Disordered Swallowing Symptoms and their Causes

Question 1

What do we look for during a swallow eval?

Answer 1

observe and identify the symptoms

connect the symptoms to hypothesized causes/disorder (may go in either direction)

think in terms of “cause & effect”

treat the cause/disorder,, not the symptom

Question 2

If the patient is not responding, what would the cause be?

Answer 2

poor level of consciousness or Rousal

Question 3

If the patient is refusing to eat, what could the cause be?

Answer 3

any phase problem, behavioral/psychological/cognitive problems

Question 4

What are some oral preparatory phase problems?

Answer 4

• weak oral structures
• weak lingual strength, motility, ROM
• Poor dentition condition
• Decreased jaw excursion/closure

Question 5

ON EXAM

What does trismus mean?

Answer 5

reduced range of motion of jaw

Question 6

What does weak labial strength/motility result in, and how would you report it?

Answer 6

results in: difficulty taking material from utensil, difficulty with buccal tension in gathering food resulting in pocketing, leakage of material out of oral cavity

Report: “Poor labial skills resulted in anterior leakage of material out of oral cavity” p

Question 7

What does weak lingual strength/motility/ROM result in, and how would you report it?

Answer 7

Results in:

• Oral pocketing in lateral or anterior sulci
• Difficulty manipulating food into a bolus
• Lingual stasis
• Premature spillage of material into pharyngeal area

Report: “Decreased lingual strength/motility resulted in difficulty manipulating the food into a bolus which resulted in residue in the left lateral sulci

Question 8

What does Poor dentition condition result in, and how would you report it?

Answer 8

•Results in: Decreased ability or inability for mastication/breakdown of the material

Report: “Pt. is edentulous which resulted in inability to masticate solids beyond pureed consistency.”

Question 9

What does decreased jaw excursion/closure result in, and how would you report it?

Answer 9

•Results in: Poor lip closure (see slide 5)– Poor mastication/breakdown of the material

Report: “Decreased jaw closure resulted in poor labial closure which in turn resulted in…”

Question 10

What are some Oral Transit Phrase Problems?

Answer 10

-Poor tongue motility/control

Question 11

What does Poor Tongue Motility/Control result in, and how would you report it?

Answer 11

•Results in:

• Tongue pumping (common in PD)
• Increased oral transit time
• Tongue thrusting

Report: “Oral transit phase time was increased due to poor tongue motility with difficulty propelling bolus into pharyngeal area.”

Question 12

What must you be able to do during the oral transit phase?

Answer 12

must be able to propel the bolus back into the pharyngeal area to initiate a swallow response

Question 13

What are some pharyngeal phase problems?

Answer 13

• poor velo-pharyngeal closure
• Swallow Delay
• Decreased Posterior tongue retraction
• decreased pharyngeal all contraction
• decreased laryngeal elevation

Question 14

PHARYNGEAL PHASE

What does Poor Velo-pharyngeal closure result in, and how would you report it? (don’t worry about strategy -for now)

Answer 14

Results in: Nasal penetration of material or nasal regurgitation

Strategy: Try a hard, effortful swallow

Report: “Pt. presented w/ poor V-P closure resulting in nasal penetration.”

*This may be part of the oral phases too—maybe with VPI or cleft-palate

Question 15

PHARYNGEAL PHASE

What does a swallow delay result in and how would you report it?

Answer 15

Results in: penetration or aspiration-it does not result in residue!!!

Strategy: chin tuck

Report: Swallow delay noted resulting in penetration/aspiration of thick liquids

Question 16

What must the velum do to close off the velopharyngeal port once a swallow is initiated?

Answer 16

retract and raise

Question 17

What must the tongue do to get good supra-glottic pressure?

Answer 17

tongue should retract back to pharyngeal wall to get supra-glottic pressure

Question 18

What does decreased posterior tongue retraction result in, and how would you report this?

Answer 18

Results in: Poor S-G pressure & residue coating the tongue base

Strategies: Hard swallow, Repeat/extra swallows, Alternate solids w/ liquids

Report: “Dec. post. tongue retraction noted resulting in residue on tongue base

Question 19

PHARYNGEAL PHASE

What does decreased pharyngeal wall contraction result in, and how would you report this?

