Exam2 Flashcards
What are the risk factors for cancer
Tobacco Alcohol HPV in oropharyngeal cancers Epstein barr in nasopharyngeal cancer Poor oral hygiene Vitamin A and B deficiency GERD in pharyngeal cancers
What causes microorganisms to grow in mouth
Lack of saliva
What does TNM stand for in cancer staging
Tumor
Nodes
Mestasis
What characterizes T stage 0
No evidence of primary tumor
What characterizes T1 stage in cancer
Tumor confined to nose or oropharynx
What characterizes T2 stage in cancer
Tumor extends into pharynx
What characterizes T3 stage in cancer
Tumor involves skull base or paranasal sinuses
What characterizes T4 stage in cancer
Intracranial extension, cranial nerves,
What characterizes N0 stage in cancer
No regional lymph node involvement
What characterizes N1 stage in cancer
Unilateral metastasis in cervical modes less than 6cm
What characterizes N2 stage in cancer
Bilateral metastasis less than 6cm
What characterizes N3 stage in cancer
Metastasis greater than 6 cm or reach the supraclavicular fossa
What characterizes MX stage in cancer
Cannot be assessed
What characterizes M0 stage in cancer
No distant metastasis
What characterizes M1 stage in cancer
Distant metastasis
In terms of TNM, what is stage 0 in cancer
Carcinoma in situ with no node involvement or metastasis
What is stage I cancer in terms of TNM
Tumor confined to naso/oropharynx with no nodes or metastasis
What is stage 2 cancer in terms of TNM
T1 with unilateral nodes and no metastasis
T2 with no nodes or unilateral nodes
What is stage III cancer in terms of TNM
T1 or 2 with bilateral nodes
T3 with no nodes or unilateral
What is stage IV cancer in terms of TNM
T 4 with any node involvement and no metastasis
Any T with distant metastasis
What is the current philosophy of cancer treatment
Chemotherapy to shrink tumor
Removal
Radiation therapy to get remaining cells
What is the biggest disadvantage of chemoradiation
Nausea
Xerostomia (dry mouth)
Fibrosis
What is fibrosis
Hardening of tissues
What are the general guidelines for cancer assessment exam
Preop conference to discuss outcomes ( 3-4 hours especially if total laryngoscopy)
Counsel about anatomy, show videos
Preop clinical swallowing exam for baseline
Preop fluoroscopy with or without postural or compensatory strategies
What can you expect with surgical removal
Removal of structures Decreased movement Scar tissue Wound dihiscene (scarring) Decreased sensation at site Tracheotomy
What are some common surgeries
Primary tumor Mandibulectomy (complete removal) or mandibulotomy ( partial removal) Maxillectomy Laser Laryngectomy Tracheostomy Gastrotomy Neck dissection Reconstruction
What swallowing problems could occur with a total laryngectomy
Cant neutralize pressure in pharynx
No subglottal pressure
No hyoid excursion
What are the effects of radiation therapy
Reduces blood supply to tissues which damages nerve endings Nausea Fibrosis Skin irritation Xerostomia due to damaged salivary glands Peripheral neropathies Tissue necrosis Reduced range of motion Reduced flexibility of pharyngeal/laryngeal structures Reduced speed and movement Reduced sensation of bolus volume Reduced synchrony of movement
What are the results of chemotherapy
Nausea Mucositis Hair loss Xerostomia Infections of oral cavity
What are the physiologic results of chemoradiation
Reduced strength and coordination of anterior tongue
Reduced posterior movement of base of tongue
Reduced laryngeal elevation
Reduced airway closure
What are common cancers
Oral cavity (lips, floor of mouth, tongue, retro-molar trigone)
Oropharynx
Nasopharynx
Laryngopharynx
What are characteristics of cancer in lips
Mostly 55-65 year old men Alcohol and tobacco risk factors Poor oral hygiene Usually present as non healing ulcers Pain in advanced stages Early lesions may be surgically removed Radiation therapy
what are the dysphagia symptoms for cancer of the lips
mostly oral stage deficits (labial seal, bolus control and transport)
can affect any other structure due to radiation effect
what are characteristics of floor of mouth cancer`
found on anterior surface of either side of midline
can spread to bone and tongue
