Adult Swallowing Condition & Assessment Flashcards
What is dysphagia?
Disorder or difficulty in swallowing
What are the stages of swallowing?
Oral
Pharyngeal
Esophageal
What is a feeding disorder?
Impairment in the process of food transport outside the alimentary system (GI Tract)
Usually an umbrella term encompassing all feeding problems regardless of the etiology severity or even the consequences.
Usually is the result of weakness or incoordination in the hand or arm used to move the food from the plate to the mouth
Feeding disorders may manifest as:
Prolonged mealtimes
Food refusal
Prolonged bottle- or breast-feeding in toddlers/older child
Failure to introduce advanced textures
What is the difference between signs and symptoms?
Signs - objective or observable phenomenon that is observed by the healthcare professional and not the patient
Subjective - this is only apparent to the patient, “feel ko…”
What are the signs of a person with dysphagia?
- Food spills from lips
- Excessive mastication time of soft food
- Poor dentition
- Tongue, jaw, or lip weakness
- Xerostomia – mouth dryness
- Bolus enters or exits the nasal cavity (there is a velopharyngeal incompetence)
- Infrequent swallows
- Excessive residue in mouth, pharynx, or esophagus after completed swallow
- Material enters the airway on radiographic study
- Aspiration of saliva or lung abnormality
- pH probe study positive for acid reflux
- Unexplained weight loss
What are the symptoms of dysphagia?
- Difficulty chewing
- Difficulty initiating swallow
- Drooling
- Nasal regurgitation
- Swallow delay
- Food sticking
- Coughing and choking
- Coughing when not eating
- Regurgitation
- Weight loss
What is aspiration? What phase is it most likely to occur?
Foreign object intended to be swallowed goes into the trachea
Most likely to occur during the pharyngeal phase of swallowing
Pharyngeal phase occurs for about how many seconds?
Less than 2 seconds
What is silent aspiration?
Swallowed material that goes below the vocal folds that does not produce a cough reflex
What are the two kinds of aspiration?
Primary aspiration
Secondary aspiration
What is primary aspiration?
Aspiratory on a bolus that comes from above the airway
Aspirated material is usually saliva, fluid, or food
What is secondary aspiration?
Aspiration on a bolus that comes from below the airway
Aspirated materials has usually been refluxed or vomited up from the gut (emesis) or has built up above a stricture or hold up in the esophagus
What are structural and physiological limits?
Structural and physiological
Structural limits - anatomical composition or structure issues that impedes feeding development
Physiologic limits - more of the processes happening or conditions present that affects the patient that impedes the feeding development
What are the structural limits happening in the oral and facial regions?
- Choanal atresia
- Micrognathia
- Macroglossia
- Dental malocclusions
- High palatal arches
What is choanal atresia?
Nasal conchae are occluded by soft tissue or bone due to failed recanalization of the nasal fossae
Also known as small jaw
Micrognathia also known as mandibular hypoplasia
What is macroglossia?
Abnormal enlargement of the tongue
What are high palatal arches?
Inadequate airway protection
What happens if a patient has macroglossia?
- May prevent the patient from lips sealing
- Difficulty with bolus manipulation
- May have excessive drooling
What is esophageal stricture?
Narrowing of esophagus
What is esophageal atresia (EA)?
Incomplete formation of esophagus
Ends in blind pouch and doesn’t connect at stomach
What is tracheoesophageal fistula (TEF)?
Abnormal connection (fistula) between the esophagus and the trachea
There is gaseous distention from the stomach
What is pyloric stenosis?
Thickening and narrowing of pylorus
Causes forceful vomiting shortly after eating
What is short bowel syndrome?
Malabsorption secondary to resection of small intestine
What is the effect of a small stomach due to fundoplication?
Child easily feels full
What is a congenital diaphragmatic hernia?
A hole in the diaphragm allows abdominal organs to herniate (migrate) into the chest
What is hiatal hernia?
Protrusion of the stomach into the mediastinal cavity
Through the esophageal hiatus of the diaphragm pushing the lower esophageal sphincter away from the diaphragm (mimics acid reflux–burning sensation, chest pain, trouble in swallowing, and regurgitation of food and liquid)
What can cause an increased physiologic stress in breathing? It has negative influence on?
Negative influence on: suck-swallow-breathe coordination, energy required for feeding
Examples: Laryngomalacia, Tracheomalacia (the trachea collapses), Holes in the heart, Aortic stenosis
What is penetration?
A foreign objects enters the airway but not beyond the vocal folds (food enters the laryngeal inlet)
What is aspiration?
Foreign object enters airway beyond vocal folds (trachea pababa papunta sa lungs)
Aspiration happens due to several factors. What are these?
- No swallow reflex
- Delayed swallowing
- Poor timing and coordination
- Residue because of poor pharyngeal movement
- Vocal cords paralysis
This is the most common GIT disorder
GERD (Gastroesophageal reflux diseases)
Stomach contents reflux proximally because of LES incompetence. Typical symptoms: vomiting and gagging. It is also the most frequent and most pervasive physiological limit.
