527 Dysphagia

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What are the 8 points on the on the PAS (Penetration-Aspiration Scale)?: 1. Material does not enter the airway.
2. Material enters the airway, remains above the VFs, and is ejected from the airway.
3. Material enters the airway, remains above the VFs, and is not ejected from the airway.
4. Material enters the airway, contacts the VFs, and is ejected from the airway.
5. Material enters the airway, contacts the VFs, and is not ejected from the airway.
6. Material enters the airway, passes below the VFs, and is ejected into the larynx or out of the airway.
7. Material enters the airway, passes below the VFs, and is not ejected from the trachea despite effort.
8. Material enters the airway, passes below the VFs, and no effort is made to eject.
Define dysphagia: a delay, or misdirection of, a fluid or solid bolus of food as it moves from he mouth to the stomach
What's the difference between a feeding disorder and dysphagia?: A feeding disorder is an impairment in the process of food transport outside of the alimentary system. In other words, a motor transfer problem; usually the result of weakness or incoordination in the arm used to bring the food from the plate to the mouth
What are some signs and symptoms of dysphagia?: drooling, change in voice quality, poor oral hygiene, weight loss, dehydration, absent/weak voluntary cough, frequent throat clearing, changes in eating patterns, frequent chest infections
What are some signs and symptoms when eating?: Slow to initiate the swallow
Uncoordinated chewing or swallowing
Multiple swallows
Pocketing
Oral or nasal regurgitation
Increased time to eat
Coughing or sneezing
Increased respiratory rate
Wet voice
What are some signs and symptoms after eating?: Wet voice, fatigue, change in respiration, change in chest status
What is the prevalence of feeding problems in the pediatric population?: 25-45% in typically developing children
33-80% in kids with developmental delays
What is the incidence of dysphagia?: Unknown
Estimated prevalence of dysphagia in children with dev. delays ranges from...: 12-71%
In CP, prevalence rates range from...: 57-92%
What % of patients with an acute stroke have dysphagia?: 50%
What % of PD patients have dysphagia?: 50-90
What % of head and neck cancer patients have dysphagia?: Depends on the treatment 45-70%
1 in ? people will experience dysphagia in their lifetime: 17
What % of ppl with psych disorders have dysphagia?: 32%
What % of nursing home residents have dysphagia?: 75%
What are the stages of the swallow?: Pre-oral, oral preperatory, oral, pharyngeal, esophageal
What are the sites of pressure generation?: lips, tongue, cheeks, soft palate, pharyngeal walls, larynx
Where does the site of pressure decrease?: Upper esophageal sphincter
What is involved in the oral preparatory stage?: Muscles of mastication: temporalis, masseter, buccinator, and pterygoid (V).

Saliva: parotids, submandibular, and sublingual (motor autonomic fibres (VII and IX)

Oral cavity: rich in mechanical (touch, pressure) receptors (V, XII)

Lips (VII)
What do the cheeks, lips, tongue and palate do during the oral stage?: Muscles of the cheeks and lips contract...tongue contracts against hard palate...soft palate elevates superiorly and posteriorly against the nasopharynx.
When swallowing, what parts of tongue are used in the oral stage? For the tongue, do we need access to sensory, motor, or both? Do we use the extrinsic or intrinsic muscles of the tongue?: -anterior 2/3 tongue
-both
-both
What does the posterior 1/3 of the tongue (tongue base) do? What happens if u don't have a functioning tongue base?: -Important in the force generation that propels a food bolus toward the pharynx.

-the tongue and soft palate cannot make contact...so nasopharynx cannot be sealed from the oral cavity, so insufficient pressure is generated --> decreased bolus propulsion
What are the events of the pharyngeal stage?: Velum elevates
Hyoid moves superiorly and anteriorly
Larynx closes
Larynx moves superiorly and anteriorly
Pharyngeal constrictors contract
Upper esophageal sphincter opens
What does the trigemincal nerve (V) do in swallowing?: -contains both sensory and motor fibers that innervate the face
-important in chewing
What does the facial nerve do in swallowing?: -contains both sensory and motor fibers
-important for sensation of oropharynx and taste to anterior 2/3 of tongue
-buccinator, holds food in contact with the cheeks
-stylohyoid m. elevates the hyoid and BOT
What does the glossopharyngeal nerve (IX) do in swallowing?: -contains both sensory and motor fibers
-important for taste to posterior tongue, sensory and motor functions of the pharynx
-stylppharyngeous elevates and dilates the pharynx
What does the vagus nerve do in swallowing?: -contains both sensory and motor fibers
-important for taste to oropharynx, and sensation and motor function to larynx and laryngopharynx
-important for airway protection
What does the hypoglossal nerve do in swallowing (XII): Contains motor fibers that primarily innevate the tongue
What is the role of the cortex in swallowing? Swallowing has ____________ but __________ representation.: sensorimotor cortex
supplementary cortex

