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Adult Swallowing Disorders > Dysphagia Unit 2 > Flashcards

Dysphagia Unit 2 Flashcards

1
Q

overview of etiologies: anatomical

A
  • structural problems
  • either sufficient tissue or too much tissue
  • birth defects
  • removal of tissue due to tumors
  • scar tissue
  • calcium deposits
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2
Q

overview of etiologies: physiological

A
  • problems with how the structures function
  • usually neurological problems
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3
Q

overview of etiologies: iatrogenic

A
  • problems secondary to medical intervention
  • side effects of medication/treatment
  • tracheostomy
  • laryngectomy
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4
Q

considerations with swallowing problems related to neurologic disorders

A
  • large number of “silent aspirators” i.e. those who have no signs that aspiration is occurring
  • fatigue factors
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5
Q

silent aspirators

A
  • no cough, throat clearing, gurgly vocal quality
  • may be unaware of their swallowing difficulties
  • no dry swallows even when food is visibly still in pharynx
  • may be as high as 50% of neurologically impaired dysphagic patients
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6
Q

fatigue factors

A
  • prone to fatigue throughout the mean and/or throughout the day
  • fatigue may negatively affect the patient’s swallow fuction
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7
Q

when does aspiration occur?

A

can occur before, during, or after the swallow

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8
Q

aspiration before the swallow

A

delayed swallow response

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9
Q

aspiration during the swallow

A

poor pharyngeal constriction

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10
Q

aspiration after the swallow

A

residue in the valleculae, pyriform sinuses, sulci (cheeks), or on the pharynx

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11
Q

questions posed by the clinician for those who may improve

A
  1. what treatment should initiated to make the swallow more normal?
  2. will the patient be able to eat a normal diet? if so, when?
  3. is the patient’s recovery typical for this type of lesion?
  4. what other factors may interact with the neurologic damage to worsen the dysphagia?
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12
Q

CVA: general considerations

A
  • non-complicated (no other co-morbidities) stroke patients recovered steadily and quickly
  • although recovery occurred, temporal measures were not normal
  • recovery was most rapid in the first 3 weeks
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13
Q

CVA: non-complicated (no other co-morbidities) stroke patients recovered steadily and quickly

A

95% returned to full oral intake by 9 weeks post assault regardless of site of lesion

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14
Q

CVA: although recovery occurred, temporary measures were not normal

A

function swallows with no aspiration were achieved but pharyngeal transit times were longer with more oral and/or pharyngeal residue evident

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15
Q

CVA: recovery was most rapid in the first 3 weeks

A
  • suggest need to assess week 1 and then reassess week 3 or 4
  • may have progressed from non-oral to oral intake in this short time
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16
Q

CVA: lesions of the lower brainstem (medulla)

A

significant oropharyngeal impairments (location of major swallowing center is in the medulla)

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17
Q

CVA lesions of the lower brainstem: 1st week post stroke

A

absent pharyngeal swallow

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18
Q

CVA lesions of the lower brainstem: 2nd week post stroke

A
  • delay 10-15 seconds
  • often have submandibular tongue base and hyoid movement but no true swallow
  • when swallow does initiate, reduced laryngeal elevation and anterior movement with reduced cricopharyngeal opening
  • may have unilateral pharyngeal weakness
  • some may have unilateral vocal folds paresis/paralysis
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19
Q

CVA lesions of the lower brainstem: 3rd week post stroke

A

sufficient recovery for functional swallow and full oral intake (modified diet?)

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20
Q

CVA: high brainstem lesion (pontine)

A
  • mild delays in oral transit time (3-5 seconds)
  • mild delays in initiating swallow response (3-5 seconds)
  • mild to moderate impairments in timing neuromuscular control in the pharynx
  • may demonstrate aspiration before due to delay in initiating pharyngeal swallow or after due to neuromotor control issues in pharynx
  • recovery to full oral intake may take 3-6 weeks
  • longer if medical complications present (ex: pneumonia, diabetes)
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21
Q

CVA: cortical stroke (anterior left hemisphere)

A
  • may result in apraxia of swallow
  • delay in initiating oral swallow with no tongue movement in response to presentation of food or mild to severe searching motions of the tongue
  • oral groping, incoordination, and inconsistent errors
  • mild oral transit delays (3-5 seconds)
  • mild delays in initiating the pharyngeal swallow (3-5 seconds)
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22
Q

CVA: cortical stroke (right hemisphere)

A
  • mild oral transit (2-3 seconds)
  • pharyngeal delays (3-5 seconds)
  • once swallow is initiated, slight delay in laryngeal
  • adds to aspiration before or just as swallow is initiated
  • slower recovery than left CVA due to inattention and difficulty sequencing-following multiple step commands even with tactile cues and physical prompting
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23
Q

