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Dysphagia > Exam 1 > Flashcards

Exam 1 Flashcards

1
Q

Aspects of Clinical/Bedside Swallowing Evaluation

A
  • Mental status
  • General ability to follow directions
  • Respiratory function and its relationship to swallow
  • Volitional cough/throat clear/hawk
  • Voice characteristics
  • Positioning
  • Motor speech/speech intelligibility
  • Oral-peripheral examination
  • Laryngeal control and palpable elevation
  • Reaction to oral sensory stimulation (taste, temp, texture)
  • Palatal and gag reflexes
  • Reactions/overt signs during attempts to swallow (wet voice quality, spon. cough, throat clear)
  • Caution: silent aspirators
  • Performance with difference consistencies
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2
Q

Oral-Peripheral Examination

A
  • Oral anatomy
  • Labial control (sensation, seal, asymmetry, closure, drooling)
  • Mouth opening/jaw movement
  • Dentition (missing? dentures?)
  • Lingual control
  • Palatal function
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3
Q

Orbicularis Oris

A

CN VII
Principle lip muscle
Oval ring of muscle with lips, sphincter muscle
Action: opens, closes, inverts, and twists mouth and puckers lips
*Closure is important for swallowing

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4
Q

Buccinator

A

CN VII
Primary muscle of cheek
Deepest facial muscle
Origin: pterygomandibular ligament on sphenoid bone
Course: horizontal, anterior
Insertion: blends with fibers of upper and lower lip
Action: compresses lips and cheeks against teeth, draws mouth corner laterally

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5
Q

Temporalis

A

CN V
Broad, think muscle on right side of skull, over temporal bone
Origin: temporal and parietal bone
Course: fibers converge and pass under zygomatic arch
Insertion: ramus of mandible
Action: elevation and retraction
*works together with Masseter

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6
Q

Masseter

A

CN V
Most powerful muscle of mastication
Thick, flat, superficial muscle covering lateral aspect of mandibular ramus
-Origin: zygomatic arch
-Course: inferior and posterior
-Insertion: angle and lateral surface of ramus mandible
-Action: elevates mandible to close jaw

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7
Q

Medial (internal) Pterygoids

A

CN V
Thick 4 sided muscle
With masseter, forms sling to strap mandible to skull
-Origin: sphenoid bone and lateral region
-Course: inferior, posterior, lateral
-Insertion: ramus and mandibular angle
-Action: elevates and closes mandible with masseter

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8
Q

Lateral (External) Pterygoids

A

CN V

  • main jaw opener
  • Origin: sphenoid bone
  • Course: horizontal and posterior
  • Insertion: superior/posterior aspect of ramus of mandible
  • Action: unilateral contraction produces side-to-side motion; lowers, opens, protrudes mandible
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9
Q

Superior Longitudinal

A

Intrinsic
CN XII
Near superior aspect of tongue, fibers run lengthwise (front to back)
-Action: shortens tongue, tongue tip elevation
*combined with inferior longitudinal, unilateral contraction moves tongue tip to side

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10
Q

Inferior Longitudinal

A

Intrinsic
CN XII
On underside of tongue, more lateral
-Action: shortens tongue, tongue tip depression
*combined with superior longitundinal, unilateral contraction moves tongue tip to side

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11
Q

Transverse (tongue muscle)

A

CN XII
Fibers run side-to-side through tongue
-Action: narrows and elongates tongue
Connects to median fibrous septum

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12
Q

Vertical (tongue muscle)

A

CN XII
Intrinsic
Fibers run vertically and laterally /\
-Action: flattens tongue

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13
Q

Hyoglossus

A

CN XII
Extrinsic
From hyoid bone to (oral) posterior 1/2 to tongue
Some fibers continue up to form palatoglossus
-Action: depresses tongue