bilateral but asymmetric
Describe the esophagus?: -closed muscular tube
-18-22 cm in length
-runs ventral to the lungs & around the aorta
-upper 1/3 is composed of striated muscle
-lower 2/3 is composed of smooth muscle
-UES & LES
What's the difference between the suckle pattern and the suck pattern?: Sickle = back and forth tongue and more jaw vertical action
Suck = up and down tongue with less vertical jaw action
What is going on in the mouth of an infant (< 4 mo): Strong oral reflexes
â€¢ Stability provided positionally
â€¢ Structures close together (larynx higher
under tongue base)
â€¢ Tongue fills approximately whole oral
cavity â€“ touches cheeks, palate and velum
â€¢ Fat pads (sucking pads) in cheeks help
support oral and pharyngeal function
What changes physically as children develop?: ⬢ Stability based on posture, connective tissue, and more highly specialised muscle control.
⬢ Tongue drops down and moves posteriorly
⬢ Increase in space allows for chewing movements and increased tongue movements
Tongue tip behind alveolar ridge
⬢ Fat pads decrease, increasing movement of lips and cheeks.
⬢ Mandibular stability increases muscle
control.
What's happening in infants about 6 months old?: â€¢ â€œMunchesâ€, jaw moves up and down.
â€¢ Biting lacks rotary chewing
â€¢ Tongue lateralization begins at 6 â€“ 7
months, with tongue moving food from
side to side
â€¢ True suck, stable jaw.
What's happening with infants about 8 years old?: ⬢ Transfers food well from centre of mouth
to sides
⬢ Rotary chewing begins, though some
vertical motion remains (continues to
improve until age three).
⬢ Tongue elevation with stable jaw, can
channel liquids.
What's happening with infants about 12 years old?: â€¢ Controlled bite through food.
â€¢ Chews adequately.
â€¢ Plays with tongue â€“ sticks out
experimentally.
By 15 â€“ 18 months:
â€¢ Stabilizes muscles around jaw, drinks well
from cup.
â€¢ Licks lower lip.
Presbydysphagia?: Presbydysphagia: refers to age-related changes in the oropharyngeal and esophageal swallowing of healthy adults
Sarcopenia: (from the Greek meaning "poverty of flesh") is the degenerative loss of skeletal muscle mass and strength in senescence. About a third of muscle mass is lost in old age.
Describe sarcopenia in detail.: reduced muscle mass and fiber diameter.
preventable and reversible muscle weakness that
accompanies aging and is a result of decreased physical activity
Up to 50% of muscle mass is lost
Decreases in strength and exercise tolerance
Decline in self performance of ADLs
Risk factors for falls
Sarcopenia has been demonstrated for the pharynx, larynx, and tongue
Aging does not create dysphagia but may contribute to it due to:: -Central and peripheral nervous system changes
-Physiologic changes (muscle mass and speed) -The elderly are more decompensated by disease
What percent of ppl over 60 have dysphagia? What are the consequences?: 40% of individuals over the age of 60 have dysphagia**
Consequences: physical discomfort; social embarrassment; life-threatening conditions
Common Age-Related DiseasesAssociated with Dysphagia: Alzheimerâ€™s
Dementia syndromes
Stroke
Head injury
Parkinsonâ€™s
Iatrogenic conditions:
drug-induced delirium,
long hospital stays,
malnutrition
How is the oral phase affected by aging?: Increased chewing
Longer oral phase
Reduced sense of smell and taste
Xerostomia
Decreased muscle strength of tongue
(tongue isometrics!!)
How does aging affect the pharyngeal stage?: Later trigger of the swallow
Decreased airway closure
Reduced range of opening of the UES
How does aging affect the esophageal stage?: Slower and less efficient esophageal clearance
Presbyesophagus
Barrettâ€™s esophagus
What are some age-related conditions?: Dentition
Xerostomia
Arthritis
Osteoporosis
Sarcopenia
Sensation (taste, temperature,tactile)
What should we look for in the mouth?: Lesions
Infections/inflammation
Moisture
Dentition
Tongue appearance
Mouth corners
Other
What are the most important nerves in swallowing?: 7, 5, 12, 10
Even though those are the most important cranial nerves, observe...: Ptosis (III)
Facial asymmetry/droop (VII)
Articulation (V, VII, X, XII)
Abnormal Eye Position (III, IV, VI)
Abnormal/asymmetrical pupils (II, III)
How can CN I be affected and how do you test it?: I Olfaction
- sensory
- perception of flavour/taste involves olfaction
- can be affected by: smoking; medication; aging; tracheostomy
- Parkinsonâ€™s disease; dementia; brain tumor
How to test: alcohol pad, instant coffee pkg; banana; cinnamon
If patient is non-verbal, note any behavioural response
How to observe CN II, III, IV, VI...: Look at the patientâ€™s eyes! Pupils/Ptosis
Do they wear glasses?
Do they neglect one side?
Screen visual fields

