dysphagia Flashcards
1
Q
typical swallow involves movements controlled by which nerves…coordinated within the
A
cranial nerve V, VII, 1X-XII aka 5, 7, 9-12 and peripheral nerves
; brainstem
2
Q
motor learning principles
A
- use it or lose it
- use it and improve it
- specificity
- repetition matters
- intensity matters
- timing
- salience
- age
- transference
- interference
3
Q
what exercises for decreased hyolaryngeal elavation
A
effortful swallow
mendelson
falsetto
effortful pitch glide
4
Q
what exercises for decreased upper esophageal sphincter opening or UES retention
A
Shaker
chin tuck against resistance
5
Q
what exercises for decreased anterior hyoid movement
A
supraglottic swallow
super supraglotic swallow
6
Q
effortful swallow: what is it and what does it help
A
swallow & squeeze really hard whlle you swallow
- tongue base retraction, food stuck in throat?
7
Q
the swallow is coordinated within the ___ mainly the ___
A
brainstem; medulla oblongata, where a network of sensory nuclei, motor nuclei, and interneurons form what is known as the “swallowing
center”).
8
Q
swallow should be 2 main things
A
safe and efficient
9
Q
what does the UES do during and after swallowing? & why?
A
- During swallowing, the upper esophageal sphincter opens to allow food and liquids to pass into the esophagus
- After swallowing it constricts to reduce the backflow of food and liquids from the esophagus into the pharynx
- prevents food from traveling down the trachea, or windpipe aka aspiration
10
Q
Unsafe swallows result in __ & 2 main types
A
Result in airway invasion either
1. Penetration - bolus stays above level of vocal cords
2. Aspiration - bolus touches or moves below the level of the vocal cords
11
Q
21 components of the swallow
A
- Open jaw (mandible)
- Rotary movement of jaw
- Lip closure (prevent anterior spillage)
- Lateral movements of the anterior tongue to mix bolus with saliva (serous and
mucous) and to move it around while chewing occurs - Posterior tongue elevates
- Velum depresses to articulate with posterior tongue
- Prevents premature posterior spillage - Tongue tip rises to touch alveolar ridge
- Posterior tongue begins to depress
- Velum elevates to close off nasopharynx
- Increased tongue to palate contact to propel bolus back. Bolus touches anterior faucial pillars/palatoglossal arch to initiate pharyngeal
swallow - Suprahyoid muscles contract for hyoid burst (superior and anterior movement)
- Airway protection
- Base of tongue articulates with posterior pharyngeal wall
- Ideally you want full articulation - Pharyngeal shortening
- Opening of the UES
- Rostral-caudal activation of pharyngeal constrictors (superior > middle > inferior)
- Longitudinal pharyngeal muscles relax and lengthens
- Residue can remain in the vallecula and/or pyriform sinuses
- LES triggered to open at point of MPC (maximum pharyngeal constriction)
- At swallow rest, UES goes back to contracted/closed state, hyoid descends, larynx
descends
12
Q
2 types of saliva and what they do
A
- Mucous saliva is more slippery and helps with lubrication
- Serous saliva to break down carbs with amylase
13
Q
Mechanisms of UES opening
A
- intrabolus pressure
- build up of positive pressure in pharynx/negative pressure in esophagus
- cricoid elevation & larygeal elevation
14
Q
Oral prep phase - what it is, what needs it, in/voluntary?