Answer 19

Results in: Poor S-G pressure & residue coating pharyngeal wall

Strategies: Hard swallow, Repeat/extra swallows, Alternate solids w/ liquids

Report: “Dec. pharyngeal wall contraction resulted in residue on posterior pharyngeal wall.”

Question 20

PHARYNGEAL PHASE

What does decreased laryngeal elevation result in, and how would you report this?

Answer 20

Results in:

Poor epiglottic inversion which in turn results in:

Residue in the valleculae

Decreased airway protection

Results in: Poor Crico-pharyngeal opening which in turn results in:

Residue in the pyriform sinuses

Backflow of material into laryngeal vestibule from CP

Question 21

What must the hyoid bone do during the pharyngeal phase?

Answer 21

hyoid must be pulled forward as the larynx is elevated

Question 22

PHARYNGEAL PHASE

What does decreased hyoid excursion result in? How would you report this?

Answer 22

See above under laryngeal elevation

report: Come up with one :)

Question 23

What can cause decreased epiglottic inversion (not from laryngeal elevation)?

Answer 23

Although the epiglottis inverts mostly due to laryngeal elevation (some post. tong. retrac. too), but it may be inhibited from inverting by anterior placement of the cervical vertebras

Osteophytes: Calcification of the vertebrae that can jut out and get really large which can inhibit the epiglottis from inverting.

Scar tissue may cause the epiglottis from inverting

Radiation (BIG TIME) affects the epiglottis from inverting.

Question 24

PHARYNGEAL PHASE

What does decreased epiglottic inversion not from laryngeal elevation result in? how would you report this?

Answer 24

Results in: Residue in the valleculae

Strategies: Hard swallow, extra/repeat swallows w/ head turns, alternate solids w/ liquids

Report:–

Question 25

Which individuals would have poor vocal fold closure and be at risk for aspiration?

Answer 25

people with paretic or paralyzed VF

Question 26

PHARYNGEAL PHASE

What does poor vocal fold closure result in, and how would you report this?

Answer 26

Results in: Decreased airway protection w/ possible aspiration

Decreased S-G pressure

Strategy: Super supra-glottic swallow

Report: “Poor Vocal fold closure resulted in decreased airway protection which in turn resulted in aspiration”

Question 27

PHARYNGEAL PHASE

What does poor C-P opening (not from laryngeal elevation) result in, and how would you report this?

Answer 27

Results in: Residue in the pyriform sinuses & laryngeal vestibule

Backflow of material from C-P

Strategies: Hard swallow, Repeat/extra swallows, Alternate solids w/ liquids, Shaker exercise

Theory is that our body’s defense against GERD/issues in the esophagus is to make our muscle tight, which creates a C-P bar.

Question 28

During the Pharyngeal phase, what must the C-P sphincter do?

Answer 28

must relax to open to allow food to enter the esophagus

Question 29

What would we look for in an MBS for Unilateral pharyngeal weakness?

Answer 29

look for residue symmetry on A-P view

Question 30

What does unilateral pharyngeal weakness result in? how would you report this?

Answer 30

Results in: More residue on one side (the weak side)

Strategies: Head turns, Repeat/extra swallows, Alternate solids w/ liquids

Report: ?

Question 31

What are some structural anomalies that may impact the pharyngeal phase?

Answer 31

Zenker’s Diverticulum

CP-Bar

Osteophytes

Swelling s/p surgery

Question 32

What are Zenker’s caused by?

Answer 32

dysfunction of the cricopharyngeal sphincter

Question 33

Describe CP bar

Answer 33

is part of the cricopharyngeal sphincter. This could lead to Zenker’s. This would make things get stuck. As soon as you see CP bar, there is likely something wrong with the esophagus.

Question 34

Describe ostephytes

Answer 34

can cause a dysfunctional swallow. But not necessarily great for surgery because this can lead to further issues with swallowing.