Test pupils to light (*pupil size and symmetry are important in patients with neuro disorders i.e head trauma, hemorrhage)
Test eye movement
- H-pattern
- nystagmus
- convergence
Rationale: eye movements are easy to test; abnormalities can signal significant neuro disease (brainstem lesions; degenerative disorders)
How to test CN V: Observe the jaw at rest
Ask your patient to open their mouth and then clench their teeth
Palpate the temporal/ masseter muscles while they do this and while making chewing movements
Test jaw strength against resistance
Test sensation (forehead, cheeks and jaw)-mostly interested in V3

Two parts:
Sensory to face
Motor to muscles of mastication
Assess sensation to face
Determine if patient can open mouth.
â€œClench your teethâ€ - feel for muscle bulk at Masseters
How to test CN VII: Observe for any asymmetry, lag, weakness, tremors
How to: raise your eyebrows
close both eyes to resistance
smile
frown
show teeth
puff cheeks
***test the corneal reflex
When and how to test VIII?: Test if pt. has difficulty with conversational speech; test routinely in children
How to: Face pt and hold out arms with your fingers near each ear;
Rub your fingers together on one side while moving your fingers noiselessly on the other
Increase intensity as needed; note any asymmetry
If abnormal, perform hearing screening; refer to audi
How to assess IX and X?: Listen to the patientâ€™s voiceâ€”is it hoarse/nasal?
Ask the patient to swallow
Ask the patient to say Ah
Watch the movements of the palate and pharynx
Test the Gag***
cough

Open your mouth.
Say â€œahâ€
Look at palatal movement. Deviates AWAY from affected side.
Assess gag reflex - not routinely done
How to assess XI?: XI Accessory
From behind, look for atrophy or asymmetry of the trapezius
Ask the patient to shrug against resistance
Ask the patient to turn their head against resistance (sternomastoid)
Listen to the articulation of the patientâ€™s words
How to assess XII: XII Hypoglossal

Listen to your patientâ€™s articulation
Observe the tongue as it lies in the mouth (against resistance)
Protrude the tongue (against resistance)
Lateralize tongue (against resistance)â€”intra and extra-orally
Sensation
Testing the â€œNonâ€-Cooperative Client?: Observe behavioural reactions
Motor function: observe spontaneous movements (swallow, lick lips); is the face symmetrical? Is the face expressionless?; does head position change during the swallow?; drooling?; voice quality before and after eating/drinking; articulation; coughing?; is there residue in the mouth after swallowing
Sensory function: How does the client/patient react to temperature, touch, texture, placement of food

Palpate the neck during the swallow
Neurogenic Disorders of Swallowing?: Stroke
UMN (cortex, internal capsule, tracts)
reduced alertness
spastic dysarthria
weakness, reduced coordination
poor oral control
reduced gag reflex
delayed swallow reflex
reduced pharyngeal peristalsis
what probs can tbi have: cognitive problems including attentional deficits, impulsivity, poor reasoning
reduced oral control
delayed or absent swallow reflex
reduced pharyngeal peristalsis
reduced laryngeal sensitivity to penetration
tracheo-esophageal fistula secondary to long-term intubation
what probs can als have?: difficulty with lingual control and oral manipulation of the bolus
nasal regurgitation
delayed initiation of the swallow
reduced pharyngeal peristalsis
reduced laryngeal elevation
UES dysfunction
esophageal reflux
esophageal dysmotility
progressive respiratory insufficiency and weakness of abdominal muscles
what probs can pd have?: tongue tremor with reduced initiation of lingual movement
repetitive tongue-pumping action
lingual festination (posterior part of the tongue remains elevated, preventing passage of bolus into the pharynx)
reduced swallowing frequency
delayed pharyngeal swallow
reduced pharyngeal peristalsis
inadequate laryngeal elevation and/or closure
reduced laryngeal sensitivity to penetration
repetitive, involuntary reflux from the valleculae and pyriform sinuses into the oral cavity
UES dysfunction
reduced esophageal peristalsis
dementia
what probs can huntington's have?: neck and trunk hyperextension
involuntary movement of the body, head, and oral motor structures that interfere with oral phase
absent or inefficient mastication
irregular breathing patterns that interrupt the normal reciprocal respiration-deglutition cycle
pharyngeal dysmotility
uncoordinated and asynchronous vocal cord adduction/abduction
what probs can dementia have?: Diseases with associated dementia
Parkinsons
MS
Huntingtons
Pick's disease
Cruetzfeldt-Jakob disease
may reduce ability to use compensatory techniques
reduced initiation of oral preparatory lingual and mandibular movements
protracted and non-purposeful bolus processing
loss of bolus control
prolonged oral transit
delayed pharyngeal swallow
may need assistance with feeding
what probs can hiv/aids have: most problems cause by infections to CNS or local infections of mouth, pharynx, larynx, esophagus, and lungs
odynophagia
dementia
what pediatric medical conditions are related to dysphagia: Prematurity
Cerebral palsy
Intellectual disabilities
Congenital structural lesions (cleft lip/palate;caniofacial syndomes)
GERD
what age related medical conditions are related to dysphagia: Poor nutrition in institutionalized long-term care is a significant cause of death, increased health costs and poor QOL
Multifactorial:
multiple medication use
GI dysfunction
poor oral health and oral care
sensory changes