A
- not everything needs this phase (water)
Food manipulation and mastication
Mastication of bolus, mixing with saliva and dividing food for transport
Almost entirely voluntarily - can be interrupted at any time
15
Q
Oral prep phase disorders
A
- Problems chewing food b/c of reduced range of lateral and vertical tongue movement
- Reduced range of lateral mandibular movement
- Reduced buccal tension
- Poor alignment of mandible and maxilla
- Difficulty in forming and holding bolus
- Abnormal holding of bolus, slippage of food into anterior/lateral sulcus
- Aspiration before swallow due to weak lip closure, reduced tongue movement, inadequate tongue and buccal tension
16
Q
Oral Prep- key muscles
A
● Orbicularis oris (CN VII)- closing lips
● Buccinator (CN VII) - counter force to the tongue to facilitate proper
bolus control
● Masseter CN V - elevates and retracts mandible -closes jaw
● Temporalis CN V - elevates and retracts mandible
● Medial pterygoid CN V - closes jaw by raising mandible against maxilla
● Lateral pterygoid CN V - assists in opening the mouth
17
Q
Tongue muscles
A
- 4 intrinsic (superior longitudinal, inferior longitudinal, vertical, transverse)
-4 extrinsic muscles (genioglossus, styloglossus, hyoglossus, palatoglossus)
18
Q
all tongue muscles innervated by
A
hypoglossal nerve (CN XII), except palatoglossus (CN X, pharyngeal branch)
19
Q
Extrinsic tongue muscles - what do they do and how do they move the tongue
A
*Connect from the tongue to an external structure
*Move the tongue within the oral cavity
*Protrusion
*Retraction
*Lateral motion (helpful during mastication)
*Elevation
*Depression
20
Q
Clinically, we look at the tongue as __ main parts, which are _____ because ____
A
● Anterior tongue
● Posterior tongue
● Base of tongue (not involved in prep phase)
● We cannot target individual muscles in therapy, and they are mostly innervated by the same nerve:
21
Q
Anterior tongue - whats its role, what part of the tongue is it, whats it innervated by for taste and general sensation
A
● Anterior tongue: formation, placement and manipulation of the bolus in the oral cavity, Front 2⁄3
○ Taste sensation (CN VII) CN7
○ General sensation (CN V) CN5
22
Q
Posterior tongue - its role, innervation, what part of tongue
A
● Posterior tongue: containment of the bolus in the oral cavity and propulsion into the pharynx, Back 1⁄3
- CN 9
○ General sensation (CN IX)
○ Taste (CN IX)
23
Q
Salivation is a ___ controlled by ___ and is activated by ___ and contains ___ & innervated by ___
A
*Motor response – controlled by the salivatory nucleus in the brainstem
*Activated by stimulation of taste receptors on the anterior 2/3 of the tongue.
*CN 5
*Contains:
Enzyme for digesting starches
Mucous for lubrications
24
Q
3 major glands for salivation (less important)
A
parotid, submandibular, sublingual
25
Prep phase- sensory components
Prep phase- sensory components
Taste and pressure
Size
Temperature
26
detailed description of the swallow
During swallowing, the larynx will close to prevent food or liquid from entering the trachea at three levels: the epiglottis, the vocals folds, and the ventricular folds (also known as the false vocal folds)
At the same time, the upper esophageal sphincter will open so the food and liquid can pass through esophagus
Extrinsic laryngeal muscles including the suprahyoid muscles such as the geniohyoid, mylohyoid, and hyoglossus elevate with the hyoid, while the thyrohyoid, suprahyoid, and the long pharyngeal muscles pull the larynx upward toward the hyoid
This will assist the epiglottis with inverting to cover the entrance to the airway
The arytenoid cartilages will also be pulled forward, underneath the epiglottis to help with this closure
Overall, the larynx will elevate anteriorly to contribute to relaxation of the upper esophageal sphincter, making it easier for food and liquid to clear out of the pharynx
All of this is coordinated with the motion of the tongue, which propels the food to the posterior oropharynx and provides downward pressure, and contraction of the pharynx, which moves the bolus of food downwards
27
Swallow Reflexes: LAR
Laryngeal Adductor Reflex (LAR):
The laryngeal adductor reflex (LAR) involves a sustained duration and pressure of vocal fold closure during ; also controlled by brainstem function
28
Cough Reflex:
The cough reflex functions to expel and clear irritants from the airway by partial adduction of the vocal folds with prolonged exhalation
This requires a high amount of intratracheal pressure and contraction of the laryngeal adductor muscles
29
Phases of Swallow - Oral preparatory phase
- formation of the bolus
Voluntary
Food/liquid is placed into and maintained within the oral cavity, without falling out of the mouth or into the sulci
Base of tongue forms a seal posteriorly against the soft palate
Food is manipulated by the tongue (and chewed) while being mixed with saliva
A bolus is formed and positioned for transport into the pharynx
30
Oral phase -
- anterior to posterior transport of the bolus
- Voluntary
- Tongue cups/holds prepared bolus
Tongue tip rises, touching alveolar ridge
Posterior tongue depresses and soft palate elevates to open the back of oral cavity
Body of tongue moves upward and creates a tongue-palate contact from anterior to posterior, propelling the bolus towards the pharynx
Reflexive pharyngeal swallow is triggered as the bolus enters oropharynx
31
Pharyngeal phase -
- bolus transport through the pharynx and opening of the UES
- Reflexive
- Velopharyngeal port closes
Hyoid pulled superiorly and anteriorly
Pharynx shortens and larynx elevates
Airway closes and epiglottis inverts
Tongue base retracts and pharynx constricts rostro-caudally to create a descending wave to clear bolus
Upper esophageal sphincter relaxes and distends to accommodate the bolus
Bolus passes into esophagus
32
Esophageal phase -
Reflexive
Cricopharyngeus muscle returns to tonic state to avoid retrograde bolus entry
Esophageal peristalsis is activated, squeezing bolus through esophagus
LES is triggered to relax and bolus is squeezed into stomach
33
The swallow is Coordinated within the _____ where the ____ receives ___ & the ___ sends out __
brainstem (primarily medulla) ;
Nucleus tractus solitarius receives information (dorsal; sensory)
and the Nucleus ambiguus (ventral; motor) sends out information
34
Intrinsic tongue muscles: how many, origin?, what to they make & do?