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14
Q

Genioglossus

A

XII
Extrinsic
Forms bulk of tongue tissue
Strongest and largest extrinsic muscle
Fibers run from inner center of mandible to tongue tip and dorsum, lower fibers go to hyoid
-Action: posterior fibers draw tongue forward for tongue tip protrusion
-Action: anterior fibers retract tongue tip into oral cavity
-Action: contraction of whole muscle depresses tongue

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15
Q

Styloglossus

A

CN XII
Extrinsic
From styloid process of temporal bone to sides/back of tongue
Blends with fibers of hyoglossus
Antagonist to genioglossus
-Action: pulls tongue upward and backward, important for tongue retraction

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16
Q

Salivary Glands

A

**All bilateral

Parotid (CN IX, Glossopharyngeal)

  • Largest
  • Stimulated production of saliva

Submandibular (CN VII, Facial)

Sublingual (CN VII, Facial)

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17
Q

Medical Red Flags during bedside swallowing eval

A 
Diagnoses
Signs/symptoms
Weight loss/nutritional status
Respiratory status
Cognitive/behavioral status
Need to be fed by caregiver
Age/frailty
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18
Q

Oral Red Flags during bedside swallowing eval

A 
Leakage of material out of mouth
Pocketing of material in oral cavity
Drooling
Labial/lingual weakness
Spitting out of food
Difficulty taking material from utensil
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19
Q

Soft Palate

A

CN IX, X
PALATOGLOSSUS in anterior faucial arch –> lowers soft palate
PALATOPHARYNGUS in posterior faucial arch –> lowers soft palate
LEVATOR VELI PALNTINI muscle, MUSCULARUS UVULAE, and SUPERIOR PHARYNGEAL CONSTRICTOR –> help elevate soft palate and close VP port
TENSOR VELI PALANTINI –> tenses soft palate and may help VP closure

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20
Q

Mylohyoid

A

CN V
Forms bulk of muscular floor
Elevates floor of mouth/hyoid
Active in chewing, swallowing, sucking and blowing
*movement of this muscle marks onset of swallowing movement

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21
Q

Digastric (anterior belly)

A

CN V
With hyoid bone fixed, helps depress mandible
With mandible fixed, elevates hyoid bone

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22
Q

Geniohyoid

A

CN XII and C1, C2, C3 - ansa cervicalis
Superior to mylohyoid
Runs from chin midline (mental symphasis)
-Action: lowers mandible (w/ hyoid fixed)
-Action: raises hyoid (w/ mandible fixed)

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23
Q

Pharyngeal Red Flags during bedside swallowing eval

A 
Coughing
Throat clearing
Sneezing
Runny Nose
Wet/gurgly voice quality
Drop in O2 saturation level
Temperature spike within 1 hr
Report of material "sticking"
Multiple swallows needed to clear material
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24
Q