Lack of education and training by caregivers
what you know about pneumonia?: Dysphagia is a risk factor for pneumonia-directly/indirectly
Of those who aspirate during an instrumental study, only 9-13% develop pneumonia
Dysphagia and aspiration are necessary but not sufficient conditions for pneumonia. Malnutrition and dehydration; oral care and dependence for feeding are other risk factors for pneumonia
what does malnutrition/dehydration have to do with dysphagia?: Study: nutritional study of pts with stroke admitted to rehab.
49% were malnourished; 65% with dysphagia were malnourished
Study: no difference in nutrition of pts with stroke with or without dysphagia on admission BUT after one week 48.3% of pts with dysphagia were malnourished but only 13.6% of those without dysphagia were malnourished

These conditions can lead to pneumonia-indirectly/directly:
thrush, decreased salivary flow, mental confusion, decreased immune system, decreased strength, decreased cough
copd: Alterations in laryngeal dynamics with subsequent decreased UES opening. It appears that the resting position of the larynx is lower than in â€œnormalsâ€. There is both prolonged laryngeal ascent and descent with more penetration of fluids during this prolonged ascent.
In severe cases, patients may not have a sufficient deglutition apneic phase as they are SOB.
Almost always have GERD

Suggestions: modify diet; breath hold technique
what is Candidiasis. treatment?: Thrush

Fungal infection
Odynophagia

Often the S-LP is the first to pick this up. Course of treatment with Nystatin, yogurt
probs from oral cancer?: May see difficulty with maintaining an oral seal; mastication; formation of the bolus; transport of the bolus; decreased sensation
probs from oropharyngeal lesions?: May see: nasal regurgitation; reduced bolus transit; aspiration; UES dysfunction
probs from partial laryngectomy?: Reduced laryngeal adduction; reduced laryngeal elevation
probs from laryngectomy?: Low risk for aspiration
structural deviations causing pockets
probs from radiation?: Oral, pharyngeal and esophageal inflammation
Diminished volume and/or thicker consistency of saliva
Change in taste, sensation
Loss of appetite
probs from Thermal Burns/Caustic Ingestion?: If severe, can impact on all â€œstagesâ€ of the swallow

Acute reaction = odynophagia, dysphagia, edema, stridor
Later= stricture formation
probs from cervical spine disease?: Large osteoarthritic spurs can develop on the cervical spines of patients:
Osteophytes
-which can reduce the pharyngeal space
-can Interfere with epiglottic inversion
-can cause aspiration

Dysphagia may also be caused by surgery for neck problems (discectomy; anterior neck fusion)
probs from AI diseases like System lupus erythematosis Mixed connective tissue disease Rheumatoid arthritis Sjogrenâ€™s disease and treatment?: May affect all â€œstagesâ€ of the swallow
Treatment: artificial saliva sprays; diet modifications
Which people present with the sensation of food sticking in their throat or chest?: ppl with esophageal disorders
What are the esophageal symptoms and manifestations of GERD?: Symptoms: Heartburn, regurgitation, dysphasia, belching, odynophasia.

Manifestations: erosive, esophagotos, esophageal ulcer, peptic stricture, Barrett's esophagus, esophageal adrenocarcinoma
Problems from esophageal disorders? Treatment?: Difficulty chewing meat, bread, apples
Sensation of food sticking
Night chokes
Dry mouth
A.M voice
Globus sensation
PND
Water brash

Treatment: Medications; Diet modifications, HOB raised at night, GOOD oral hygiene
What are the symptoms and treatment of the esophageal problem called Zenker's diverticulum?: an out-pouching that forms at the level of the UES
Symptoms: regurgitation of undigested food, bad breath, weight loss, nocturnal cough or aspiration