30% involve sub-maxillary nodes
what are the dysphagia symptoms for cancer of the floor of mouth
mostly oral stage
can affect other related physiologic processes
radiation can affect other structures
Where would you find tongue lesions
anterior 2/3 affect oral cavity
posterior 1/3 affect oropharynx
lesions at base and poserior 1/3 invade tonsils and are more advanced
treatment is radiation or glossectomy
what are the results of tongue cancer on swallowing
mostly oral stage
partial glossectomy affects bolus prep and hold
total glossectomy affects transport
removal of base of tongue: pharyngeal stripping and hyoid excursion
velopharyngeal port if there is velar resection
what is retro-molar trigone
cancer in triangular space behind last molar
rare
affects tongue, ear canal pain, trismus (jaw spasm)
treated with radiation: affects mastication, oral control, transport
what structures are involved in cancer of the oropharynx
base of tongue tonsils soft palate uvula lateral-posterior pharyngeal walls
what structures are involved in cancer of the nasopharynx
postero-superior pharyngeal wall
lateral pharyngal wall
eustachian tube
adenoids
what structures are involved in cancer of the laryngopharynx
pyriform sinuses
posterior cricoid
lower posterior pharyngeal walls
what are common surgeries for cancer of pharynx
palatal resection
pharyngeal resection
laryngo-pharyngectomy
what are the physiologic results for cancer of pharynx
pharyngeal stripping VPC BOT to PPW UES opening hyoid excursion trismus leading to poor mastication
what is the leading cause of cancer of the larynx
smoking
what are the characteristics of larynx cancer
supraglottic lesions are usually large usually spreads to epiglottis lymph node involvement in 40-50% not life threatening: removal of larynx subglottic cancers can cause airway obstruction total laryngectomy in most casses
what are the results of laryngeal cancers
laryngel penetration/aspiration
changes due to radiation
TEP and tracheostomy influences
can influence hyoid excursion and UES opening
what are the physiologic results of a hemilaryngectomy
compromised airway protection
unilateral weakness in pharynx
what are they physiologic results of a total laryngectomy
airway protection
pressure issues for bolus flow
what are two types of artificial airways
endotracheal tube
tracheostomy tube
what are complications of a tracheostomy
loss of voice psychologic distress speech, language delay loss of smell and taste leading to poor appetite aspiration and impaired swallowing impaired hyoid excursion loss of pressures (subglottal) reduced cough reduced airway sensitivity (dry mouth affets this) difficulties with secretions
what impact can surgery have on dysphagia
damage to nerve endings (peripheral nerve damage)
damage to brainstem during skull based surgeries
edema(temporary)
what are results of a thyroidectomy
impaired vagus nerve leading to VF paralysis
what is a carotid endarterectomy
removal of plaque from arteries
can impair vegas nerve for pharyngeal constrictor action,
folds impacted
what are possible results of cervical spine procedures
impaired CN IX (glossopharyngeal) and X (vagas)
could impair brainstem connections to peripheral nerves
anterior cervical fusions: decompresses spinal cord nerve roots
what are iatrogenic causes of dysphagia
surgery
medications
what meds can cause dysphagia
antipsychotics
anticonvulsants
antipsychotics and antidepressents: tardive dyskinesia and xerostomia
respiratory and cardiac meds: LES (lower esophageal sphincter) and GERD
cholesterol controllers: generalized myopathies
what is COPD and how does it affect swallowing
chronic obstructive pulmonary disease
swllowing during inhalation or right after a swallow
residue in pharynx could be drawn into airway
what are some esophageal disorders
achalasia diffuse esophageal spasms nutcracker esophagus strictures shatzki ring GERD LPR esophageal diverticula scleroderma
what is achalasia
insufficient LES relaxation and loss of peristalsis
can be hereditary, degenerative, autoimmune, or from an infection
symptoms: dysphagia for solid and liquid, regurgitation and chest pain
