Dysphagia Lecture 1 Flashcards
What is dysphagia? (3)
1 Difficulty swallowing
2 Difficulty moving bolus from the mouth to the stomach
3 Not age-specific (newborn>elderly)
*Not just a one time event. More chronic than that.
Etiologies of dysphagia (4):
1 infection
2 structural malformations
3 surgery (thyroid/RLN/cervical)
4 conditions that weaken/damage muscles/nerves
(CVA, PD, TBI)What are the possible Consequences of dysphagia? (4)
1 Dehydration (e.g. coughing on thin liquids so pt avoids them)
2 Malnutrition (avoiding food that they have a hard time swallowing so not getting a rounded diet)
3 Aspiration pneumonia (repeated bouts of aspiration, food/drink gets pushed down and sits in lungs and grows bacteria.)
4 Quality of life
What are the Types of dysphagia? (4)
1 Oral (tongue mvmt, lip closure, pocketing, transport)
2 Pharyngeal (airway closure, residues, motility, UES (upper esophageal sphincter))
3 Oropharyngeal* (both oral and pharyngeal dysphagia)
4 Esophageal (motility, LES (lower esophageal sphincter), fistula, diverticulum, HCl – reflux; ulcer)
What are the Stages of dysphagia? (3)
1 (Oral Prep) / Oral (time varies with bolus consistency)
2 Pharyngeal (~ 1 second)
3 Esophageal (~ 10 seconds)
Oral Prep / Oral Stage of dysphagia:
(time varies with bolus consistency)
Involves: mastication, bolus formation, and bolus transport from the oral cavity to the pharynx
Pharyngeal Stage of dysphagia:
Time: (~ 1 second)
Involves: epiglottis inverts over the laryngeal vestibule
larynx and hyoid bone are pulled anteriorly and superiorly to open the pharynx, relax the cricopharyngeus (UES) muscle, and assist the vocal folds in closing off the glottis
bolus is propelled through the pharynx toward the esophagus by action of pharyngeal constrictors
Esophageal Stage of dysphagia:
Time: (~ 10 seconds)
Involves: bolus flows through the esophagus via peristaltic contractions of striated and smooth muscle along the esophageal wall
relaxation of LES (lower esophageal sphincter) allows bolus to flow into the stomach
Signs and Symptoms of Oral or pharyngeal dysphagia: (14)
1 Coughing or choking with swallowing
2 Difficulty initiating swallowing
3 Food sticking in the throat
4 Sialorrhea (excessive siliava)/ xerostomia (dry mouth)
5 Drooling or spillage (e.g. premature spillage-over the tongue base and pharyngeal phase not triggering)
6 Unexplained weight loss (10% weight loss in a short time)
7 Change in dietary habits (avoiding certain things)
8 Penetration (bolus or part of bolus gets past epiglottis and into laryngeal vestibule area)
9 Aspiration (bolus gets past the vocal folds)
10 Recurrent pneumonia
11 Change in voice (wet, gurgly voice quality)
12 Nasal regurgitation
13 Tearing and/or nose running (typically signs of silent aspiration)
14 Sore throat (reflux involved?)
Signs and Symptoms of Esophageal dysphagia: (7)
1 Sensation of food sticking in the chest or throat (happens frequently with radiation patients, causes esophageal narrowing/esophageal strictures)
2 Chest pain
3 Oral or pharyngeal regurgitation
4 Change in dietary habits
5 Recurrent pneumonia
6 Reflux
7 Aspiration
Signs and Symptoms of SILENT ASPIRATION!!
NO s/s!
No cough reflex
Possible signs: tearing, runny nose
Feeding =
= placement of food in the mouth before initiation of swallow
Stages of Feeding: (1)
Oral prep stage (salivation, presentation)
Swallowing =
= transfer of food/drink from mouth to stomach
There are 3 stages:
- Oral stage
- Pharyngeal stage
- Esophageal stage
What is all included in a Swallow Screening? (5)
1) 10-15 minute administration/ observation of a small bolus
2) Bedside clinical assessment
3) Assess Signs & symptoms
4) Cannot assess A & P
5) Pre-diagnostic
What is included/assessed during the bedside clinical assessment for a swallow screening: (6)
1 Bedside clinical assessment 2 Medical history 3 Level of alertness 4 Pt interview 5 Oral motor exam 6 Assess swallow with small bolus
What Signs & symptoms to look for during the bedside clinical assessment (9):
1) Spillage?
