Dysphagia Flashcards
Left CVA lesion
deficits in oral phase and initiation of swallow, but better recovery of swallow function than right CVA
Right CVA lesion
deficits in pharyngeal phase and aspiration/penetration before swallow is initiated, delayed pharyngeal constriction.
Pons lesion
hypertonicity, delayed/absent swallow response, reduced laryngeal elevation, cricopharyngeal dysfunction, and slow recovery
Medulla lesion
longer pharyngeal response time, increased duration for velar and laryngeal elevation, delayed opening of UES
Subcortical lesion
mild oral and pharyngeal transit delays, aspiration, laryngeal penetration
Dementia clinical findings
trouble with bolus prep, self feeding, and food prep, prolonged oral stage
Basal ganglia (parkinson’s) clinical findings
repetitive tongue pumping, difficulty in all stages, progressive in nature
CN V
normal function: sensation in anterior ⅔ of tongue, sensation to teeth, gums, and oral mucosa, salivary flow to major and minor glands, motor control of mouth opening, mandible motion and mastication, motor innervation to floor of mouth muscles to elevate larynx and hyoid
Abnormal function: difficulty chewing, forming a bolus (oral stage deficits), inability to initiate swallow response, deficits in hyoid elevation, insufficient epiglottic tilt
CN VII
Normal function: taste in anterior ⅔ of tongue, sensation to soft palate, salivation from all salivary glands (except parotid), motor control of lip motion and bilabial seal, motor control for the facial muscles, floor of mouth, and cheeks, assists in elevation of hyoid and larynx to protect airway.
Abnormal function: loss of bolus through front of mouth, drooling, over or under salivating (oral stage deficits), pocketing of food, insufficient epiglottic tilt,
CN IX
Normal function: taste in posterior ⅓ of tongue, sensation to faucial pillars and soft palate, salivation from parotid, sensation to the pharynx and larynx, motor velopharyngeal closure, motor control of the upper pharyngeal constrictor muscle
Abnormal function: residue in the pharynx, nasopharyngeal regurgitation (incomplete seal due to decreased pharyngeal constriction), weakness in pharyngeal constriction, impaired opening of UES, impaired laryngeal elevation, inability to initiate swallow response
CN X
Normal function: controls sensory information for pharyngeal and esophageal phases, sensation for pharynx, larynx, and trachea, visceral sensory for mucosa of the valleculae, pharynx, larynx, lungs, stomach, and abdomen, motor innervation to the base of tongue and pharyngeal muscles, major innervation to the larynx, diaphragm, and lungs, pharyngeal contraction and esophageal peristalsis
Abnormal function: nasopharyngeal regurgitation (decreased pharyngeal constriction), decreased pharyngeal constriction (residue in the pharynx), aspiration due to incomplete closure of the v.f., silent aspiration due to decreased sensation in the larynx, residue in the pyriform sinuses, residue in valleculae, inability to propel the bolus, absence of peristalsis in esophagus
CN XI
Normal function: partial innervation of soft palate and uvula, assists with velopharyngeal elevation, partial innervation of muscles of upper pharynx, provides stability of shoulder and neck muscles during swallow and allow rotation of the head and neck
Abnormal function: nasopharyngeal regurgitation, residue in pharynx
CN XII
Normal function: motor for all tongue muscles, seal oral cavity and prepare bolus, motor innervation of the pharynx, aids in hyolaryngeal elevation and airway protection
Abnormal function: residue in the oral cavity, inability to form bolus, premature loss of bolus, residue in the vallecula, aspiration, penetration, insufficient epiglottic tilt
Temporalis
mandibular branch of CN V. raise/brace mandible, chewing, closing oral cavity
Masseter
mandibular branch of CN V. raise/brace mandible, chewing, closing oral cavity
Medial pterygoid
mandibular branch of CN V. raise/brace mandible, chewing, closing oral cavity