CVA: multiple strokes

A
  • often have more significant and multiple problems
  • effects of CVA may be cumulative in nature
  • failure of swallow to return to “normal”
  • oral transit delays of 5 seconds or more
  • delays in initiating pharyngeal swallow (5 seconds or more)
  • may have reduced laryngeal elevation
  • unilateral pharyngeal weakness with residue on pharyngeal walls and/or in pyriform sinuses
  • reduced closure of the laryngeal vestibule resulting in penetration
  • decreased attending skills and difficulty following swallowing strategies
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24
Q

CVA: other considerations

A
  • tracheostomy
  • medications may worsen swallow
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25
Q

CVA: tracheostomy

A
  • inflated cuffs with trachs reduce laryngeal elevation due to “drag” resistance of cuff on tracheal wall
  • if longer than 6 months reduces laryngela closure due to limitation of air flow on vocal folds reducing stimulation to sensory receptors there
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26
Q

CVA: medications may worsen swallow

A
  • antidepressants slow coordination making swallow worse
  • xerostomia (dry mouth) as side effects or some medications or combinations of medications
  • visual neglect
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27
Q

TBI (closed head trauma): general considerations

A
  • swallowing problems can become quite complex dependent on extent and site of head injury, other bodily injuries, and nature of emergency care
  • generally swallowing problems become more severe the longer the patient is in a coma
  • usually tracheostomy, sometimes due to emergency situation due too high resulting in damage to the larynx
  • prolonged intubation can also cause laryngeal damage
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28
Q

TBI (closed head trauma): injuries from direct head injury

A
  • contra-coup damage
  • twisting and shearing of the brainstem
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29
Q

TBI (closed head trauma): also potential puncture wounds of the head and neck region

A

laryngeal fractures, penetrating chest wounds affecting the esophagus

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30
Q

TBI: swallowing related considerations

A
  • reduced lip closure, tongue range of motion
  • poor bolus control
  • abnormal reflexes (ex: bite reflex)
  • reduced laryngeal elevation
  • reduced closure of the airway entrance
  • unilateral or bilateral pharyngeal wall paresis or paralysis
  • tracheoesophageal fistula
  • reduced velopharyngeal closure
  • reduced laryngeal closure and reduced cricopharyngeal opening
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31
Q

tracheoesophageal fistula

A

an abnormal connection between your trach and esophagus

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32
Q

reduced velopharyngeal closure

A

preventing residue from going into the nasopharynx

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33
Q

TBI: other considerations

A
  • impulsivity
  • cognitive difficulties
  • reduced sensation
  • issues with compliance with treatment
  • seem to be able to tolerated aspiration at first but will eventually create problems for them
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34
Q

TBI: impulsivity

A

tendency to put too much in their mouths too quickly

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35
Q

TBI: cognitive difficulties

A

decreased understanding of swallowing maneuvers

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36
Q

TBI: reduced sensation

A

reduced awareness of swallowing difficulties

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37
Q

cervical spinal cord injury

A
  • swallowing problems even with no head injury present (with no head injury swallowing problems are generally pharyngeal)
  • delay in initiating pharyngeal swallow
  • reduced laryngeal elevation
  • reduced cricopharyngeal
  • reduced tongue base retraction
  • decreased unilateral or bilateral pharyngeal wall functioning
  • problems with vocal fold closure secondary to traumatic emergency airway management or to prolonged tracheostomy
38
Q

cervical vertebrae 1 or 2

A

no sensory awareness of swallowing difficulty

39
Q

cervical vertebrae 3 or above

A

generally in cervical brace on mechanical ventilation with trach tube with an inflated cuff

40
Q

cervical vertebrae 5 or above

A

very high incidence of pharyngeal swallowing problems

41
Q

cervical vertebrae 4, 5, or 6

A

decreased laryngeal movement and resulting reduced cricopharyngeal

42
Q

cervical bracing

A
  • not sure of effects on swallowing
  • in a study done with normal halo brace, swallowing “felt more difficult” when wearing the brace
  • MBS results showed increased duration of airway closure during the swallow while in brace but no other abnormal measurements
43
Q

cervical fusion

A
  • done to stabilize vertebrae in case of injury or degenerative disc disease
  • post operatively swelling in posterior pharyngeal wall
  • reduced laryngeal elevation and anterior movement with reduced closure of airway entrance and reduced cricopharyngeal opening
  • unilateral or bilateral pharyngeal wall movement
  • may have oral stage problems and delay in initiating swallow response
  • may have some reaction to hardware in the neck area from surgical procedure
  • generally significant recovery 3 months postoperatively
44
Q

Guillian-Barre syndrome

A
  • viral disease causing rapid onset of paresis which may progress to complete paralysis requiring tracheostomy and mechanical ventilation
  • general weakness: paralysis begins several days after swallowing difficulty noticed
  • generalized weakness in oral and pharyngeal swallow with reduced range of motion of oral tongue, tongue base, and larynx
  • progressive paralysis over a period of several days
45
Q

progressive neurological disease: questions raised by the clinician for these individuals