what is DES
diffuse esophageal spasm peristaltic action affected repetitive, high amplitude contractions of smooth muscles of esophagus corkscrew esophagus muscular hypertrophy
what is nutcracker esophagus
variant of DES
very high amplitude contraction in distal esophagus
what are strictures
loss of lumen area (canal opening)
normal is 20mm
strictures when diameter is less than 15mm
symptom: dysphagia when diameter is less that 15mm
what are schatzki rings
narrowing in lower esophagus
rings of mucosal/muscular tissue
what is GERD
mucosal damage produced by abnormal reflux of gastric contents in the esophagus
what are the symptoms of GERD
frequent heartburn persistent sore throat hoarseness chronic cough asthma chest pain lump in throat
what causes GERD
LES impairment
relaxation of LES
low resting LES pressure
increased gastric pressure
What is LPR
laryngo-pharyngeal reflux
gastric contents reach UES and spill in larynx
causes erosion of laryngal mucosa and contact ulcers
vocal symptoms and aspiration
identified by pH monitoring
what is normal pH acidity
below 7 is acidic
7-14 is alkaline or basic
what is esophageal diverticula
sac that protrudes from esophageal wall
most common is Zenkers close to UES in area of killian’s triangle (between cricopharyngeal sphincter and inferior pharyngeal constrictor muscles)
associated with cough, bad breath, regurgitation, repeated pneumonia
may see bulge in throat
treat with surgery
what is scleroderma
connective tissue disorder
weakens LES
affects smooth muscles in lower 2/3 of esophagus
causes hypomotility, heartburn, and dysphagia
what is an osteophyte
bone outgrowth that can push against esophagus
what is a CP bar
projection at level of C5-C6 causing problems with the UES
what are prenatal causes of pediatric dysphagia
maternal diabetes
phenylketonuria
preeclampsia
drug use
what are the results of maternal diabetes
disturbances in carbohydrate metabolism (maternal diabetes)
causes stillbirths, abnormally large infants, congenital malformations is heart, skeletal and neural tube defects
can result in hypoglycemic episodes
is is PKU
phenylketonuria is due to the deficiency of the enzyme phenylalanine hydroxylase
causes increased phenylalanine concentrations
issue with protein metabolism
can cause intellectual disability and microcephaly
what is preeclampsia
hypertension associated with protein in urine
causes hypotonia and respiratory deficits
what are results of maternal drug use
reduced and abnormal ear development cleft palate hydrocephaly neural tube deficits heart anomalies
what are neurologic causes of pediatric dysphagia
hydrocephalus micro and macrocephaly intracranial hemorrhage seizure neuropathy, myopathy infections (meningitis, poliomyelities) cerebral palsy
what are some congenital structural anomalies
cleft lip/palate
esophageal atresia/tracheo-esophageal fistula
mandibular hypoplasia
how does cleft lip affect swallowing
loss of oral pressure
nasal regurgitation
hypernasality
nasal air emission
with is esophageal atresia, fistula
hole on wall of esophagus
failure of the laryngotracheal tube to separate from esophagus during embryonic development
upper two thirds of esophagus ends in closed pouch
liquids enter the trachea causing choking, coughing, gag or cyanosis
communication between trachea and esophagus
how does mandibular hypoplasia affect swallowing
mastication
oral pressure
oral transport
oral pressure can also affect pharyngeal pressure
what are pediatric gastro intestinal disorders
necrotizing enterocolitis
GERD
What is necrotizing enterocolitis
inflammation and tenderness of intestine
ischemia or toxic damage weakens mucosal lining of intestines. bacteria then reacts to breast milk or formula and causes bowel gas that leads to necrosis
will have GERD and aversions to food
what are problems associated with GERD in infants
abnormal muscle tone
exaggerated gag
not able to rhythmically move the tone to suckle
infantile bite reflexes
drooling
aspiration
poor trunk control
behavioral feeding problems (food and texture aversions)
preference for thin liquids
emesis, reswallowing
oral defensiveness/delayed feeding skills
