**2.5 Treatment**

The first important step to take, after stabilization of the patient, is to determine if the dysphagia is a consequence of an acute attack or not (the other differentials could be pseudo relapse due to infections, progression of previously encountered mild dysphagia, medication adverse events, local pathologies of the gastrointestinal tract, or another disease like Guillain-Barre syndrome, botulism, myasthenia gravis or many other diseases). If the relapse is proven, anti-inflammatory treatments of acute relapse may be helpful to alleviate the symptom. These treatments include steroids, intravenous immunoglobulins (IVIg), and plasma exchange in refractory cases. The treatment choice would depend on the patient's condition, contraindications for receiving any of the aforementioned options, and the availability of the treatment. The next step is to decide if the disease-modifying treatment should be switched, or started in a treatment-naïve patient.

#### Medical history


#### Further evaluation:


*DYMUS: DYsphagia in MUltiple Sclerosis, EAT: Eating Assessment Tool, SWAL-QoL: Swallowing Quality of Life, FEES: fiberoptic endoscopic evaluation of swallowing, VFSS: videofluoroscopic study of swallowing.*

#### **Table 2.** *Approach to dysphagia in MS.*

*Dysphagia in Neuroinflammatory Diseases of the Central Nervous System DOI: http://dx.doi.org/10.5772/intechopen.101794*

Apart from the initial immune therapy, an integrated multidisciplinary approach is needed to see the patients' needs. Neurologists, dentists, and otolaryngologists should be informed about the subject. Speech therapists [27] and dieticians could be of great help. Lifestyle modifications (finding the best head, neck, and chest position, the most proper food consistency [28], oral hygiene) and investigation for possible guilty medication could be the first steps to take. Electrical stimulation [29, 30] and botulinum toxin injection are the two most studied treatments for dysphagia in MS [31]. Botulinum toxin is suitable when there are signs of the hyperactive sphincter (cricopharyngeal muscle) [32]. It should be performed by experienced hands to avert the possible adverse effects [31, 33]. The evidence on electrical stimulation is still not sufficient but some promising effects have been seen [30, 34, 35]. Marrosu et al. suggested that this modulation of central pattern generators of swallowing via vagus nerve stimulation could have positive effects [29].

Gastrostomy is the final solution in advanced cases. It has been shown that more than 50% of MS patients with gastrostomy lived two or more years after the procedure [36].

Transcranial direct current stimulation is another investigatory method with initial positive results [37, 38].

Cognitive rehabilitation could be a useful strategy to tackle the associated problems that may worsen the swallowing problems [39].