Esophageal Red Flags during bedside swallowing eval

A 
Globus sensation/referred pain
Belching
Heartburn
Material moving slowly downward
Acid taste in mouth
Coughing after eating/drinking
Coughing at night/while lying down
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25
Pharyngeal Plexus
Bundle of nerves | Sensory: pharygeal branches of CN IX and X
26
Nasopharynx
CN V, plus Pharyngeal plexus Extends from posterior choanae of nose to soft palate Contains adenoid tissue and orifices of eustacian tubes Can only view with instrumentation (endoscope)
27
Oropharynx
CN IX, X (no CN V) Portion of pharynx visible when viewing via mouth Extends from uvula superiorly to hyoid bone inferiorly (lower border of valleculae) Posterior and lateral walls are formed by the superior and middle pharyngeal constrictor muscles
28
Valleculae
Wedge-shaped space between tongue base and epiglottis | Anterior to the epiglottis
29
Hypopharynx
CN IX and X Extends from mid-epiglottis to cricopharyngeal muscles where pharynx empties into cervical esophagus Posterior and lateral walls formed by middle and inferior pharyngeal constrictor muscles Extends anteriorly to include mid/lower esophagus Larynx can be included in hypopharynx (laryngopharynx)
30
Pyriform Sinus
2 large cavities/pouches bounded medially by the lateral walls of larynx (posterior pharyngeal wall and posterior cricoid mucosa forms posterior aspect of the hypopharynx)
31
Superior Pharyngeal Constrictor
CN IX, X 4 muscles bundles -Course: from tendon on sphenoid bone where buccinator ends to midline pharyngeal raphe FORMS UPPER PORTION OF PHARYNX -Action: circular contraction of the nasopharynx and oropharynx -superior portion assists VP CLOSURE Lower portion forms GLOSSOPHARYNGEUS muscle helps achieve TONGUE BASE RETRACTION provides BULGING OF POSTERIOR PHARYNGEAL WALL
32
Middle Pharyngeal Constrictor
CN IX and X -Course: from horns of hyoid bone, courses up and back to insert in midline pharyngeal raphe Narrows diameter of pharynx
33
Inferior Pharyngeal Constrictor
CN X Divided: Thyropharyngeal portion originates on thyroid cartilage Cricopharyngeus portion originates on cricoid cartilate - this lower portion forms lower cricopharyngeus muscle -Action: circular contraction of the pharynx -CP portion acts like a sphincter and only relaxes during the swallow (stays contracted to prevent reflux up from esophagus)
34
Epliglottis
upper: CN IX, lower: CN X gag and cough reflex Upper anterior attachment to hyoid bone via hyoepiglottic ligament Base of e. attached to thyroid cartilage (at notch) by thyro-epiglottic ligament Epiglottic inversion may be due to elevation of the hyplaryngeal complex and bolus pressures
35
Hypopharynx Structures: Larynx
CN X - SLN and RLN Hyoid bone Primary cartilages: thyroid, cricoid, arytenoids Laryngeal vestibule (from laryngeal aditus to VFs) Trachea extends below the cricoid True and false VF Aryepiglottic folds Epiglottis Sensory receptors contribute to cough reflex (internal branch of SLN, RLN)
36
Hypopharynx Structures: Muscles
Extrinsic: hyolaryngeal elevation: Digastric, geniohyoid, stylohyoid, mylohyoid, *thyrohyoid Intrinsic: laryngeal closure: Thyroarytenoid Lateral cricoarytenoid Interarytenoids
37
GI Tract
Gastrointestinal tract ~ 30 ft long Transfers nutrients from external world to internal cells via circulatory system Prevents retrograde movement of gastric contents Digestive process: chewing, salivary glands add enzymes, pharynx and esophagus: pathway to stomach, stomach adds hydrochloric acid, enzymes and pepsin to food particles
38
Normal Aging Changes in Oral Phase of Swallowing
Bolus position: floor of mouth vs. roof of mouth Slight increase in duration of oral transit phase At >60 yrs, small increase of frequency and amount of oral residue
39
Normal Aging Changes in Pharyngeal Phase of Swallowing
Increase in duration At >60 yrs, small increase in frequency and amount of pharyngeal residue Increase in freq of laryngeal penetration Reduced extent of hyolaryngeal elevation Less flexibility in duration and extent of crico-pharyngeal opening in subjects >/= 80 yrs
40
Normal Aging Changes in Esophageal Phase of Swallowing
Less efficient peristaltic action of esophageal musculature Esophageal transit slower Esophageal clearance less efficient
41
Pulse Oximetry
