Exam 2 Flashcards
Risk factors for H&N cancers (7)
- Tobacco
- Alcohol
- HPV (in oropharyngeal cancers)
- Epstein-Barr virus (in nasopharyngeal cancers)
- Poor oral hygiene
- Poor nutrition
- GERD (in pharyngeal cancers)
TNM Classification
Categories of Primary tumor (T), lymph nodes (N), and metastasis (M) are rated. These correlate with stages of cancer, ranging from 0-4
General guidelines for treating H&N cancers
- Preoperative conference to discuss outcome options and PEG tube options
- Preoperative evaluation of swallowing–likely already problems
- Preoperative VFSS, with and without maneuvers
Side effects of surgical removal of cancer (5)
- Decreased movement
- Scar tissue formation
- Wound dehiscence
- Decreased sensation at suture/graft site
- Presence of tracheotomy
Common Surgeries for H&N cancers (7)
- Primary tumor surgery
- Mandibulectomy and mandibulotomy
- Maxillectomy
- Laryngectomy
- Tracheostomy
- Gastrotomy
- Neck dissectioni
- Reconstruction
Side effects of radiation therapy (12)
- Nausea
- Fibrosis
- Irritation to skin
- Necrosis to tissue
- Damage to salivary glands
- Reduced range of motion
- Reduced speed
- Damaged nerve endings
- Reduced sensation
- Peripheral neuropathy
- Necrosis of tissue
- Reduced synchrony of swallow
Side effects of chemotherapy (7)
- Nausea
- Mucositis
- Hair loss
- Xerostomia
- Loss of appetite
- Infections of the oral cavity
- Reduced function of oropharyngeal structures
Cancer in the lips
Primary risk factors are alcohol, tobacco, and poor oral hygiene. Usually persist as non-healing ulcers. Primarily treated with radiation.
Cancer in the floor of the mouth
Appear on the anterior surface on either side of the midline. They can spread to the tongue and the bone. Mostly affects oral bolus control.
Cancer in the tongue
Can affect either the anterior 2/3 or posterior 1/3. When the posterior 1/3 is affected, the tonsils are also usually affected. Creates oral stage deficits such as propulsion of the bolus and BoT movement. and usually treated with radiation or glossectomy. SOmetimes VPC can be affected.
Cancer in retro-molar trigone
VERY PAINFUL. Affects jaw movement, chewing pattern, can create ear canal pain. Rare.
Cancer in the pharynx
Can occur in orropharynx, nasopharynx, or hypopharynx.. Can be treated with palatal resection or pharyngeal resection or pharyngectomy.
Affects pharyngeal stripping, VPC, BoT, PPW, UES, hyolaryngeal excursion, etc.
Cancer in the larynx
Can be supraglottic, glottic, or subglottic; not life-threatening unless it spreads or is severe. Lymph nodes may be involved. Total laryngectomy needed in most cases, causing loss of ability to build supraglottal pressure and affects the apneic period in swallowing.
Dysphagia symptoms include laryngeal penetration/aspiration; changes due to radiation; TEP and tracheostomy influences; hyoid excursion and UES opening
Endotracheal tube v. tracheostomy tube
Endotracheal tube goes through the mouth or nose; tracheostomy tube goes through the trachea
Cuffed v. Cuffless trachs
Cuffed trachs prevent the flow of air from the trachea to the larynx and through the nose and mouth. This creates a more secure airway for those who are more compromised, but also prevents voicing.
Effects of tracheostomy on swallowing (4)
- Poor sub-glottic pressure}
- Disrupted laryngeal elevation
- Reduced upper-airway sensitivity
- General muscle weakness
Passy-Muir valve
Allows speech by closing off the trach and forcing air to exit through the larynx and oral/nasal cavities
NEVER USE A SPEAKING VALVE WITH A CUFFED TRACH. YOU WILL CHOKE THE PATIENT.
Effects of surgery on swallowing (3)
- Damage to nerve endings may cause problems with sensation or movement
- Damage to the brainstem may cause problems with sensation or movement
- Edema may cause temporary difficulties
Cancer-related surgery effects on swallowing
- Thyroidectomy–could impair vagus nerve and lead to VF paralysis
- Carotid endartorectomy–could impair vagus nerve; impairing pharyngeal constrictors and VF movement
Side effects of medication and swallowing
Typically found in anti-depressants, anti-convulsants, and anti-psychotics; may cause tardive dyskinesia or xerostomia
Respiratory medicines may cause LES impairment leading to GERD
COPD and swallowing
People with COPD are more likely to swallow when they have low subglottal pressure. This may lead to aspiration risks and residue being drawn into the airway.
Achalasia
Primary esophogeal motility of unknown cause; insufficient LES relaxation and loss of esophogeal peristalsis.
Diffuse esophogeal spasm
Repetitive, high amplitude contractions of the smooth muscle portion of the esophagus. Also called “corkscrew esophagus.”
Nutcracker esophagus
Very high amplitude contractions in the distal esophagus
Stricture
Loss of lumen anywhere in the esophagus; diameter is usually less than 15 mm (20 mm is normal)
Schatzki ring
Narrowing of the lower part of the esophagus caused by a ring of mucous/muscular tissue.
Gastro-esophageal reflux disorder (GERD)
Mucosal damage caused by abnormal reflux of stomach contents into esophagus. Frequently seen as persistent heartburn, etc.
