Alterations to the Normal Swallow Flashcards
What are some warning signs of dysphagia?
- Reports problem
- Drooling/poor oral hygiene
- Dysarthria +/- dysphonia
- Gurgle voice
- Increased time with meals OR refusal to eat or drink
- Coughing on food/fluids
- Recurrent chest infections/unexplained
temperature spikes - Fluctuating level of consciousness
- Primitive oral reflexes
- Weight loss
- Confused mental state
- Diminished/absent cough
- Certain medications
How does aspiration impact swallowing function, before, during and after the swallow?
Before:
i.e. food/fluid content from a swallow will enter airway before the swallow is triggered (eg. Poor oral control allows spillage of bolus over base of tongue and down into pharynx and airway before a patient even triggers a swallow)
During:
i.e. food/fluid content from a swallow will enter airway while the swallow is happening (e.g. as the bolus is passing through the pharynx and part of it enters the airway because of failure to protect the airway e.g., failure of the vocal folds to close)
After:
i.e. food/fluid content from a prior swallow will enter the airway at a later time-point (e.g. residue left post swallow sits in oral cavity/pharynx and can later enter airway)
How does labial contraction/closure impact the person’s swallow/risk of aspiration?
Impact to oral prep and oral stage
- Impaired ability to remove food from spoon
- Food or liquid may leak/spill from the mouth
- In moderate to severe weakness – lack
of saliva control, drooling
How does impaired tongue function impact the person’s swallow/risk of aspiration?
Impact to oral prep, oral stage & consequences for pharyngeal stage
BEFORE:
↓ability to form and hold bolus (at tip & base) – lack of bolus control in oral stage
particles may fall over the base of the tongue during oral stage and be aspirated before swallow is initiated
AFTER:
↓ ability to control/manipulate food in the mouth during mastication
food inadequately masticated, food/fluid spreads throughout oral cavity + bolus separated into and swallowed in “bits” rather than a cohesive whole – piecemeal deglutition
Residue may remain in mouth that can later fall over the base of the tongue and be aspirated after that swallow has happened - the residue will fall down into an unprotected airway later
Poor tongue base retraction impacts hyoid movement, laryngeal elevation and epiglottic deflection…. impairs airway protection
Impaired lingual propulsion & tongue retraction – impacts hyoid elevation & there is lack of pressure behind bolus tail to assist bolus flow through pharynx → residue in pharynx
Residue may remain in pharynx, valleculae and pyriform sinus, and be aspirated at a time point later after that swallow has happened
How does reduced jaw strength and function impact the person’s swallow/ risk of aspiration?
Impacts oral prep stage
- Food inadequately masticated into size for safe swallowing
- increased risk of choking
How might reduced buccal tension impact the person’s swallow/ risk of aspiration?
Impacts oral prep stage
- Food may fall into the lateral sulcus during chewing and remain there as residue ……….need assistance to be removed from active tongue movement / other (eg., finger)
- particles may later fall over the base of the tongue and be aspirated at a time point later after that swallow has happened
How might reduced oral sensitivity impact the person’s swallow/ risk of aspiration?
Impacts oral prep, oral stage, swallow initiation
BEFORE
* Inability to appropriately prepare bolus for swallowing (size, texture, wetness)
Lack of sensory awareness leads to premature spillage of bolus over base of tongue → before swallow is initiated
aspirated before the swallow
AFTER
Material falls/lodges in areas of reduced sensitivity & left as residue in mouth
food particles may later fall over the base of the tongue and be aspirated after the swallow.
How might impaired velopharyngeal function/SOFT PALATE impact the person’s swallow/ risk of aspiration?
Impacts oral and pharyngeal stage
BEFORE
* VP fails to drape against base of tongue during oral stage. If there is also poor tongue function, lack of additional protections from VP can also contribute to aspiration before the swallow is initiated
AFTER
* Failure to contract and seal nasal cavity - Material may enter the nasal cavity – leading to discomfort + reside that can later fall into pharynx → aspiration after the swallow
How might delayed/absent swallow impact the person’s swallow/ risk of aspiration?
Impacts pharyngeal stage
BEFORE
- If absent - Bolus is transferred into pharynx and the airway is not protected, causing aspiration of bolus
- If delayed, bolus will reach pyriform sinuses and potentially overspill into laryngeal inlet before airway protection is in place – smaller amounts of aspiration
→ aspiration before the swallow is initiated
How might reduced laryngeal closure impact the person’s swallow/ risk of aspiration?
Impacts pharyngeal stage
DURING
Airway protection is compromised as larynx/airway is not closed allowing aspiration to occur during the swallow
How might reduced laryngeal elevation impact the person’s swallow/ risk of aspiration?
Impacts pharyngeal stage
BEFORE
- If larynx doesn’t elevate then its not “tucked” under tongue
aspiration may occur before the swallow as the airway is not fully protected when the bolus transitions from oral cavity to pharynx (i.e. before swallow trigger)
AFTER
* if larynx is not elevated, you get poor epiglottic deflection → can cause residue to trap in valleculae
Aspiration can occur after the swallow when any residue in valleculae can later slide into airway
- if larynx is not elevated, then the CP sphincter is also probably not being pulled open very well – causing problems with bolus flow & causing residue in pyriform sinus
Aspiration can occur after the swallow when that residue can enter into airway
How might reduced pharyngeal contraction impact the person’s swallow/ risk of aspiration?
Impacts pharyngeal stage
- Impacts laryngeal elevation (long muscles of pharynx assist elevation)
AFTER
* Impaired bolus transition through pharynx → residue may remain in the valleculae & pyriform sinuses and particles may later fall into the airway, aspiration may occur after the swallow
How might weak cricopharyngeus muscle impact the person’s swallow/ risk of aspiration?
Impacts pharyngeal and oesophageal stage
AFTER
- Failure to close behind the tail of the bolus
- Peristaltic activity in may force some of the bolus that had passed through UES to return into the pharynx through the semi-open sphincter - and spill into the airway, causing aspiration after the swallow.
How might poor esophageal peristalsis/ physical obstruction impact the person’s swallow/ risk of aspiration?
Impacts oesophageal stage and can impact pharyngeal stage
AFTER
* Boluses may not transit efficiently (slowing/stasis)…causing subsequent boluses to build up behind prior slow moving boluses (or any physical obstruction) and ultimately stop any further contents from passing through UES
- Subsequent boluses backflow/remain in pharynx with nowhere to go…but into the opened airway post swallow, causing aspiration after the swallow.
What 6 other factors influence a swallow?
Age
Volume
Viscosity
Delivery of bolus
Impaired respiratory support
Saliva, taste, flavour perception
