXANDRA HOSPITAL

SINGAPORE – For most people, eating and drinking are basic actions they do not think twice about. But for some, every bite or sip can come with discomfort, fear and even danger.

Swallowing disorders such as dysphagia and achalasia can affect people of all ages. They not only make eating difficult, but can also take a toll on a person’s mental health, social life and overall quality of life.

This was the reality for 24-year-old Muhammad Rahimi Hamdan, a student at ITE College West and part-time delivery rider, after a traffic accident in December 2024.

Thrown off his motorbike, Mr Rahimi suffered a traumatic injury that affected the left side of his brain, impacting movement on the right side of his body.

He also developed dysphagia, or difficulty in swallowing.

Ms Michelle Kwan, senior speech therapist at Alexandra Hospital (AH), says traumatic brain injury can cause dysphagia, when areas of the brain that control the swallowing muscles are damaged.

This affects the coordination and strength needed to chew and transfer food from the mouth to the stomach safely.

Mr Rahimi had to use a nasogastric tube, which is inserted through the nose and into the stomach to provide nutrition and medication.

He was warded at National University Hospital for a month before moving to AH in January for rehabilitation. He was eventually discharged in March.

Homemaker Zarina Hassan, 59, says whenever she spoke to her son, he would look at her blankly and not be able to answer.

“I asked the doctor how long it would take to see improvement, and was told ‘Maybe one year, two years or more,’” says Madam Zarina, who is married and has two other children aged 35 and 34.

“When I saw my son on the bed, not being able to talk, think and being only 24, I had to pull myself together to think that the only thing that can help him is therapy,” she adds.

With the help of the speech therapist, Mr Rahimi is now able to consume food and drink orally.

In his case, Ms Kwan explains that thickening liquids helps him swallow more safely.

“Thickened liquids flow more slowly, thus allowing him to have better control over it and reducing the risk of aspiration (when food or drink accidentally enters the airway),” she says.

Ms Michelle Kwan, senior speech therapist at Alexandra Hospital, preparing thickened fluids for a swallow assessment with a patient.PHOTO: ALEXANDRA HOSPITAL

Mr Rahimi’s appetite returned in April, and he asked for some of his favourite foods, such as roti prata and pasta. But progress had to be gradual.

After thickened fluids, he was introduced slowly to food such as mashed digestive biscuits with Milo, mashed potato, porridge and fish soup. He eventually regained his swallowing function with close support and supervision from Madam Zarina.

She was advised to stop if Mr Rahimi, who has not regained his full mobility and uses a wheelchair to get around, coughed and/or developed a fever.

“Thankfully, he was fine and now eats just about everything without the need for soft or minced foods,” she says.

What causes swallowing difficulties?

Apart from traumatic brain injuries, dysphagia can be caused by neurological conditions such as Parkinson’s disease, dementia or stroke.

According to AH, about 15 per cent of seniors in Singapore suffer from dysphagia.

It can also arise after head and neck cancers, spinal cord injuries or in people with chronic respiratory conditions such as chronic obstructive pulmonary disorder.

Depending on the underlying condition, Ms Deborah Yew, speech therapist at Singapore General Hospital’s (SGH) department of speech therapy, says dysphagia can occur at various areas – within the mouth, throat or the oesophagus.

People with dysphagia may have swallowing difficulties across one or multiple areas, and symptoms vary depending on which part is affected.

For instance, symptoms of swallowing difficulties in the mouth include food or drink spilling while eating or drinking, food pooling in the mouth or cheeks and difficulty with chewing and drooling.

Symptoms of swallowing difficulties within the throat include difficulty initiating the swallow reflex, coughing or choking during or after swallowing, a sensation of food getting stuck in the throat and nasal regurgitation of food or drink.

Symptoms of swallowing difficulties within the oesophagus include a sensation of food sticking in the chest area, chest pain or pressure while swallowing, heartburn and food coming back up several minutes after eating.

At AH, about 22 to 30 per cent of inpatients are referred to a speech therapist. Of these referrals, more than 90 per cent are for patients with dysphagia, says Ms Jaymie Chai, principal speech therapist at AH.

At SGH, Associate Professor Andrew Ong, senior consultant at the hospital’s department of gastroenterology and hepatology, says dysphagia is a relatively common condition seen in general gastroenterology clinics at the hospital.

Dysphagia relatively common, achalasia is rare

Achalasia, meanwhile, is a rare swallowing disorder that affects the oesophagus.

In people with achalasia, the nerves in the oesophagus degenerate. As a result, the muscles do not contract properly and move food down towards the stomach.