2) Oral residue?
3) Long transit time?
4) Cough?
5) Throat clear?
6) Gurgly voice?
7) Tearing?
8) Runny nose?
9) Wrong sound (auscultation)?
Diagnostic Procedure: (5)
1) ID symptoms to explain abnormalities in anatomy or physiology causing dysphagia (etiology)
2) Examines Physiology
Timing, tongue base motion, epiglottic dysfunction, laryngeal excursion, UES dysfunction, peristalsis, paralysis, sensitivity
3) Examines immediate effects of tx’s
4) Imaging:
FEES/FEESST (Fiberoptic endoscopic evaluation of swallowing), videofluoroscopy*, ultrasound, videoendoscopy, scintigraphy
5) Nonimaging:
EMG, EGG, acoustic (accelerometer or stethoscope), pharyngeal manometry
What’s the leading cause of Death for PD pts?
Aspiration pneumonia
When should the pharyngeal swallow should be triggered?
As soon as the bolus gets transported to the back of the tongue and the head of the bolus gets to the anterior+posterior faucial pillars, what should happen?
Many things happen: upper esophageal sphincter opens. Epiglottis closes. VF close. etc.
Which stage dysphagia is the most common?
pharyngeal dysphagia
If the bolus gets into the laryngeal vestibule it is:
penetration
If the bolus gets past the vf it is:
aspiration
T?F
If the bolus gets past the vf but the person coughs it out we don’t call it aspiration.
FALSE.
We still say they have aspiration with a cough.
Flash penetration =
bolus penetrates but doesn’t stay
How would someone get a wet/gurgly voice?
If they penetrate and the bolus lays on the vf
What stage does silent aspiration occur during?
Pharyngeal
If the vagus nerve is effected, then what reflex might be effected?
the cough reflex
Examining Physiology during diagnostic: (8)
Look at:
1) Timing
2) tongue base motion
3) epiglottic dysfunction
4) laryngeal excursion
5) UES dysfunction
6) peristalsis
7) paralysis
8) sensitivity
Types of Imaging for Swallowing: (5)
1) FEES/FEESST (Fiberoptic endoscopic evaluation of swallowing)
2) videofluoroscopy*
3) ultrasound
4) videoendoscopy
5) scintigraphy
Types of Non-Imaging for Swallowing: (4)
1) EMG
2) EGG
3) acoustic (accelerometer or stethoscope)
4) pharyngeal manometry
Types of Treatment for Swallowing: (8)
1) Diet modification
2) Compensatory
3) Maneuver
4) Exercise
5) Stimulation
6) Experimental
Done by other professionals:
7) Prosthetic
8) Surgery
Who is a part of the multidisciplinary swallowing team? (10)
1) SLP
2) Physician / Neurologist / ENT
3) Nursing
4) Dietician
5) OT
6) PT
7) Radiologist (especially for MBS)
8) Pharmacist (lots of meds can cause dysphagia)
9) Social worker
10) Psychologist
Treatment: Diet Modification can include (5)
- volume
- viscosity
- texture
- temperature
- NPO (no food through the mouth)- NG tube, G tube, PEG, J tube, TPN)
Treatment: Types of Compensatory Treatment Methods:
Positional: posture, chin tuck, head rotation
Multiple swallows
Treatment: Types of Maneuvers (4):
1) Supraglottic Swallow
2) Super-supraglottic Swallow
3) Mendelsohn Maneuver
4) Effortful Swallow
Treatment: Types of Exercises for Swallowing: (3)
1) Shaker
2) Masako
3) Oral muscle strengthening
Treatment: Types of Stimulation:
Thermal/Tactile Stim
Treatment: Types of Experimental Treatments: (4)
1) Neuromuscular electrical stimulation [NMES: “VitalStim”]
2) Deep Pharyngeal Neuromuscular Stimulation [DPNS]
3) Myofascial release [MFR]
4) Botox
Treatment done by other professionals: Prosthetic (2)
1) Palatal lift
2) Obturator
Treatment done by other professionals: Surgery (3)
1) CP myotomy
2) Diverticulectomy
3) Dilation