GERD
Factors that contribute to GERD
- Respiratory problems (e.g., labored breathing, overinflated lungs)
- Increase pressure due to coughing
- Medication for respiratory stress
What are the respiratory effects of GERD?
- Larynx irritation (cough and hoarseness)
- Micro-aspiration or refluxed contents - Chronic bronchitis and asthma-like symptoms
- Apnea
What are postural problems?
Respiratory problems due to postural problems (e.g., kyphosis, scoliosis)
Decreases the depth of respiratory volume
What are respiratory issues due to tone problems?
- Poor basis of respiratory control
- Difficulty moving chest muscles
- May develop compensatory methods of breathing that provide less respiratory support for feeding
What are the effects of a tracheostomy tube?
-Mechanically restrict upward movement of larynx= increases the chances of aspiration
- Can lead to desensitization of the larynx = reduce protective reflexes and can lead to uncoordinated closure
True or False. Children with cardiac or respiratory problems will have poor feeding endurance and become short of breath while feeding and poor growth and nutrition
t
Mouth may hang open or move up and down excessively when trying to suck.
Exaggerated jaw movement
This is related to general jaw instability, would make?
It is associated with?
- The jaw slip and shift forward or to the side
- Associated with low postural tone and poor stability of neck and truck
- Associated with poor control of TMJ
What is jaw thrust? When does it happen? What can it cause?
Strong downward movement of jaw when utensil or food is presented to the mouth–different from normal full mouth opening
May include sudden shifts forward to the side
Can cause TMJ dislocation
What is the tonic bite reflex? When does it happen? May be caused by?
- When biting surfaces of teeth or gums are touched, the child bites with associated tension– meal times may be challenging, because it is hypertonic. This may be caused due to the hypersensitivity.
Bite is not easily released
What is jaw clenching? Possibly because of? May lead to?
- The jaw is tightly closed involuntarily.
- Possibly due to: part of primary flexor in the shoulder and neck, oral hypersensitivity, self-stimulating a tonic bite
- May lead to the shortening of jaw muscles and connective tissue therefore it could lead to limited ROM at the TMJ
What is jaw retraction? It could cause difficulty with?
- Jaw is pulled backward
- There is difficulty with opening of the mouth fully
What is tongue retraction? This may lead to? How do others compensate?
- Tongue is pulled backward
- May be due to shoulder girdle retraction–due to limits in postural tone, neck may also be hyperextended with chin tipped up.
- Leads to a smaller airway
- Some compensate by pressing tongue against the hard palate
What is a low-toned tongue?
- Lacks ability to flatten, thin, and cup
- Thick and lacks central groove
- Difficult to present spoon or nipple as it interferes with comfortable placement
Rhythmical extension and retraction of tongue but movement during the extension portion goes beyond gum ridge and teeth. Common in children with low tone and respiratory disorders
Exaggerated tongue protrusion
Very forceful protrusion of tongue from the mouth. It is arrhythmitic (no sequence) and may cause food to be pushed out. Makes inserting a nipple or spoon difficult. Persistence of infantile swallow pattern during late childhood.
Tongue thrust
Low-tone lips may cause what?
Food may fall out of the mouth
Low-tone cheeks will
Cause the food to fall into the cheek cavity
Lips are pulled forward from lip retraction, action similar to a drawstring closing a laundry bag
Lip pursing
What is lip retraction? Can cause difficulty in?
- Lips are drawn back in a tight horizontal line
- Difficulty for lips to assist in sucking, removing food from the spoon, etc.,
- May be due to extension and retraction patterns in the neck and shoulder girdle
What is velopharyngeal insufficiency? What can it cause?
Soft palate is too short
Food can enter the nasal cavity
Overall difficulties with tone and movement may contribute to this
Inaccurate timing of palate elevation
It reflects the underlying muscle tone (e.g., mouth hangs open due to low muscle tone)
Primary problematic patterns
Compensating for underlying issue of tone and instability (e.g., tensing some of the jaw muscles to increase stability for tongue movement)
Compensatory (problematic) patterns
What is hyperreaction? What are its possible causes?
- Unexpectedly strong reaction to a specific sensation
- Increase in tone and reflex patterns appear to reduce sensory thresholds
-History of tube feedings may also be a cause
What is hyporeaction? What are its possible causes?
- Reduced reaction to specific sensations
- Can cause severe feeding disorders or indifference toward eating
- Can also be caused by certain meds ‘Often accompanies lowe postural tone
What is sensory defensiveness?
- System perceives a sensation as dangerous (moves into fight or flight)
- Cans cause different reactions
- One or several sensory system may be involved
What is sensory overload?
Difficulty modulating amount and type of sensory information consciously processed
Some may be overwhelmed and unable to function
Some maye be hyperreactive and unable to function
Some may be hyperreactive and distractible
Some may present with fleeting attention
Some may engage in rhythmic behaviors
Bottle-or breast-feeding requires what?
