Ch 1 - Stroke: Dysphagia Flashcards
What types of strokes are dysphagia seen in?
– 67% brainstem
– 28% left hemispheric
– 21% right hemispheric
When is dysphagia more commonly seen?
Bilateral> unilateral hemisphere strokes
Large>small vessel strokes
What is the MCC of dysphagia?*
Delayed pharyngeal swallow
What is the gold standard of evaluating dysphagia?*
Videofluorographic swallowing evaluation (VFSS)
Also called modified barium swallow (MBS)
Describe Fiberoptic endoscopic evaluation of swallowing (FEES).*
Visualizes anatomic structures that might cause potential bolus obstruction and natural
bolus flow and containment
What stage of swallowing does Fiberoptic endoscopic evaluation of swallowing (FEES) evaluate?*
Pharyngeal stage of swallowing
What is aspiration?
Entry of a substance through the vocal folds (true vocal cords) into the trachea
What percentage of aspiration is missed on bedside swallow evaluation?*
40-60% of patients have silent aspiration
How does aspiration appear on videofluorographic swallowing study (VFSS)?
Penetration of contrast material below the true vocal cords
What are predictors of aspiration on penetration on videofluorographic swallowing study (VFSS)?
– Delayed initiation of the swallow reflex
– Decreased pharyngeal peristalsis
What are predictors of aspiration on penetration on bedside swallow exam?*
– Abnormal cough – Cough after swallow – Dysphonia – Dysarthria – Abnormal gag reflex – Voice change after swallow (wet voice)
What are risk factors for aspiration pneumonia?*
– Decreased level of consciousness – Tracheostomy – Emesis – Reflux – Nasogastric tube (NGT) feeding – Dysphagia – Prolonged pharyngeal transit time
What are the four phases of swallowing?*
- Oral preparatory phase
- Oral phase
- Pharyngeal phase
- Esophageal phase
Is the oral preparatory phase of swallow voluntary or a reflex?
Voluntary
Describe the duration of the oral preparatory phase of swallow.
Variable duration based on food consistency and number of times a person chews
What are the hallmarks of the oral preparatory phase of swallow?
Preparation of bolus
What does the oral preparatory phase of swallow require?
- Tension of labial/buccal musculature to close mouth
- Circular motion of jaw for mastication
- Depression and forward movement of soft palate to seal oral cavity posteriorly
- Saliva
What are problems with the oral preparatory phase of swallow?
- Drooling
* Pocketing
Is the oral phase of swallow voluntary or a reflex?
Voluntary
Describe the duration of the oral phase of swallow.
Lasts usually less than 1 second
What are the hallmarks of the oral phase of swallow?
- Tongue that elevates and occludes the anterior oral cavity and compresses the bolus toward the oropharynx
- Contraction of the palatopharyngeal folds
- Elevation of the soft palate
What does the oral phase of swallow require?*
• Closure of anterior and
lateral sulci.
• Tongue to move bolus to the pharynx.
• Soft palate elevation and velopharyngeal port closure to close off the nasal cavity and prevent regurgitation into the nasopharynx
What are problems with the oral phase of swallow?
- Drooling
- Pocketing
- Head tilt
Is the Pharyngeal phase of swallow voluntary or a reflex?
Reflex
Describe the duration of the Pharyngeal phase of swallow.
Lasts ~ 0.6 to 1 sec
What are the hallmarks of the Pharyngeal phase of swallow?
• Bolus propelled from mouth to esophagus
• Aspiration most likely to occur during this phase*
• Inhibition of breathing occurs to
prevent aspiration
What does the Pharyngeal phase of swallow require?*
Airway protection with soft palate/laryngeal elevation, velophraryngeal closure, vocal cord adduction and pharyngeal constriction and cricopharyngeal relaxation to facilitate bolus transport to esophagus
What are problems with the Pharyngeal phase of swallow?
Food sticking Choking and coughing Aspiration Wet/gurgling voice Nasal regurgitation
Is the Esophageal phase of swallow voluntary or a reflex?
Reflex
Describe the duration of the Esophageal phase of swallow.
Longest phase—lasts 6 to 10 sec
What are the hallmarks of the Esophageal phase of swallow?
• Bolus pass from pharynx > esophagus > stomach
• Esophageal clearance is assisted by gravity but requires relaxation of
the gastroesophageal sphincter
What does the Esophageal phase of swallow require?
- Cricopharyngeal muscle contraction
* Coordinated peristalsis and LES relaxation
What are problems with the Esophageal phase of swallow?
Heartburn
Food sticking
What are treatments of dysphagia?
Modified diets NPO Posture and head position Elevate HOB Feeding upright position Compensatory strategies Oral/motor exercises Thermal stimulation
What does a chin tuck prevent?*
Preventing bolus entry into larynx and allowing airway protection
Where does food bolus travel with a chin tuck?*
Dec space b/w tongue and posterior pharyngeal wall to inc pressure to move bolus through pharyngeal region
How should the head be rotated in dysphagia?*
Turn head towards paretic side to force bolus into contralateral pharynx
How does head tilt guide food bolus?
Uses gravity to guide bolus into ipsilateral pharynx
Describe a supraglottic swallow for dysphagia treatment.
Concomitant breath holding and swallowing closes the vocal folds to protect the trachea
Describe a super supraglottic swallow for dysphagia treatment.
Adds Valsalva maneuver to maximize vocal fold closing
Describe a Mendelsohn maneuver for dysphagia treatment.
Patient voluntarily holds the larynx at its maximal height to lengthen the duration of the cricopharyngeal opening
How does thermal stimulation treat dysphagia?
Sensitize the swallowing reflex
How do oral/motor exercises treat dysphagia?
Improve tongue and lip strength, ROM, velocity, and precision, and vocal fold adduction
What is malnutrition in stroke patients associated with?
Prolonged LOS Slower functional gains Higher stress reaction Higher infection rates Higher decubitus ulcer rates
What did the Ickenstein et al research on dysphagia find?*
72hr post stroke: 1 to 3 on functional communication measure of swallowing and level 5 to 8 on penetration-aspiration scale were 11.8x less likely to be orally fed 90 days post-stroke
What causes nasal speech?*
Partial or complete failure of soft palate to close off nasal cavity from oral cavity or incomplete closure of hard palate
What prevents nasal speech?*
Uplifting soft palate