Extrinsic tongue muscles: how many? ORIGIN? what do they do?
INTRINSIC : 4
- No bony origin
Form body of tongue
Change tongue shape
EXTRINSIC: (4 total)
- Originate outside of the tongue at a bone
- Change tongue position
35
Face: innervated by
facial nerve (CN VII)
36
Mastication: innervated by
trigeminal nerve (CN V), except for geniohyoid
37
Tongue: innervated by
hypoglossal nerve (CN XII), except for palatoglossus
38
Suprahyoid muscles – supports
laryngeal elevation
39
Larynx: innervated by
vagus nerve (CN X), except for thyrohyoid
40
Pharynx: innervated by
vagus nerve (CN X), except for stylopharyngeus
41
Airway Protection - how is it protected, multiple ways
Primary Protection
- Laryngeal vestibule closure
- Arytenoid adduction and anterior arytenoid movement
- Epiglottic inversion
Secondary protection
- Closure of the true and false vocal folds
Passive protection
- Diversion of the bolus through lateral channels of the pharynx (e.g., vallecula)
42
larynx closes from top to bottom or bottom to top & why
bottom to top cz if something enters it can help eject it
43
UES Opening - detailed description
- Relaxation of the cricopharyngeus muscle
- Hyolaryngeal elevation provides traction on the cricopharyngeus to stretch it
- Intrabolus pressure and volume pushes it open even further (e.g., small bolus = smaller UES opening; large bolus = larger UES
44
Profiles of specific populations who may present with dysphagia (e.g., developmental disorders, neurogenic disorders, surgical procedures).
AHHHHHH LOL
45
*Swallow is triggered when bolus hits
anterior faucial pillars
46
Compensatory Strategies
Compensatory Strategies
COMPENSATE for a problem
Are not intended to change swallowing physiology, but rather modify external factors in order to improve swallowing function
Diet texture modification
Chin tuck
Chin up
Head turn
Head turn, chick tuck
Effortful swallow
Saliva swallow
Water wash
Superglottic swallow
Super-supraglottic swallow
Mendelsohn maneuver
47
Rehabilitative Strategies
FIX the problem
Work to change/improve swallowing physiology
Shaker
Mendelsohn maneuver
Effortful swallow
Masako maneuver
Tongue pressure training
Expiratory muscle strength training
48
Chin Down/Chin Tuck
Chin Down/Chin Tuck
Posture: “chin-to-chest” (not look down)
Target(s):
Widens valleculae
Helps patient keep bolus in the oral cavity
Narrows airway
Clinical Indications:
Vallecular residue
Oral containment issues (posterior loss of bolus resulting in aspiration)
Reduced airway closure
49
Chin-up
Chin-up
Posture: chin is tilted up
Targets(s):
Facilitates posterior movement of the bolus from the oral cavity
Clinical indications:
Pharyngeal phase must be intact
Use with patients with poor anterior-posterior propulsion of bolus (e.g., glossectomy)
50
Head Turn
Posture: Turn head to the weak side
Target(s):
Directs the bolus to the stronger side
Clears unilateral residue
Clinical Indications:
Unilateral pharyngeal paralysis or paresis
51
Head-turn-plus-chin-down
Head-turn-plus-chin-down
Posture: turn head and tuck chin
Target(s):
Directs bolus to one side
Widens valleculae
Narrows airway
Clinical indications:
Presence of vallecular residue, without any pyriform sinus residue
Risk of aspiration AND unilateral residue
52
Effortful Swallow
Effortful Swallow
Maneuver: Swallow with extra strength/pressure/force
Instructions:
Swallow as hard as you can with food or saliva (“like you’re swallowing a whole grape”)
Push as hard as you can with the tongue against the roof of your mouth while you swallow
Target(s):
Increase strength of the overall swallow
Clear residue
Clinical Indications:
Vallecular residue
Patient says they feel post-swallow residue
Reduced tongue base retraction
53
Liquid Water Wash
Liquid Water Wash
Clinical Indications:
Use when residue remains in the oropharynx
Instructions:
After swallowing an item that leaves residue (e.g., thickened liquid or solid), ask patient to take a sip of water (or thinnest liquid that the patient is able to swallow, safely)
54
Saliva Clearing Swallow
Clinical Indications:
Use when residue remains in the oropharynx
Instructions:
After swallowing an item that leaves residue (e.g., thickened liquid or solid), ask patient to swallow their own saliva as they normally would
55
Mendelsohn Maneuver
Maneuver: prolonged hold of larynx in its maximally elevated position during the swallow
Instructions:
Swallow normally. Feel the larynx lift during the swallow.