To swallow well, Prof Ong says the oesophagus needs to be able to do two things: push food down by contracting and relaxing the muscles in a coordinated pattern, and relax at the junction of the oesophagus and the stomach, so that food can enter the stomach.

“When these functions are disrupted, a person will struggle to swallow,” he says.

The exact cause of achalasia remains unknown, says Prof Ong, but it is likely that some patients have a genetic predisposition to the condition. It may also be triggered by viral infections and/or autoimmune diseases.

The hold-up of food in the oesophagus causes chemical irritation in the surrounding area, and the patient may have symptoms of gastro-oesophageal reflux disease such as heartburn, regurgitation or chest pain.

The symptoms can also be extremely uncomfortable, especially the chest pain during meals, which can sometimes be mistaken for heart attacks, highlights Prof Ong.

At SGH, approximately two to three cases of achalasia are diagnosed each month, amounting to about 30 cases a year.

Ms Chai says achalasia is rarely seen in patients at AH, although no statistics are available.

Conditions take a toll on mental and emotional health

Although the causes differ, dysphagia and achalasia make the simple act of eating and drinking a daily challenge.

“Patients often lose weight and are miserable, as they are not able to digest the food nor absorb the nutrients. They will be at risk of losing muscle mass and dehydration due to the lack of nutrition and fluids,” says Prof Ong.

Traditionally, he says, patients with achalasia were offered either surgery to cut the muscle at the junction between the oesophagus and stomach, or a balloon procedure performed endoscopically to stretch this area.

In recent years, some endoscopists have been able to cut the muscle using an endoscope, eliminating the need for surgery.

“The procedure, known as peroral endoscopic myotomy, has become a popular option among patients and has shown very good results,” says Prof Ong.

For patients who are not fit for surgery, another option is to inject botox into the muscles of the lower oesophagus, although the effect tends to wear off over time, he adds.

Treatment for dysphagia varies, depending on its cause and severity.

Speech therapy intervention for dysphagia can range from the use of compensatory strategies such as diet and liquid consistency modifications or prescribing swallowing rehabilitation, which may involve performing specific exercises to strengthen and coordinate swallowing muscles.

For instance, many people with the condition may need diet and fluid modifications, assistance with feeding or reliance on a feeding tube like in Mr Rahimi’s case, says Ms Kwan.

“This might result in them losing their enjoyment of food and drinks, feeling embarrassed or having to isolate themselves in social situations, and developing anxiety or depression from a fear of choking or a loss of independence,” she says.

Speech therapists, she adds, play a key role in assessing and managing dysphagia.

They begin with a thorough evaluation to identify specific swallowing difficulties, and then tailor the treatment based on the findings.

Management strategies for dysphagia may include slowing the feeding pace; using a smaller spoon for feeding; modifying food texture through cutting, mincing and blending; thickening liquids; and adjusting posture – like tucking in the chin while swallowing – to reduce the risk of choking.

Rehabilitation also often involves targeted swallowing exercises to help strengthen the muscles involved, gradually improving the patient’s ability to eat and drink safely.

Helping people with dysphagia enjoy local food

In 2021, Alexandra Hospital launched an initiative called Smaller Bites To Swallow Right to help individuals with dysphagia enjoy hawker fare.

Its speech therapists train hawkers to prepare their food using techniques such as chopping, cutting, mincing and blending, so older customers can enjoy the food safely.

So far, about 30 hawkers from Alexandra Village Food Centre and ABC Brickworks Food Centre in Jalan Bukit Merah have been trained.

Separately, social enterprise GentleFoods has been offering texture-modified meals tailored for people with dysphagia since 2020. The meals have various consistency levels based on the framework set out by the International Dysphagia Diet Standardisation Initiative. These include food that is pureed, minced, soft and bite-size or liquid.

Pureed ang ku kueh, chee cheong fun and chicken rice from GentleFoods.PHOTOS: GENTLEFOODS

Dr Shen Yiru, founder of GentleFoods, says about 70 per cent of its customers are seniors, while the remaining are adults starting from their late 20s.

The majority of senior customers have dysphagia due to conditions such as dementia, stroke, cancer and Parkinson’s disease.

Among the younger customers, dysphagia is typically caused by stroke or cancer. There are also younger individuals who choose GentleFoods’ meals temporarily after wisdom tooth surgery or while wearing braces, says Dr Shen.

Some of the brand’s top-selling items include local fare such as chicken rice and ang ku kueh.

“I’ve received encouraging feedback from caregivers who say that mealtimes for their loved ones are easier and more enjoyable,” says Dr Shen.