Treatment: surgery if patient is a candidate; otherwise, diet and compensatory strategies
Intubation/trach: Intubation:
edema, granuloma, subluxation of the arytenoid(s), temp. or permanent paralysis of the RLN
Tracheostomy: frequency of aspiration is 50-83%
inflated cuff*
desensitization of laryngeal sensory receptors
odynophagia
decreased laryngeal elevation
decreased subglottic pressure (cough; shortened expiratory phase)
origin and symptoms of lyme disease: Tick bite:
initially, flu-like symptoms (stiff neck, headache, fatigue)
over next few weeks, unique enlarging rash. Symptoms may include: cranial nerve involvement, dysphagia, difficulties chewing, vocal fold problems, facial paralysis, dysnomia, sensitivity to sound/light, cognitive changes, psychiatric problems
Why do psych patients die more because of asphyxiation?: medications (neuroleptic-induced extra-pyramidal syndrome [EPS]).
What are the long-term effects of alcohol and the effects of using it with other drugs?: Long-term Effects:
Damage to vital organs; including liver, heart and pancreas. Linked to several medical conditions; including gastro intestinal problems, malnutrition, high blood pressure, and lower resistance to disease. Also linked to several types of cancer; including esophagus, stomach, liver, pancreas and colon.
Effects with Other Drugs:
Alcohol produces a synergistic effect when taken with other central nervous system depressants. These include: sedative hypnotics, barbiturates, minor tranquilizers, narcotics, codeine, methadone, and some analgesics.Alcohol can be additive in nature when taken with antipsychotic medications, antihistamines, solvents or motion sickness preparations. When used on a daily basis, in conjunction with aspirin, it may cause gastro intestinal bleeding. Also, when used with acetaminophen, an increase in liver damage could occur.
Side effects related to swallowing: Akathesia Dystonia
Appetite changes Esophageal ulceration
Ataxia Extrapyramidal syndrome
Changes in olfaction Movement disorders
Confusion Sedation and inattention
Cough Tardive dyskinesia
Delirium Tardive dystonia
Xerostomia Taste changes
Dyskinesia Tremor
What drugs can cause dry mouth?: Drugs that Cause Dry Mouth
ACE inhibitors (Capoten)
Antiarrythmics (Procan)
Antiemetics (Reglan, Antivert)
Antihistamines and decongestants (Benadryl, Sudafed)
Calcium channel blockers (Norvasc)
Diuretics
Selective serotonin reuptake inhibitors (SSRIs) (Celexa, Paxil, Zoloft)
Tricyclic antidepressants (Amitriptyline)
Antipsychotic/Neuroleptic Medications These drugs work by blocking dopaminergic transmission. For this reason, patients can develop symptoms similar to Parkinsonâ€™s disease (pseudo-parkinsonism). Over time, this condition can lead to an irreversible: Chlorpomazine
Haldol
Zyprexa**
Seroquel
Risperidone
Stelazine
Most commonly these are drugs used to treat cancer or suppress the immune system. They can cause dysphagia through two different mechanisms: 1) chemotherapy directly injures the esophagus mucosa, 2) immunosuppressants predisposes patients to fungal or vi: Taxol
Imuran
Atgam
High dose corticosteroids When used over a long period of time and in high doses, steroids can cause skeletal muscle wasting. The esophagus can be affected. The S-LP can offer compensatory strategies, usually diet modifications. What are 2 examp: Decadron
Prednisone
Medications that depress the CNS can be a potential cause of serious dysphagia because they make patients drowsy and confused. There is deceased voluntary muscle control and patients may have difficulty initiating the swallow. Examples of these?: Antiepileptics (Tegretol, Neurontin, Dilantin)
Benzodiazepines (Xanax, Valium, Ativan)
Narcotics (Tylenol #3, Diluadid, Demerol, Oxycodone)
Skeletal muscle relaxants (Baclofen)
What usually causes medication-induced esophageal injury? And name some meds.: This kind of injury is usually caused by local irritation of the esophageal mucosa by orally-ingested drugs. Symptoms are quite characteristic and include a sudden onset of dysphagia, chest pain and odynophagia within 4 to 12 hours after taking the medication. The most common site of esophageal injury from medication is near the level of the aortic arch