On the next swallow, feel your larynx elevating and hold it up with your neck muscles.
Do not try to lift the larynx early. Let the larynx lift normally and then hold it up so that it does not drop for ___ seconds. Complete the swallow.
Target(s):
Improve laryngeal elevation
Widen the valleculae
Clinical Indications:
Reduced laryngeal elevation
Reduced UES opening
Uncoordinated swallow
56
Jaw Opening Exercises(MEH)
Improve hyoid/hyolaryngeal excursion; increase UES opening
Increased suprahyoid muscle strength
Instructions; isometric and isotonic jaw opening exercises (with and without resistance); clinician and/or bio-feedback
57
Head Lift/Recline Exercise (Shaker)
Head Lift/Recline Exercise (Shaker)
Improve hyolaryngeal excursion; increase UES opening
Increased suprahyoid muscle strength
Patient to lift head either while in a supine position or white seated at a 45º angle;
Hold position for 1 min (isometric) and then rest for 1 min; and/or
Lift head and return to rest position (30x)
58
Chin Tuck Against Resistance
Chin Tuck Against Resistance
Various; increased laryngeal elevation; improved epiglottic deflection
Increased activation and strength of suprahyoid muscles
CTAR device or stress ball; Instructions to place ball between chin and chest and then execute neck flexions; Demonstrations of the exercise; Emphasis/feedback on correct posture
59
Tongue Resistance Training(MEH)
Tongue Resistance Training
Increase isometric and swallowing tongue pressures
Strengthen the tongue and suprahyoid muscles using isometric pressure exercises; repetition and overloading
Tongue pressure manometer and bulb; provide instruction of anterior or posterior isometric presses; provide biofeedback; cue for saliva swallows; reposition bulb between swallows
60
Expiratory Muscle Strength Training(MEH)
Various; increased hyoid bone displacement; improved airway protection; increased expiratory force; increased cough strength
Increase strength and contraction of expiratory and submental muscles
Calibrated EMST device or breather device; training load set weekly; nose plugs; demonstration; practice with supervision before independent use; written and verbal instructions; feedback & weekly check-ins
61
LSVT
(MEH)
Increased UES opening; increased cough effectiveness; improved tongue function
Increased neuromuscular control of the aerodigestive tract
Instructions; prescribed voice exercises; training self-monitoring of vocal loudness; daily practice; carryover activities
62
Masako Maneuver
Masako Maneuver
Improve pharyngeal constriction
Increased recruitment of the superior pharyngeal constrictor
Provide instructions to place tongue between teeth and hold in place lightly with teeth while swallowing
63
Mendelsohn Maneuver
Increase laryngeal elevation and maximal hyoid superior displacement; increase duration of UES opening
Increased activation of suprahyoid muscles; prolonged hyolaryngeal excursion (more time for clearance)
Instructions and encouragement to swallow “long and strong” with squeeze and hold at the peak of swallow for 3 seconds
64
Effortful Swallow
Increase oral and pharyngeal swallow pressures; reduce pharyngeal residue
Increased recruitment of tongue and pharyngeal muscles during swallowing
Provide instruction to press tongue against hard palate while squeezing neck muscles and swallowing forcefully; visual observation and palpation to confirm accuracy; supervision and encouragement during training; biofeedback (where available); rest provided as necessary
65
McNeil Dysphagia Training Program
McNeil Dysphagia Training Program
Improved initiation and coordination of swallowing
Progressive strengthening and coordination/organization of muscle movement, via hierarchical program
Instructions; progression through a defined program hierarchy (unpublished); record of progress and clinical signs; home practice and dietary recordings
66
Respiratory Swallow Training
Respiratory Swallow Training
Improved coordination of swallow and respiration
Acquisition and mastery of exhale-swallow-exhale sequence
Verbal and visual instructions and feedback; graphic illustrations; hierarchical tasks/training for motor learning phases (identification, acquisition, mastery)