A
  1. are there typical changes in the swallow that can help identify the disease?
  2. are there predictable changes in swallowing in keeping with the lesion locations?
  3. how long can the patient continue eating by mouth?
  4. what techniques can prolong safe oral intake?
46
Q

Alzheimer’s vs. Dementia

A
  • dementia is a general term for a decline in mental ability severe enough to interfere with daily life
  • alzheimer’s is the most common cause of dementia
  • alzheimer’s is a specific disease and dementia is not
47
Q

Alzheimer’s disease

A
  • progressive dementia
  • food agnosia
  • feeding apraxia
  • swallowing apraxia
  • decreased lateral tongue motion for chewing
  • delay in initiating pharyngeal swallow
  • bilateral pharyngeal wall weakness
  • reduced laryngeal elevation
  • reduced tongue base retraction
48
Q

dementia

A
  • disconnect between oral and swallow and pharyngeal swallow
  • may be several minutes before the pharyngeal swallow initiates
  • pharyngeal swallow is intact once it is initiated
49
Q

dementia: disconnect between oral and swallow and pharyngeal swallow

A

disconnect between neural pathways between the cortex (controls oral swallow) and medulla (brainstem that controls pharyngeal swallow)

50
Q

ALS

A

progressive upper and lower motor neuron degeneration involving the corticobulbar tracts, corticospinal tracts, or both

51
Q

ALS: corticospinal tract

A

carries motor signals from the primary motor cortex in the brain, down the spinal cord, to the muscles of the trunk and limbs (involved in the voluntary movement of the muscles of the body)

52
Q

ALS (corticospinal tract): swallowing complications

A
  • slow to develop swallowing problems
  • reduced velar movement with food in nasal cavity
  • reduced pharyngeal wall contraction
  • 1st sign may be slow progressive weight loss and little/no awareness of a swallowing problem
53
Q

ALS: corticobulbar tract

A

carries motor, information from the primary motor cortex to the muscles of the face, head, and neck by synapsing with motor cranial nerves in the brainstem (responsible for innervating the muscles of the face, head, and neck as well as the muscles involved in swallowing, phonation, and facial expression)

54
Q

ALS (corticobulbar tract): swallowing complications

A
  • decreased tongue mobility (less able to control material in oral cavity)
  • unable to increase tongue pressure to handle thicker foods (reduced lip closure, drooling, food spillage from front of mouth)
  • reduced velar function (food in nasal cavity)
  • reduced tongue base retraction with reduced pharyngeal contraction resulting in residue in the pharynx (potential aspiration after the swallow)
  • delay in initiating pharyngeal swallow (risk of aspiration before the swallow)
  • reduced laryngeal elevation and reduced cricopharyngeal opening
  • complete laryngeal closure is impaired with resulting laryngeal penetration
  • respiratory compromise
55
Q

Parkinson’s disease

A
  • typical repetitive anterior to posterior tongue rocking pattern in oral transit
  • slight delay initiating swallowing response
  • decreased tongue base retraction
  • reduced pharyngeal wall contraction with residue in pharynx and pyriform sinuses after each swallow
  • reduced laryngeal closure
  • some cricopharyngeal dysfunction may also occur
  • end stage of disease may include dementia and severe rigidity making postural changes difficult
56
Q

Parkinson’s disease: readuced laryngeal closure

A

incomplete vocal fold closure resulting in aspiration during the swallow

57
Q

post polio

A
  • symptoms appearing 30 years post assault even for those who may have had no swallowing problems with the initial assault
  • unilateral and bilateral pharyngeal wall weakness
  • reduced tongue base retraction
  • reduced laryngeal elevation with decreased closure of the laryngeal vestibule resulting in aspiration after the swallow
  • patients don’t realize the increased swallowing difficulties and have to be convinced of changes by showing results of MBS study
58
Q

multiple sclerosis

A
  • multiple plaques in the neurological system from the cortex to the brainstem and cerebellum to the corticospinal tracts
  • most common problems: delay in triggering pharyngeal swallow, reduced tongue base retraction, reduced pharyngeal contraction with residue in the valleculae
  • depends on which cranial nerves are involved
59
Q

multiple sclerosis: hypoglossal (XII)

A
  • reduced lingual control of bolus
  • reduced control of chewing and oral transport of bolus
60
Q

multiple sclerosis: vagus (X)

A
  • reduced tongue base movement
  • reduced pharyngeal wall movement
  • reduced laryngeal function
61
Q

multiple sclerosis: glossopharyngeal (IX)