what respiratory problems are associated with dysphagia in infants
apnea
Infant respiratory distress syndrome
transiet tachypenea
bronchopulmonary dysplasia
what is apnea
cessation of breathing for more than 15 sec
caused by CNS problem with no respiratory gas flow and no respiratory effort
reduced endurance
uncoordinated suck swallow breath/suck
number of sucks per swallow increases
agitation during feedings
what is infant respiratory distress syndrome IRDS
alveoli open then collapse and stick after each breath inhibits pulmonary gas exchange increases work load of respiration leads to apnea and hypoxemia surfactant deficiency
what is transient tachypenea TTN
poor clearance of lung fluid during birth
temporary. no oral feeding during first few days
what is bronchopulmonary dysplasia BPD
chronic lung disease CLD of prematurity
damage to lung tissue
most common cause is mechanical ventilation and oxygen therapy
what cardiac disorders are common with dysphagia
congenital heart disease CHD
congestive heart failureCHF
atrioventricular septal defect AVSD
what is congenital heart disease CHD
any malformation of the cardiovascular system in infants
what is congestive heart failure
stress to the heart from an overload of fluid and edema
what is atrioventricular septal defect AVSD
malformation of the heart holes between chambers blood does not flow correctly has lower amount of oxygen characteristic of downs syndrome lungs receive more blood and heart has to work harder
what genetic syndromes are associated with dysphagia
down syndrome
CHARGE syndrome
what characteristics of Downs syndrome is associated with dysphagia
hypotonia leading to poor postural control, neck control, and weak suck
GERD is common
what is CHARGE syndrome
Caloboma (cleft of iris) Heart disease Atresia of the nasal cavity Retardation Genital abnormalities Ear disorders dysphagia related to respiratory problems and heart developmental delays also source of feeding problems
what is compensation
interventions that do not change the physiology. If the interventions stop, the effect will not remain
what is rehabilitation
interventions that change the physiology. If therapy stops the effects will last longer
what are the 3 parts of a clinical bedside exam
history/observation
cranial nerve/physical exam
trial swallows
what is the purpose of a clinical swallow exam
to determine candidacy for an objective eval
detect possible aspiration
to determine which textures are safe
to monitor progress of therapy and possibly upgrade recommendations
what should you observe prior to CSE
mental status: alertness, initial communication attempts, posture
nutritional status: feeding tube. presence of suctioning
respiratory status: tracheostomy tube or labored breathing
throat clearing: info on residue, sensation, secretions
what should you include in the history
specific symptoms of choking: patient complaint
weight loss
past and current medical history: neurological, ENT, GI, VF paralysis, GERD
any previous swallowing assessments
cultural considerations
How do you test the trigeminal nerve
test facial sensation with cotton wisp, sharp object and check temperature perception
corneal reflex looking for asymmetries in blink
feel masseteur during jaw clench. test for jaw jerk reflex; observe symmetry of jaw opening
how do you test the facial nerve
look for asymmetry of shape, facial expressions, and blinking
have patient smile, puff cheeks, clench eyes tight, wrinkle row
check tasts with sugar, salt, or lemon juice on lateral sides of tongue
what does holding air in cheeks assesses
intraoral pressure
how do you test the glossopharyngeal nerve
gag reflex
does palate elevate symmetrically when patient says aah
check taste in posterior tongue
how do you test the vagus nerve
vocal functions: pitch, loudness, quality
ability to cough voluntarily
how do you test the hypoglossal nerve
note atrophy or fasciculations
stick out tongue to see if it curves to one side or the other
push against tongue from side
look for errors in articulation
what are fasciculations and atrophy signs of
motor neuron lesions
unilateral lesions of the motor cortex cause?