Aspirin
Bisphosphonates (Fosamax)
Iron containing products (Feratab, Fer-Iron)
Nonsteroidal anti-inflammatory drugs (NSAIDS) (Advil, Motrin, Aleve)
Potassium chloride (Slow-K, K-Tabs)
Vitamin C products
Who are most vulnerable to medication induce esoph. injury? how can you reduce risk?: Elderly.
take meds with lots of water, well before bedtime. larger pills first, gel capsules first, circular pills before oval.
What are the components of the clinical examination?: -history
-chart review
-physical exam
-swallowing exam
-instrumental exam
Questions to ask about kids?: -How long do mealtimes typically take?
-Are mealtimes stressful?
-Does the child show any signs of respiratory distress?
-Has the child not gained weight in the past 2 to 3 months.
What to find out in the history?: Referral source
Patient location
Specific complaint
Duration and course of problem
Morbidities
Prior treatment
Medication
What's on the chart review?: Date of admission
Why admitted/diagnosis
Health notes from physician/nurse
Meds
Lab Results
Imaging Results
What are some screening alerts?: -BMI is
More screening alerts?: Has difficulty chewing or swallowing
-history of bone pain or fracture
has a poor appetite
needs assistence with self-care
has evidence of cog. impairments, depression or illness
What's involved in the physical examination?: Physical status
Feeding method
Respiratory status
Mental status and cognition
Oral mech
Cranial nerve assessment
Test swallows
Extenders
Meal observations
What should we know about physical status in assessment?: Ambulatory
Wheelchair
Arm/hand function
In distress?
What are the feeding method options?: NGT
PEG/PEJ
IV
Parenteral
Oral
What is enteral nutrition?: involves intestines or other portions of the digestive tract. if the gut works, use it.
What do we pay attention to re: respiratory status in assessment?: Pattern
SpO2 level
Tracheostomy
Ventilator
What to look for in mental status and cognition portion of assessment?: AAO
Cooperative
Endurance
Memory
Language
Assessment: Extenders...different tests?: Cervical auscultation
Pulse Oximetry
Blue dye test
Water test
What are the two types of instrumental assessments for swallowing?: Videofluoroscopy (aka modified barium swallow)
&
Fibreoptic-Endoscopic evaluation of swallowing (FEES)
What is the procedure for the videofluoroscopy (aka MBS)? What is the purpose of it?: -a dynamic study conducted with radiologist
-uses calibrated boluses
-uses a variety of consistencies
Purpose:
-measures the speed of the swallow and the efficiency. Defines the movement patterns of structures in the oral cavity, pharynx and larynx, and evaluates the effectiveness of rehab strategies.
What are the advantages to the videofuoroscopy (aka MBS)?: -shows all phases of the swallow
-allows good visualization of posterior tongue movement
-allows examination of overlapping structural movements
-can detect timing of aspiration
What are the disadvantages to MBS?: -exposure to radiation
-barium changes food consistencies
-restrictions on patient positioning
-small window of time
-not transportable
-variation in inter-judge reliability
What is FEES? What does it involve?: FEES is a procedure that allows for the direct viewing of swallowing function when regular food materials are eaten.The procedure involves passing a very thin flexible fibre-optic tube through the nose to obtain a view directly down the throat during swallowing. The tube is passed into the oro-pharynx and provides a bright light so the swallow can be observed.
Does FEES complement the fluoroscopy procedure?: Yes
FEES is a comprehensive eval of the ______ phase of swallowing that can reveal the nature of the _______ and guide _________, improve efficacy and outcome. It can also be used as a ________ tool in therapy.: pharyngeal
problem
management
biofeedback
Is FEED safe, valid and reliable? Can it be used in different settings for different purposes?: Yes yes
What is the purpose of FEES?: Diagnose a pharyngeal stage dysphagia (premature bolus loss; penetration, aspiration, pharyngeal residue)
To determine the underlying anatomic or physiologic cause of the dysphagia
Make recommendations about the safety of the swallow
Use of appropriate strategies (behavioural/diet) that facilitate a safe swallow
What are some logistical indications for using FEES?: Fluoroscopy not available
Transportation to radiology risky; medically fragile patient
Transportation to a hospital problematic
Family input desired during exam
Positioning problematic: contractures, quad, neck halo, obese, on ventilator
Concern about radiation
What are some clinical indications for using FEES?: Visualize surface anatomy, mucosal abnormalities, resection, velopharyngeal incompetence
Visualize laryngeal movement/vocal fold mobility
Need conservative exam: compromised pulmonary clearance; medically compromised patient
Does not change food/fluid consistency
Clinical question of secretion management; extended therapeutic exam wanted
Biofeedback is desired: therapy session
Disadvantages of FEES?: Cannot assess the oral phase
Blind spot during the swallowing
Does not test the esophageal phase
Does our intervention help prevent aspiration pneumonia?: Implementation of a systematic program of
diagnosis and treatment of dysphagia in an
acute stroke management plan may yield
dramatic reductions in pneumonia rates.
Feeding tubes are a powerful predictor of ...: pulmonary complications
What are some treatment considerations?: The nature of the swallowing deficit
Patient profile
Specific treatment technique
Medical/surgical options?
Behavioural approaches
When we're looking at the nature of the swallowing deficit...what are we looking at?: Feeding and or swallowing issues
Voluntary or involuntary processes
Stage of deficit
Deficit or compensatory strategy
What are we looking for when we're looking at patient characteristics?: Etiology
Severity
Eating history
psychosocial factors
Anticipated medical course
caregiver factors
What are we looking at when we're looking at choice of approach/technique?: Active vs passive
Options?
Clinical indicators
Functional outcome
patient choice
What are we looking at when we're considering medical options?: Pharmacologic: antireflux, prokinetic, salivary management

Dietary: special diets, IV/alternate feeding routes
What are we looking at when we're considering surgical treatment?: Improve glottic closure:
medicalization thyroplasty, injection

Protection of airway:
stents, tracheostomy tubes, laryngectomy
What are we looking at when we're considering surgical treatment?: Improve glottic closure:
medicalization thyroplasty, injection