Laryngo-pharyngeal reflux (LPR)
When stomach contents reach the level of the UES and spill into the larynx. Includes vocal symptoms and sometimes aspiration.
Esophageal diverticula
A sac that protrudes from the esophageal wall; most commonly Zenker’s diverticulum, but also sometimes Killian’s triangle. Associated with cough, bad breath, regurgitation of undigested food, and repeated pneumonia.
Scleroderma
Connective tissue disorder that weakens the LES.
CP bar
Bar of muscle that can prevent pharyngeal stripping and block the progress of the bolus.
Feeding disorder
Persistent failure to eat adequately–involves getting food to the mouth rather than swallowing
Risk factors for infant swallowing disorders
- Low birthweight
- Prematurity
- Prenatal drug exposure
- Diet restrictions
- Physical abnormalities
- Cardiac problems
- Negative parent behaviors
Risk factors for swallowing disorders in older children.
- Disruptive behaviors
- Inefficiency
- Overselectivity
- Refusal
- Feeding delay
Prenatal milestones for sucking
Oral movements by 10-14 weeks; swallow developed by 15 weeks; consistent by 22-24 weeks; some healthy preterm infants suckle enough to sustain oral feedings at 34 weeks
Clinical symptoms of oral difficulty in infants (5)
- Anterior spillage
- Inefficient extraction
- Disorganized suck/swallow/breathe pattern
- Decreased ability to latch
- Disorganized jaw/tongue function
Clinical symptoms of pharyngeal difficulty in infants (5)
- Coughing
- Spitting/gagging
- Drop in 02, heart rate, etc.
- Wet, weak, hoarse cry
- Changes in upper airway sounds
Clinical symptoms of oral difficulty in older children (6)
- Inefficient extraction from sippy cup
- Poor labial seal on spoon/cup/straw
- Decreased mastication
- Anterior spillage
- Decreased bolus control
- Disorganized jaw/tongue function
Clinical symptoms of pharyngeal difficulty in older children (5)
- Coughing/throat clearing
- Gagging or emesis
- Drop in 02, heart rate, etc.
- Changes in upper airway sounds
- Wet, gurgly voice
Purpose of clinical bedside exam (4)
- Determine candidacy for an instrumental eval
- Determine penetration/aspiration
- Determine safe texture
- Monitor progress of therapy
Three major concerns in a CSE
- Mental status
- Nutritional status
- Respiratory status
Trigeminal nerve assessment (3)
- Facial sensation
- Corneal reflex
- Feel masseter muscles
Facial nerve assessment (2)
- Look for asymmetry in facial shape
- Check taste
UMN lesions cause contralateral damage to the lower part of the face, LMN lesions involved ispilateral damage on the entire side of the face
Glossopharyngeal assessment (3)
- Palatal elevation on “ah”
- Gag reflex
- Taste in posterior part of tongue
Vagus assessment (2)
- Vocal quality
2. Ability to cough voluntarily
Hypoglossal assessment (2)
- Note atrophy or fasciculations on the tongue (fasciculations are usually a sign of LMN lesions)
- Look for errors in articulation
Trial Swallows in CSE
Use thin, puree, and solid consistencies. Observe via laryngeal palpitation, timing, vocal quality, coughing, and oral residue.
Standardized CSE Tests (3)
- Toronto Beside Swallowing Screening Test
- Mann Assessment of Swallowing Ability
- Functional Oral Intake Scale
What to look for in a radiographic assessment
- Oral prep and transit time
- Initiation of swallow
- Closure of velopharynx
- Closure of epiglottis, hyolaryngeal excursion, and, vestibular squeeze
- Retraction of BoT
- Opening of UES
- Pharyngeal transit duration
Postural change for prolonged transit time
Head back
Postural change for delayed swallow initiation
Chin tuck
Postural change for impaired BoT retraction
Chin tuck
Postural change for unilateral laryngeal dysfunction
Head rotation to impaired side
Postural change for pharyngeal/pyriform sinus residue
Head rotation to impaired side
Postural change for unilateral oral/pharyngeal weakness
Head tilt to unimpaired side
Only FEES allows
- Visualization of secretions
- Visualization of tissue (see edema, color, etc.)
- Effects of altered anatomy
- Visualization of glottic closure
Only VFSS Allows
- Visualization of the bolus throughout the swallow
- Visualization of the oral stage
- Visualization of UES opening
- Submucosal changes
Equipment components of FEES (4)
- Fiberoptic nasoendoscope
- Light source
- Camera
- Video/audio recording device
First action of the swallow event
Movement of arytenoids to midline (can only be seen on FEES)
Possible complications of FEES
- Epistaxis (nosebleed)
- Mucosal abrasion
- Laryngospasm
- Sneezing
- Gagging
- Vasovagal response (fainting)
When to consider other studies after a FEES
When there are symptoms that would be better observed in VFSS such as suspected UES or oral stage difficulties, or suspected Zenker’s diverticulum. Also when the patient has behaviors that disrupt the FEES.
Advantages of FEES (5)
- More portable–can be administered at bedside, in skilled nursing facilities, etc.
- No risk of radiation
- More variability in textures, foods, postures
- Assessment can be lengthier
- Less expensive
Advantages of VFSS
Visualizes all stages of swallow
Salient findings for FEES (6)
- Spillage
- Penetration
- Aspiration
- Residue
- Anatomical abnormalities
- UES regurgitation
