8f. Neurologically Based Communication Disorders and Dysphagia -- SWALLOWING DISORDERS Flashcards
Dysphagia
Impaired execution of the oral, pharyngeal and esophageal stages of swallow
Oral Preparatory Phase and Its Disorders
*In this phase, food placed in the mouth is first masticated. Well masticated food is prepared for swallow in the oral preparatory phase by making a bolus
Disorders:
- Problems chewing food b/c of reduced range of lateral and vertical tongue movement, reduced range of lateral mandibular movement, reduced buccal tension, and poor alignment of the mandible and maxilla
- Difficulty in forming and holding bolus, abnormal holding of bolus, slippage of food into anterior and lateral sulcus, aspiration before swallow due mostly to weak lip closure, reduced tongue movement, and inadequate tongue and buccal tension
Oral Phase and
*This phase begins with the anterior-to-posterior tongue action that moves bolus posteriorly; the phase ends as the bolus passes through the anterior faucial arches when the swallowing reflex is initiated
Disorders:
- Anterior, instead of posterior, tongue movement and generally weak tongue movement; reduced range of tongue movement and elevation; tongue thrust; reduced labial, buccal, and tongue tension and strength
- Food residue in various places, suggesting imcomplete swallow
- Premature swallow of solid and liquid food and aspiration before swallow, caused by apraxia of swallow
- Piecemeal swallow (attempts at swallowing abnormally small amounts of bolus)
Pharyngeal Phase and Its Disorders
*This phase consists of reflex actions of the swallow. Reflexes are triggered by the contact the food makes w/ the anterior faucial pillars. The pharyngeal phase involves VP closure, laryngeal closure by an elevated larynx to seal the airway, reflexive relaxation of the cricopharyngeal muscle for the bolus to enter, and reflexive contractions of the pharyngeal contractors to move the bolus down and eventually into the esophagus
Disorders:
- Difficulties in propelling the bolus through the pharynx and into the pharyngoesophageal sphincter (PE) segment; delayed or absent swallowing reflex; nasal and airway penetration of food
- Food coating on the pharyngeal walls; food residue in valleculae (space bet. BOT and epiglottis), on top of airway, in pyriform sinuses, and throughout the pharynx; delayed pharyngeal transit; reduced pharyngeal peristalsis, or the constricting and relaxing movements of the pharynx; pharyngeal paralysis
- Inadequate closure of airway; aspiration before and after swallow
- Reduced movement of BOT; reduced laryngeal movement; cricopharyngeal dysfunctions
Esophageal Phase and Its Disorders
*This swallowing phase is not under voluntary control. It begins when the food arrives at the orifice of the esophagus; food is propelled through the esophagus by peristaltic action and gravity and into stomach. Bolus entry into esophagus results in restored breathing and a depressed larynx and soft palate.
Disorders generally caused by a weak cricopharyngeus
- Difficulty passing bolus through the cricopharyngeus muscle and past the seventh cervical vertebra
- Backflow of food from esophagus to pharynx; reduced esophageal contractions
- Formation of diverticulum (a pouch that collects food); development of tracheoesophageal fistula (a hole); esophageal obstruction (e.g., by a tumor)
Assessment of Swallowing Disorders
- Detailed case hx, review medical records, interviewing…and
- Assess ethnocultural b/g, food habits/diet restrictions
- Screen speech, voice, lang, writing
- Screen concrete and abstract lang comprehension
- Laryngeal exam w/ indirect laryngoscopy or endoscopic eval
- Administer test swallows (and correctly position pt)
- Appropriately place food in mouth
- Use different kinds of foods in evaluating test swallows
- Give instructions for head position and swallowing
- Manually examine swallowing movements
- Videofluorographic assessment (modified barium swallow) of oropharyngeal swallow
- Manometric assessment w/ esophageal manometer, which measures pressure in upper and lower esophagus
- Electromyographic assessment (electrodes on structures of interest) and endoscopic assessment (movement of bolus until triggers pharyngeal swallow and any food residue after swallow)
- Ultrasound to measure tongue and hyoid movement
Swallowing Disorders: DIRECT Treatment
- Food or liquid is placed in pt’s mouth to shape appropriate swallowing