Protection of airway:
stents, tracheostomy tubes, laryngectomy

Improved pharyngoesophageal segment opening:
dilation, myotomy, botoc

Can also be done on the LES

Nissen fundoplication
What are some behavioural interventions?: -modify the food
-modify the feeding activity
-modify the patient
-modify the swallow
-modify the mechanism
How can we modify the food?: -Rheeology
-Volume
-Temperature
-Taste and smell
-Aesthetics
What are the effects of changing the volume of the bolus?: Decreased oropharyngeal transit times
Longer duration of palatal elevation
Shorter pharyngeal delay times (Bisch et al., 1994)
Increased extent and duration of hyolaryngeal
excursion (Bisch et al., 1994)
Increased extent and duration of UES
opening (Bisch et al., 1994
Longer deglutitive apnea (Hiss, Treole, & Stewart, 2001)
Increased oropharyngeal pressure profile
Longer thyroarytenoid contraction
What are the effects of changing the viscosity of the bolus?: -oropharyngeal transit time
-lingual pressure
-duration of pharyngeal pressure
What taste of bolus has been suggested to facilitate swallowing: sour
Sour bolus presentation may benefit individuals with oropharyngeal dysphagia who present with:: Delayed initiation of the swallow
Reduced pharyngeal constriction during the
swallow
(Stimulus would be presented prior to and
during the course of a meal)
What are the effects of a sour bolus?: Improves timing of the swallow (i.e., shortens swallow
duration) (Ding et al., 2003; Logemann et al., 1995;Palmer et al., 2005)
- Increases strength of muscle contraction during the
swallow (Ding et al., 2003; Palmer et al., 2005)
- Reduces incidence of penetration and aspiration
(Pelletier & Lawless, 2003)
- Increases the number of spontaneous swallows
following initial bolus presentation (Pelletier & Lawless)
How can we modify the feeding activity?: -use of feeding aids
-meal schedule
-cyclic ingestion
-environment
How can we modify the patient?: Positioning strategies: whole body or head
How can we modify the mechanism?: Motor exercises, sensory stimulation, Prosthetic adjustments
How can we modify the swallow?: Behavioural treatment strategies
80% of hospitalized patients are _______ at some time during their admission: dehydrated
Is swallowing made up of just stages?: No it's more than that...it's a complex process.
Does the brain get better at what it has been trained to do?: y
What are compensation strategies?: Strategies that provide an immediate but
typically transient effect on the efficiency
or safety of swallowing.
As a rule, if the strategy is not consistently
executed, swallowing will return to the
prior dysfunctional status.
What are some compensatory techniques (postural techniques and changing bolus characteristics)?: Postural techniques: chin tuck, head turn, head tilt, side lying.

Changing bolus characteristics: volume, taste, viscosity.
What is chin tuck as... 1) Direct intervention 2) Compensation 3) behaviourl intervention: 1) involves functional swallowing
2) transiently improves the swallow
3) requires active participation, relatively intact cognition, motivation, instrumentally directed
How does a chin tuck work?: -Opens the vallecular space
-Shifts anatomy posteriorly
-Reduces the A/P dimensions of the pharynx
What are the effects of the chin tuck on the pharyngeal swallow?: Improved airway protection through narrowing of the airway entrance
(Welch et al., 1993)
-Pushing of the tongue base and epiglottis toward the posterior
pharyngeal wall (Bulow et al., 1999; Welch et al., 1993)
â€“ Widening of the vallecular space (Logemann, 1983)
â€“ Decreased distance between the larynx and the hyoid bone and the
mandible (Bulow et al., 1999)
â€“ Reduced depth of contrast penetration in the larynx and trachea when penetration occurs (Bulow et al., 2001)
â€“ Reduction in aspiration of material (Bulow et al., 2001; Logemann et al.,1994; Rasley et al., 1993).
What are some nitty-grittty maneuvers/techniques?: Techniques to improve UES opening

Techniques to improve tongue-base-pharyngeal wall Approximation

Techniques to facilitate laryngeal closure
What needs to get moving in order for the UES to open?: the hyoid
What are some techniques for opening the UES?: head raise (Shaker)
Mendolsohn
What is the purpose of the Shaker and who is it appropriate for?: Purpose:
Strengthens the suprahyoid muscles that elevate the hyolaryngeal complex