Lateral pterygoid
mandibular branch of CN V. lower/protrude/rock mandible, chewing
Obicularis oris
CN VII. seal lips/mouth
Buccinator
CN VII. push food toward teeth during mastication, help close mouth
Superior longitudinal
intrinsic tongue muscle, CN XII. shorten tip/deflect (up lateral)/concave bow tongue, bolus prep/formation/positioning/transport
Inferior longitudinal
intrinsic tongue muscle, CN XII. shorten tip/deflect (up lateral)/concave bow tongue, bolus prep/formation/positioning/transport
Transverse
Intrinsic tongue muscle, CN XII. narrow/lengthen tongue, bolus prep/formation/positioning/transport
Verticalis
Intrinsic tongue muscle, CN XII. broaden/flatten tongue, bolus prep/formation/positioning/transport
Hyoglossus
extrinsic tongue muscle, CN XII. lower/retract tongue, bolus prep/formation/positioning/transport
Genioglossus
extrinsic tongue muscle, CN XII. protrude/retract tongue, bolus prep/formation/positioning/transport
Styloglossus
extrinsic tongue muscle, CN XII. raise/retract tongue, bolus prep/formation/positioning/transport, seal oral cavity
Mylohyoid
suprahyoid, CN III. raise/stabilize hyoid. stabilize tongue, FOM
Geniohyoid
suprahyiod, CN XII. raise/protract/stabilize hyoid bone
Stylohyoid
suprahyoid, CN VII. raise/retract/stabilize hyoid, elongate mouth floor
Anterior belly of diagastric
suprahyoid, CN III. raise/stabilize hyoid, lower mandible
Posterior belly of diagastric
suprahyoid, CN VII. raise/retract/stabilize hyoid, lower mandible
Omohyoid
Infrahyoid. Lower/stabilize hyoid
Sternohyoid
Infrahyoid. Lower/stabilize hyoid.
Thyrohyoid
Infrahyoid. Lower/stabilize hyoid, raise larynx to hyoid
Sternothyroid
Infrahyoid. Lower/stabilize larynx
Tensor veli palatini
CN V. Tense soft palate
Levator veli palatini
CN XI and X. Raise/retract soft palate, widen entrance to oropharynx, seal nasopharynx
Palatoglossus
CN XI and X. Raise uvula, brace soft palate
Stylopharyngeus
CN IX. Raise/shorten pharynx, raise larynx
Palatopharyngeus
CN XI and X. Lower palate, raise/shorten pharynx, raise larynx, seal oral cavity
Salpingopharyngeus
CN XI and X. Raise/shorten pharynx, raise larynx
Superior pharyngeal constrictor
CN XI and X. Narrow pharyngeal lumen, seal nasopharynx, bolus transport
Middle pharyngeal constrictor
CN X. Narrow pharyngeal lumen, bolus transport
Inferior pharyngeal constrictor
CN XI and X. Narrow pharyngeal lumen, bolus transport, most distal component of upper esophageal sphincter
Lips/face/teeth OME
Nonspeech: Symmetry at rest; labial retraction, pucker, labial seal, raise eyebrows, wrinkle forehead, smile, frown
Speech: DDKs
Jaw OME
Nonspeech: Symmetry, open, close, resistance, lateralization, tactile sensations, range of motion
Speech: bite block (not used normally)
Velum/pharynx OME
Nonspeech: Position at rest, breathing nasality, gag reflex (no longer used to determine problems)
Speech: oral/nasal minimal pairs (note vs. dote), no nasal assimilation to oral consonant (bambi; pamper)
Tongue OME
Nonspeech: Protrusion, lateralization, elevation, strength against resistance
Speech: DDKs, speech articulation
Respiratory mechanism OME
Nonspeech: breathing at rest, rate, depth, quiet/noisy
Speech: MPT, habitual loudness, loudness range, syllables per breath
Larynx OME
Nonspeech: cough, throat clear, larynx rise during swallow
Speech: sustain voice sounds; alternate voice/voiceless; voice quality (CAPE-V)
Benefits of clinical examination
locus of the patient’s dysphagia, that is, whether it is oral or pharyngeal
patient’s readiness for a radiographic study
patient’s ability to accept food into the mouth
oral reaction to placement of various tastes, temperatures, and textures in oral cavity
presence of any oral apraxia, abnormal oral reflexes such as tonic bite
any particular postural and behavioral needs of the patient that must be addressed during the radiographic study.
Laryngeal Function as it may affect airway protection and aspiration during the swallow.