A

reduced triggering of pharyngeal swallow

62
Q

muscular dystrophy

A
  • muscular definition
  • overall problem for muscular dystrophies of all types is reduced pharyngeal wall contraction
63
Q

muscular dystrophy: myotonic dystrophy

A
  • prolonged contraction and difficulty relaxing involved muscles
  • sternocleidomastoid
  • muscles of mastication
  • cricopharyngeal sphincter
64
Q

muscular dystrophy: oculopharyngeal dystrophy

A
  • selectively involves ocular and pharyngeal muscles
  • reduced pharyngeal contraction
  • dysfunction of the muscular portion of the cricopharyngeal juncture (doesn’t relax)
65
Q

chronic obstructive pulmonary disease (COPD)

A
  • demonstrate airflow limitations (failure to exhale sufficient amounts of carbon monoxide)
  • no aspiration found in COPD patients studied but differences with some confirmation of same in studies of individual patients
  • suggested that during exacerbation of respiratory issues patients swallowing on inhalation as opposed to exhalation (increased risk for aspiration)
  • COPD patients may experience more GERD and increased risk of aspiration due to reflex
  • unable to determine if some of the above is cause of or result of exacerbation
66
Q

oral swallowing concerns

A
  • apraxia of swallow
  • trismus
  • reduced length strength/range of motion
  • reduced labial tension/tone
  • reduced buccal tension/tone
  • reduced tongue range of motion/strength
  • reduced tongue coordination
  • reduced tongue-palate contact/reduced tongue elevation or strength
  • residue in the oral cavity related to scar tissue
  • poor dental status
67
Q

trismus

A
  • reduced mouth opening
  • often a side effect of radiation treatment to the mouth/pharynx
68
Q

reduced lip strength/range of motion

A

food spillage out of the front of mouth/drooling

69
Q

reduced labial tension/tone

A

residue in anterior sulci

70
Q

reduced buccal tension/tone

A

residue in lateral sulci

71
Q

reduced tongue range of motion/strength

A

residue on the tongue

72
Q

reduced tongue coordination

A
  • poor bolus formation/transport/loss of liquid or pudding consistency into the pharynx
  • premature slippage over the back of the tongue
73
Q

reduced tongue-palate contact/reduced tongue elevation or strength

A

residue on the hard palate

74
Q

pharyngeal swallowing concerns

A
  • reduced velopharyngeal strength
  • unilateral or bilateral pharyngeal wall weakness
  • reduced tongue based retraction
  • reduced laryngeal elevation/reduced cricopharyngeal opening
  • laryngeal penetration
  • reduced vocal fold closure
  • cricopharyngeal dysfunction
75
Q

reduced velopharyngeal strength

A

nasal emesis

76
Q

unilateral or bilateral pharyngeal wall weakness

A

residue on pharyngeal walls

77
Q

reduced tongue based retraction

A

residue in the valleculae

78
Q

reduced laryngeal elevation/reduced cricopharyngeal opening

A

residue in the laryngeal vestibule and/or pyriform sinuses with potential aspiration after the swallow

79
Q

laryngeal penetration

A

bolus in the laryngeal vestibule either coughed out or aspirated after the swallow

80
Q

reduced vocal fold closure

A

aspiration during the swallow

81
Q

cricopharyngeal dysfunction

A
  • residue in the pyriform
  • slow or partial entry of bolus into esophagus
82
Q

esophageal swallowing concerns

A
  • cricopharyngeal dysfunction
  • esophageal stenosis (narrowing) or constrictors
  • tracheoesophageal fistula
  • Zenker’s diverticulum
  • reduced esophageal motility
  • acalasia
  • gastroesophageal reflex disease (GERD)
  • laryngoesophageal reflux
83
Q

cricopharyngeal dysfunction

A

reflex of material back into esophagus

84
Q

esophageal stenosis (narrowing) or constrictors

A
  • failure of bolus to pass through esophagus and/or possible reflux into pharynx
  • aspiration after the swallow
85
Q

tracheoesophageal fistula

A
  • a hole develops between the tracheal-esophageal wall
  • aspiration after the swallow
86
Q

Zenker’s diverticulum

A
  • side pocket that forms when the esophageal or pharyngeal wall herniates
  • food collects in the pocket
  • aspiration after the swallow
87
Q

reduced esophageal motility

A

slow transport of bolus through the esophagus

88
Q

acalasia

A
  • lower esophageal sphincter fails to relax
  • often disrupts peristaltic movement as material backs up in the esophagus
89
Q

gastroesophageal reflux disease (GERD)

A
  • generally described as heartburn
  • may also include chest pain, recurrent sinusitis, chronic cough, hoarseness, asthma, laryngitis, globus sensation, and/or middle ear infections
90
Q

laryngoesophageal reflex

A

when stomach acids reach the level of the larynx

Adult Swallowing Disorders (3 decks)

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