Appropriate for individuals who aspirate after the swallow secondary to reduced hyolaryngeal excursion and/or reduced upper esophageal sphincter opening.
How do you do the Shaker?: Instructions:
Lie flat with shoulders against a firm surface
Elevate head only and look at your feet
Do three times in groups of 30
Then,
Elevate your head and hold for 60 seconds
Do three times
(duration is six weeks)
What are the effects of the Saker exercise?: Strengthens suprahyoid muscles
Improves UES opening
Reduces post-deglutitive residuals
Eliminates aspiration after the swallow
What does the Mendelsohn do?: Shortens pharynx
Approximates the UES and tongue base
Decreases the size of the laryngeal vestibule and pyriform sinuses
What are the instructions for the Mendelsohn?: Instructions:
Place your finger on your voice box and feel it rise and fall as you swallow
This time when you swallow and feel it move up, try and hold it up and not let it fall back
Hold it there for a count of three
Have all studies shown the Mendelsohn to be effective?: No

pt with a brain stem lesion only benefited when given both a myotomy and underwent Mendolsohn training
Garcia et al, 2004 â€œUnexpected consequences of effortful swallowingâ€
Techniques for the tongue-pharyngeal wall...: yawn
gargle
hawk
hard swallow
masako
showa
What does the Showa maneuver do?: improves airway closure and hyoid movement
What are the instructions for the showa maneuver/: Instructions:
Take a breath and hold it tightly.
As you do this, push your tongue against the roof of your mouth as tightly as you can
Keep squeezing throat as you swallow
Who should use the Hawk: head and neck cancer patients
What is the hawk (how to do)?: Exaggerate speech movements on words, such as HAWK...strong emphasis on an exaggerated K.
What does the masako exercise? How does it work?: pharyngeal wall

Have patient stick tongue between teeth and then swallow. Can increase load by adding resistance...pulling tongue out more.
techniques for laryngeal closure?: -supraglottic closure
-super supraglottic closure
-valsalva
How to do the supraglottic?: Inhale through nose
Hold it
Swallow
Clear/cough
Swallow
Breathe
What are some potentially negative effects of the supraglottic and super-supraglottic swallow?: Delayed onset of hyoid movement
Delayed onset of laryngeal movement
Delayed laryngeal closure
Delayed base of tongue retraction
Delayed base of tongue to posterior pharyngeal wall
contact
What does the Lee Silverman Voice Treatment consist of? What are the daily exercises?: 4 weeks of Rx
4X/week for one hour each session
3 daily exercises
THINK LOUD, THINK SHOUT

Maximum duration of sustained vowel phonation

Maximum fundamental frequency range

Maximum functional speech loudness drills
What was LSVT originally designed for?: Treatment program originally designed to improve speech intelligibility in patients
with hypokinetic dysarthria secondary to
Parkinsonâ€™s disease.
And there is some evidence that it improves
swallowing
What does lingual weakness correlate with?: Increased oral transit times (Meyers, 1986)
Oral residue on the tongue after the swallow
What is lingual strength correlates with?: Decreased oral and pharyngeal transit times (Lazarus,2000, 2001)
Maximal swallow pressures
What are the effects of lingual strengthening exercises?: improved tongue strength
increased swallowing pressures
improved penetration-aspiration scores
Electrical stimulation (e-stim) is used to enhance muscle performance by:: Increased ROM
-improving strength
-reeducating contraction patterns and timing
-correcting abnormal muscle tone
E-stim was recently introduced as a means of treating individuals with: oropharyngeal
dysphagia
What does e-stim do?: -Increased motor cortex excitability and increased area of cortical representation for the pharynx 30-60 minutes after stimulation (Hamdy et al., 1998; Fraser et al., 2002; 2003)
- Increased swallowing corticobulbar excitability in the undamaged hemisphere in patients with stroke (Fraser et al., 2002)
-Improved swallow function (Fraser et al., 2002; Freed et al., 2001; Leelaminit et al., 2003)
But (Power et al., 2004) found no functional changes in
swallowing function in patients with stroke.
And more negative effects
Do feeding tubes prevent aspiration pneumonia?: No
How to change the environment for people with congitive decline?: -reduce distractions
-reduce agitation
-increase supervision
-access to food and drink
How to change food for ppl with cognitive decline?: Strong flavours
Use of smell
Liquid supplements
Things to consider for PD: -cognitive slowing
-limb control deficits
-cyclic effect of medications
Treatment Foci in PD:: weight and nutritional status
-impact of meds
-change in clinical presentation and swallowing deficits as the disease progresses
Treatment strategy for PD: Normal swallowing: monitor weight, answer questions.

Mild symptoms: monitor weight, maximum effort therapy/LSVT, Coordinate eating with drug cycle

Moderate symptoms: teach maneuvers, increase sensory stimulation, aids to promote independence, small frequent highly nutritious meals

Moderate severe symptoms: teach patient postures and maneuvers effective for that treatment, limit oral intake to safe consistencies, consider tube-feeding supplements to maintain independence
ALS swallowing management considerations:: hydration
caloric intake/weight
aspiration risk
length of meals
social aspects of eating
burden of care
What is a major problem for ALS that we can help with and how.: Oral Secretions!!!
Thick secretions are a major problem:
Increase fluid intake
Eliminate caffeine
Guaifensein
Papain

If thin (pt drooling):
Chart fluid intake (dehydration)
Medications (Elavil etc)

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Deck Info

Number of cards 183

Created By sabn1987