Coughing status
Decision on Best Posture
Best Position of Food in Mouth
Oral Sensitivity
Best Food Consistency
Selection of Optimum Swallowing Instructions (Posture or sequence of postures)
Limitations of clinical examination
38 - 40% of patients who aspirate are not identified on clinical examination
Pharyngeal events are not observable
Basis for aspiration cannot be determined
Benefits of VFSS (MBS)
Dynamic
Thorough
Unlimited review capacity
Readily available in hospital setting
Limitations of VFSS (MBS)
Exposure to radiation “Snapshot” of swallow function Abnormal environment Transport to radiology may be problematic Not easily accessible outside hospital
Benefits of FEES
No radiation exposure
equipment is portable,
The clinician can assess VPI (velopharyngeal incompetence) and vocal cord issues
Gives immediate results
Limitations of FEES
Invasive - Difficulty maintaining cooperation in 12 mos - 4 yrs olds
doesn’t give info on interaction of oral, pharyngeal and esophageal phases of swallowing
How is the modified evans blue dye test performed?
EBDT -Described by Cameron et al 1973
–Place 4 drops of aqueous solution of Evans blue dye on patient’s tongue q 4 hours
–Monitor tracheal secretions for bluish discoloration for 48 hours
–Any evidence of blue dye in tracheal secretions indicates aspiration
–Perform routine tracheostomy care
Components of MEBDT:
•Color liquids and solids with blue dye
•Deflate cuff
•Present boluses in order of difficulty
•Suction after each bolus consistency
•Examine tracheal secretions for evidence of blue tint
•Recommend diet; specify compensations and conditions of PO intake
What are the limitations of MEBDT?
Not sensitive enough to detect trace aspiration, increased risk for sepsis, burns, shock, surgical intervention, renal failure, celiac sprue, IBD
Oral stage deficits
Lips don’t seal, no teeth, flaccid cheeks, drooling, poor bolus formation, prolonged oral stage, unable to propel bolus, reduced/weak lingual movement, kinking of the soft palate, loss of bolus over base of tongue, premature leakage
Pharyngeal phase deficits
poor soft palate seal, nasopharyngeal regurgitation, sluggish elevation of the soft palate, constrictors don’t contract, unilateral asymmetry, retention in vallecula/pyriforms, absent hyoid elevation, incomplete/absent epiglottic tilt, vocal folds open during swallow, aspiration/penetration, problem with cricopharyngeus opening late/closing early
Esophageal stage deficits
dysmotility, reflux, spasms, stenosis, diverticulum, GERD, fistula
How can a tracheostomy affect swallowing?
Restriction of laryngeal elevation, decreased laryngeal sensitivity, decreased glottal pressure, interrupts the cricopharyngeus, causes difficulty in expelling air
Be able to state factors which increase risk of aspiration pneumonia in individuals with dysphagia
Impaired consciousness, poor mobility, COPD, medication, age, poor oral hygeine
State the main limitations of electrical stimulation as a therapeutic intervention.
Many limitations to existing research (ie., unequal treatment, dosage of stim unreported, multiple
threats to internal/external validity)
Unanswered questions (which muscles stimulated?, where place electrodes, effects LT/ST?)
Potential for harm - anecdotal reports worsen swallow & ES resulted in decreased hyoid elevation
Surface ES stimulates superficial, not deep muscles
Lost time (family & clinician)
Slowed progress
Lost hope and misplaced trust
Loss of credibility
Know the steps of a clinical/bedside swallow evaluation from referral through recommendations
- Interview patient and caregivers
- Examine speech/swallow components
- Observe what happens when patient is fed
- Teach compensations
- Tailor instrumental exam
Assessment of functional components
Respiratory- breathing rate, sustained phonation, loudness
Laryngeal- laryngeal elevation, sustained phonation, voice quality (rough, strained), voiced/voiceless contrasts
Velum/pharynx- mirror under nose, nasal sounds (look for nasal assimilation or stuffiness)
Tongue- protrusion, DDK
Lips/face/teeth- pucker, raise eyebrows, DDK
Jaw- open against resistance, range
Understand how a tracheostomy cannula may preclude some swallowing strategies
Restriction of laryngeal elevation Decreased laryngeal sensitivity Decreased glottal pressure Interrupts the cricopharyngeus Causes difficulty in expelling air