Measures blood-oxygen saturation level in arteries Blood color reflects level of O2 Light is passes thru tissue, sensors detect wavelengths emitted to give O2 saturation level Placed on finger-tip or earlobe Normal saO2 97-99%, <90%: poor oxygenation Helpful for medically fragile patients
42
Electromyography (EMG)
Record of muscle activity from electrodes applied to that muscle Measures electrical energy generated by muscle Surface vs. intramuscular EMG Often used with imagining technique Biofeedback for therapy for laryngeal elevation and "hard/effortful" swallow Used to assess laryngeal elevation, lip and jaw muscles
43
Electroglottography (EEG)
Small, high freq electrical signal passed between 2 electrodes Tracks VF movement by recording signal change (VFs contracting = more current flow) Can be modified to track laryngeal elevation (determine onset/termination of pharyngeal swallow; determine extent/duration of laryngeal elevation
44
Pharyngeal Manometry
Uses pressure sensors to sense rapid pressure changes in pharynx Sensors encased in a ~3 mm tube & inserted nasally w/ sensors at these levels: -tongue base -crico-pharyngeal sphincter (UES) -cervical esophagus Sensors pick up pressure changes from more or less push/squeeze on tube during pharyngeal swallow Generally used with fluoro or FEES Allows measurement of intrabolus pressures and timing of pharyngeal contraction Allows indirect examination of relaxation of CP muscle -drop in pressure at CP spincter sensor Used mostly in research, but also to further diagnose/characterize CP muscle dysfunction
45
Ultrasound
Observe soft tissue characteristics (tongue, oral transit, hyoid motion) Real-time assessment without radiation exposure Difficult to visualize the pharynx/larynx Used for oral phase study by SLPs (useful in treatment: biofeedback for various oral tongue exercises - better elevation, better retraction, more muscle activity) (Also used to observe fetus swallowing in womb)
46
Scintigraphy
Only method to objectively quantify amounts of bolus during swallow Nuclear medicine test (SLPs don't run this test) Physiology to determine the cause of the problems cannot be assessed Often used to test for reflux in esophagus
47
Fiberoptic (or Flexible) Endoscopic Evaluation of Swallowing (FEES)
AKA Videoendoscopy For swallowing, must use flexible (nose) endoscope Visualize pharyngeal and laryngeal structures from above Visualization of pharynx/larynx BEFORE AND AFTER swallowing (not during) Great info about degree of residue and timing of delay of swallow Can also observe whether residue is on one or both sides
48
Advantages of FEES
Portability Gives optimal information of residue (laterality, location, degree) Flexibility with positioning (can use in reclined position) Time/length of exam can be modified No radiation exposure May give similar sensitivity, specificity and predictive values as MBS Can be used as biofeedback tool during Tx Can observe consequences of residue
49
Disadvantages of FEES
Does not view oral stage of swallowing Moment of actual swallow is not viewed Must infer aspiration and nature of physiology from the location of residue after swallow Inferring from the location of residue after swallow Invasive procedure Need specialized equipment Increased training due to invasivness of procedure
50
Videofluoroscopy Swallow Examination (VFE/VFSE)
- Most frequently used swallowing evaluation method - Gold standard for swallowing assessment - AKA: Modified barium swallow (MBS), videofluoroscopic swallow study (VFSS), cookie swallow study - Inpatients (hospital): VFSE usually follows Clinical/Bedside Swallow Evaluation - Outpatients (hospital,clinic): may go directly to VFSE/MBS - If any pharyngeal red flags noted during Clinical/Bedside Swallow Evaluation, imaging technique is needed - Can be recorded digitally for review - Patient receives relatively small dose of radiation per study - A variety of bolus consistencies are used - Always done in the "Lateral View" (missing esophageal stage) - ---Supplement with "Anterior-Posterior View" (A-P) if needed
51
Components of VFSE that cannot be assessed with FEES
Identifying normal and abnormal physiology Oral and pharyngeal transit time Airway integrity before, during and after the swallow Hyolaryngeal elevation and more!
52
VFSE Objectives
Evaluate anatomy and physiology of swallowing mechanism Identify/evaluate patterns of impaired swallow physiology Identify consequences of impaired swallow physiology Match physiology to patient's symptoms Evaluate impact of treatment strategies: position changes, swallow maneuvers, diet changes