contralateral tongue weakness
What consistencies should you test during a CSE
thin: 5, 10, 20 mL and continuous
puree or pudding: 5mL
solid
what should you observe during the trial swallow
laryngeal palpatation for elevation timing/completeness # of swallows pre-post voice quality coughing/clearing throat oral residue
What are some standardized CSE tests
Toronto Bedside Swallowing Screening Test: measures voice quality, lingual movement, ability to manage water by teaspoon and cup
Mann Assessment of Swallowing Ability
Functional Oral Intake Scale
what other procedures are used during a CSE
ausculation: stethoscope over airway to listen for aspiration
Dye test: presence of aspiration in a trach patient
what is ingested during a radiographic assessment
barium sulfate
what is the purpose of a VFSS
assess impairments in swallowing physiology
evaluate the efficacy of strategies
what is the hierarchy of consistencies during a VFSS
thin nectar thick honey thick pudding solids
what procedures are followed during a VFSS
try all different consistencies and volumes of barium mixture
get both a lateral and anterior/posterior view
protect against radiation
what is the goal of strategies
to keep the diet as least restrictive as possible
what postural changes are used to compensate
chin tuck
head turn
head tilt
what does the chin tuck help
delayed swallow initiation
impaired base of tongue retraction
aspiration especially during swallow
what does head rotational help
unilateral laryngeal dysfunction and pyriform residue
what does head tilt help
residue in valleculae
pharyngeal weakness
which way do you tilt and turn
tilt to strong
turn to weak
what strategies are used for residue clearance
liquid wash
repeat swallows
what maneuvers aid swallowing
supraglottic swallow
effortful swallow
masako
What does FEES stand for
fiberoptic
endoscopic
evaluation
swallowing
what is the advantage of FEES over VFSS
visualize secretions directly view surface assess mucosal abnormalities (edema etc) visualize glottic closure clear view of bolus path thru hypopharynx
what is the advantage of VFSS over FEES
visualize the heighth of swallow
see oral and esophageal phases
observe completeness of BOT retraction, UES opening and extent of aspiration
view submucosal changes such as osteophytes
what can only be seen by endoscope
closure of the vocal folds which happens right before hyoid elevation
What is cerebral palsy
Motor speec disorder in infants
Causes brain structure abnormalities
Nonprogressive lesion
Causes low muscle tone, spasticity
what is the procedure for changing a passe muir valve
deflate cuff place valve listen to speech have them cough look for respiratory distress do a clinical swallow exam
what impact does a tracheostomy have on swallowing
increased risk of aspiration due to: poor sub-glottic pressure poor laryngeal elevation reduced upper airway sensitivity because air is not moistened thru nose general muscle weakness (already in ICU)
what is barrett’s esophagus
precancerous changes in the mucosa due to prolonged acid in esophagus
what are possible results of a supraglottic laryngectomy
pharyngeal proplusion impaired
airway compromise
what are the theories related to cognitive aging
- general slowing: speed of executive operations decreases
- inhibition deficit: irrelevant info less suppressed which creates distraction
- region specific neural aging:
- transmission deficit: connections between representational units (tip of the tongue phenomenon)
- working memory reduced
- resource theory: finite pool of resources shared simultaneously by other cognitive processes
- frontal lobe aging: loss of activity in frontal regions plays a role in inhibiting irrelevant material
what are the 2 subtypes of mild cognitive impairment
- amnestic: affects memory
2. nonamnestic: affects thinking skills other than memory
what is dementia
- includes memory deficits and at least one of the following: aphasia, apraxia, agnosia, or disturbance in executive functioning.