Ability to latch onto the nipple
Ability to create negative pressure to suck the milk
Ability to let the milk flow an uninterrupted stream to the pharynx
When a child has concerns with sucking, there are difficulties with which structures? What else?
Jaw, tongue, lips, cheeks or palate will contribute to sucking problems
Problems with organization will have an effect as well
Biting requires?
Normal jaw control
Normal sensory perception of thickness, hardness and size
Swallowing requires
- Ability to organize the bolus to move toward the back to initiate the swallow reflex
- Ability to time and coordinate breathing with eating
- Strong enough muscles to move bolus with eating
If you have swallowing problems, you will have difficulties with the following:
Difficulties with jaw (e.g., open-mouth posture), tongue, lips, cheeks, or palate will contribute to swallowing difficulty
Problems with sensory awareness and organization will have an effect as well
Chewing requires
- Keeping the food in the mouth with the lips and cheeks
- Coordination of jaw and tongue movements
The following have the greatest effect on chewing:
Jaw thrust
Jaw clenching
Tonic bite
Tongue retraction
Tongue thrust
Chewing difficulties with sensory acuity or perception will have an effect as well:
Some children refuse food with certain textures
Some children just swallow solids wholes, without chewing
Some children are unaware that some food was left in the mouth
Saliva is for
- Moistening food
- Helping break down food with enzyme
- Protecting teeth from diseases and infection
- Keeping the mouth wet for smooth articulation
Possible causes of sialorrhea (excessive drooling)
- Difficulty maintaining posture
- Airway obstruction → open mouth posture
- Decreased sensation
- Reduced ability to concentrate and remember to swallow
This is the most common condition to create congenital neurologic dysphagia
Cerebral palsy
This is the greater dysfunction in phases with significant voluntary components (oral stage)
Spastic CP
What are the common limiting patterns for spastic CP?
Tongue thrust
Hyperactive or hypoactive gag reflex
Hypersensitivity
Tonic bite reflex
Inadequate function of lip and cheek muscles → poor bolus formation → inhibits distal propulsion of bolus
Difficulty coordinating swallowing with breathing
Pharyngeal dysfunction is also common with spastic CP. True or False
True. There is difficulty with coordinating swallowing with breathing
What is cortical damage? What are its manifestations?
Manifestations range from no observable swallow activity to poorly coordinated execution of the act of swallowing
What are the frequent cortical pathologic conditions?
Stroke
Dementia
TBI
What happens to a patient who has either a unilateral/bilateral hemispheric stroke?
Unilateral lesions may demonstrate dysphagia to varying degrees
Bilateral = most severe and persistent dysphagia
Swallowing motor functions are bilaterally represented in the hemispheres. True or False.
True
If a dominant hemisphere is limited, a contralateral “backup” is available. True or False.
True
Cortical plasticity may occur over time increasing…
Increasing the utility of the intact, nondominant hemisphere to control swallowing motor functions
What are the swallowing deficits in association to hemispheric stroke?
- Dry swallow (poor initiation of saliva swallow)
- Incoordination of the oral (voluntary stage) components of swallowing
Delay in initiation of the pharyngeal component of the swallow - Increased pharyngeal transit time and reduced pharyngeal constriction and clearing → Aspiration
- Dysfunction of the pharyngoesophageal segment – cricopharyngeal muscle
- Poor relaxation of the lower esophageal sphincter
Over 50% of acute strokes have dysphagia. True or False.
True
Recovery for hemispheric stroke may take?
1st 6 months post-stroke
Dysphagia in acute stroke is associated with
- Poor long-term outcome
- Death
- Increased rate of institutionalization
What are the swallowing deviations for a person with mild dementia?
- Slow oral movement
- Slow or delayed pharyngeal response
- Overall slow swallowing duration
Basically slow lahat
There is 60 - 90% dysphagia prevalence among acute and subacute TBI patients. True or False
True
Most patients regain some degree of functional swallowing within the first 3 to 6 months after injury
True
Severity of the initial injury emerged as a strong predictor of
Swallowing deficits
Time to recovery of functional swallowing ability
Problems with the basal ganglia may create
- Excessive tone and/or extra, unintended movements
What is the function of basal ganglia?
- Regulate tone and steadiness of movement
What are the associated swallowing problems with a person who has basal ganglia deficits?
Poor bolus control: involuntary movements
Residue from inefficient swallow
Difference among swallow types
Severity dependent
This is the slowly progressive disease of the basal ganglia. The key problem is in the execution of voluntary movements.
Parkinson’s disease
What are the classic features of Parkinson’s disease?
Resting tremors
Bradykinesia
Rigidity
Postural instability
A.K.A Lou Gehrig’s disease or motor neuron disease. It is also a progressive degenerative disease of unknown cause.
ALS
What are the clinical presentations of ALS?
Progressive weakness; corticobulbar deficits contribute to progressive dysphagia