53
What to evaluate in VFSE? | 4 main areas
ANATOMICAL STRUCTURES SWALLOW PHYSIOLOGY - oral containment of liquids/solids - mastication of semisolids and solids - oral transit of material (anterior to posterior lingual mvmt; propulsion of material into hypopharynx) - hyoid movement - laryngeal elevation and closure - pharyngeal contraction - crico-pharyngeal sphincter opening CONSEQUENCES OF IMPAIRED PHYSIOLOGY - spillage (anterior or posterior) - residue (oral, tongue base, pharyngeal) - misdirection of bolus and airway compromise (penetration or aspiration) IMPACT OF THERAPEUTIC MANEUVERS - postural adjustments - head position changes - swallowing timing changes - breath-hold and other swallow maneuvers - **bolus changes**
54
Ways to Rate the Swallow (3)
Penetration-Aspiration Scale (Rosenbeck et al.) MSBImP Swallow Safety Scale (Ludlow et al.)
55
Dysphagia Inventories
Self-reported impact of swallowing deficits SWAL-QOL & SWAL-CARE -quality of life and quality of care outcomes tolls MD Anderson Dysphagia Inventory -for patients with head and neck cancer
56
Weak buccal strength results in (5)?
``` difficulty taking material from utensil leakage of material out of oral cavity pocketing of material in anterior sulci difficulty in holding/collecting food on midline on tongue pocketing in lateral sulci ```
57
Poor dentition condition results in (1)?
Decreased ability or inability for mastication/breakdown of the material
58
Decreased jaw excursion/closure results in (2)?
poor lip closure (see weak buccal strength) | poor mastication/breakdown of the material
59
Weak lingual strength, motility, elevation, ROM results in (3)?
oral pocketing in lateral or anterior sulci difficulty manipulating food into a bolus lingual stasis and/or residue on hard palate
60
Piecemeal Deglutition | Fear of aspiration, neurologic deficits results in (1)?
repeated swallows to clear small bolus from oral cavity
61
Reduced lingual coordination, control, and movement results in (5)?
difficulty propelling bolus back into pharyngeal area to initiate swallow response (A to P tongue and bolus movement reduced) tongue pumping premature spillage of material into pharyngeal area increased oral transit time tongue thrusting
62
Poor Velo-Pharyngeal Closure results in (2)?
nasal regurgitation of material | difficulty moving bolus through upper pharynx/pharyngeal residue
63
Swallow Delay results in (2)? | usually assessed with?
penetration and/or aspiration before pharyngeal swallow *premature spillage of liquids during oral preparatory or transit phases may be due to reduced tongue control or lingual-uvular contact, not a swallow delay - the whole bolus has not been sent back (usually assessed with liquids; once past mandible line, then considered a delay)
64
Decreased Posterior Tongue Retraction results in (3)?
decreased pharyngeal driving pressures residue coating the tongue base residue in vallecula
65
Decreased Pharyngeal Wall Contraction results in (4)?
decreased pharyngeal driving pressures increased pharyngeal transit time residue coating pharyngeal wall may contribute to pyriform sinus residue
66
Decreased Laryngeal Elevation results in (3 ---with a and b for each--- )?
1. reduced airway protection (reduced tucking of laryngeal opening under base of tongue): ): ):(
67
Decreased epiglottic inversion (not from laryngeal elevation) results in (2)?
residue in vallecula | decreased airway protection
68
Poor Vocal Fold Closure results in (2)?
decreased airway protection with possible aspirtaion | decreased pressure as bolus moves through pharynx
69
Decreased epiglottis inversion results in (2)?
Residue in vallecula | Decreased airway protection
70
Poor PES opening (not from laryngeal elevation) results in (2)?
Residue in the pyro form sinuses | Spillage of material into laryngeal vestibule from pyriform sinuses
71
Unilateral pharyngeal weakness results in (2)?
Asymmetric bolus transit through pharynx | More residue on one side
72
CP Muscle Dysfunction (PES/UES)
Can occur with stroke, scar tissue in region, or fibrosis/stricture related to chemo-radiation treatment in CA Incomplete relaxation/opening of PES results in stasis in pyriform sinuses

Dysphagia (2 decks)

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