- Designed to reduce problems that are evident in the diff. stages of swallow
Direct Treatment: Oral Preparatory Phase
Tx of disorders of the oral prep phase involves teaching pt to better masticate food and generally better handle food in the mouth
- Teaching pt to press tongue against hard palate
- Teaching pt to keep food on more mobile side of tongue or on stronger side of mouth
- Applying gentle pressure w/ one hand on damaged cheek to increase cheek tension
- Teaching pt to keep head tilted to stronger side to maintain food on that side
- Teaching pt to tilt head forward to keep food in front of mouth until ready to swallow
- Tilting head back to promote the swallow
- Holding bolus in anterior or middle portion of mouth
Direct Treatment: Oral Phase
- Teaching pt to place tongue on alveolar ridge and initiate a swallow w/ an up and back motion to prevent tongue thrust swallow
- Teaching pt to compensate by placing food at back of tongue and then initiating a swallow
- Teaching pt to compensate for tongue elevation probs by placing food posteriorly in pt’s oral cavity, placing a straw almost at level of faucial arches to help pt swallow liquid, and then tilting pt’s head back and letting gravity push food from oral cavity into pharynx
- Teaching pt to compensate for disorganized anterior to posterior tongue movement by holding bolus against the palate w/ the tongue and beginning the swallow with a strong, single, posterior movement of the tongue
Direct Treatment: Oral Phase
- Teaching pt to tilt head forward while swallowing, to compensate for delayed or absent swallowing reflex
- Teaching pt to switch between liquid and semisolid swallows so that the liquid swallows help clear the pharynx to compensate for reduced peristalsis
- Teaching pt to tilt head toward stronger side if pt has a unilateral paralysis in lingual function and pharynx
- Teaching pt to tilt head forward while swallowing or placing pressure on the thyroid cartilage on the damaged side to improved laryngeal closure
Direct Treatment: Esophageal Phase
Handled medically but SLPS may counsel the pt to:
- Avoid certain foods
- Eat small portions of food and eat 2-3 hours before bed; elevate the head of the bed
- Lose weight if overweight
- Stop smoking
- Stay in an upright position for 30 minutes after eating
Swallowing Disorders: INDIRECT Treatment
- Does not involve food
- Instead, various exercises designed to improve muscle strength are prescribed and practiced
- Oral-motor control exercises
- Exercises to stimulate swallow reflex(e.g., thermal stim)
- Exercises to improve adduction of tissue at top of airway by using lifting and pushing to improve laryngeal adduction (which protects airway during swallowing)
Specific Swallow Maneuvers (4)
- Supraglottic swallow: Helps close airway at level of VFs to prevent aspiration; Pt holds food in mouth, takes deep breath and holds it, swallow while holding breath, and coughs after swallow
- Super-supraglottic swallow: Also helps close airway before and during swallow; Also promotes false VF closure; Pt holds breath tightly by bearing down and swallows while holding breath and bearing down, coughs after swallow
- Effortful swallow: Helps increase posterior motion of tongue and increase pharyngeal pressure; Pt squeezes as hard as possible while swallowing
- Mendelsohn maneuver: Helps elevate larynx and thus widen the cricopharyngeal opening; Pt is first educated about laryngeal elevation, then asked to palpate laryngeal elevation when swallowing saliva, and finally taught to hold laryngeal elevation during swallowing for progressively longer durations
MEDICAL Treatment of Swallowing Disorders (6)
- Cricopharyngeal myotomy (Cricopharyngeal muscle is split; Parkinson’s, ALS, and other pts whose main prob is cricopharngeal dysfunction)
- Esophagostomy: feeding tube into esophagus and stomach through a hole (stoma)
- Gastrostomy: feeding tube into stomach through an opening in abdomen
- Nasogastric feeding: pt fed via a tube inserted through nose, pharynx, and esophagus into stomach
- Pharyngostomy: tube inserted into esophagus and stomach via a surgically created hole through pharynx
- Teflon injection into VFs: surgical implant method designed to improve airway closure during swallow; teflon injected into a normal or reconstructed VF or any remaining tissue on top of airway to increase the muscle mass that helps close airway