- must be severe enough to impair social and occupational functioning
what are standardized screening tools for dementia
- mini mental status exam ( gold standard)
- clinical dementia rating scale
- Blessed dementia scale (family member report)
- Global Deterioration Scale
what are components of comprehensive assessment
- case history and interview: medical status, education, occupation, socioeconomic, cultural, linguistic background. Auditory, visual, motor, cognitive, and emotional status. Patient/family goals and preferences as well as concerns
- observation: observe ability to attend, perceive, organize, remember verbal and nonverbal info in ideal conditions in context of various activities
- informal assessments
- formal assessments
what are informal assessments for dementia
- oral motor
- language sample
- comprehension tasks: follow directions
- visual comprehension tasks
- expressive tasks: answering questions, describing
- reading, and writing tasks
- cognitive tasks: delay recall, orientation
what are formal standardized assessments for dementia
- Alzheimers Quick Test
- BDAE
- Cognitive Linguistic Quick Test
- Functional Skills Survey
- NEUROPSI-Attention and memory
- RAINBO: evaluates communication and swallowing
- WAB
what are symptoms of lewy body dementia
- symptoms and memory vary significantly from day to day
- early symptom is difficulty walking, decrease in balance, ability to control physical movements. Frequent falling
- flat affect
- visual hallucinations
- REM sleep disorder. Physically act out the situation in their dreams
- more men than women
what are characteristics of Alzheimers
- insidious onset
- progressive course
- heterogeneous disease
what are pathological changes in AD
- cortex shrinks
- shrinkage in the hippocampus
- ventricles grow larger
- abundance of beta-amyloid plaques and eurofibrillary tangles
what are language symptoms in each AD stage
early stage: mild word retrieval, mild decrease in comprehension
middle stage: frequent word retrieval deficits, ungrammatical sentences, reduced conversation
late stage: nonfunctional reading/writing, limited comprehension, speech limited to single words, bizzare and devoid of meaning
what are the 3 common presentations for lewy body dementia
type 1: begins with memory impairment or cognitive disorder over 2 or more distinctive lewy body dementia features
type 2: begins with movement disorder that leads to PD then develops symptoms of dementia
type 3: begins with neuropsychiatric symptoms
what are the core clinical features of lewy body dementia
- fluctuating cognition
- neuropsychiatric symptoms
- motor features of parkinsonism
what is the neuropathology of fronto temporal dementia
- accumulation of abnormal tau protein in cells
- tau becomes tangles
- progressive loss of nerve cells in frontal and temporal lobes
- gliosis: tissue scarring
- vacuolation: holes form in brain
- Picks bodies: abnormal cells begin to form
what are the characteristics of fronto temporal dementia
- uninhibited and socially inappropriate behavior
- loss of awareness of concern about behavior change
- major increase in appetite
- loss of speech/language
- compulsive and repetitive behaviors
- memory loss
what are the subtypes of fronto temporal dementia
- fronto variant: initial personality change, executive dysfunction, impaired working memory, attention deficits
- semantic dementia: initial language abnormality, emotional distance, fluent dysphasia,
- progressive aphasia: like semantic dementia but with non fluent aphasia
what are the characteristics of Picks disease
- personality and behavior change
- loss of empathy
- obsessive-compulsive
- food craving
- use of wrong words, echoing
- difficulties in thinking, attention, gradual emotional apathy
what are the characteristics of FTDP17
- behavioral change
- psychiatric symptoms
- cognitive decline
- evntual mutism
what are the characteristics of supranuclear Palsy
- motor difficulties: problems with balance and gait
- personality/behavioral changes: apathy, irritability,
- characteristic gaze palsy (vertical eye movement)
- pseudobulbar palsy (face movement)
- rigidity of neck and upper trunk
- poor visual function
what are the characteristics of corticobasal degeneration
- signs of Parkinsonism
- cognitive and visual-spatial impairment
- hesitant and halting speech
- sudden contractions of muscles
- difficulty swallowing
- phonologic and spelling impairment
- visuospatial impairment
what is the presentation of vascular dementia
- comes on suddenly then slow stepwise progresssion from multiple strokes
- personality and intellect are preserved until late stages
what are the characteristics of primary progressive aphasia
- decline in one or more language functions
- begins gradually with word finding issues
- does not affect memory, reasoning and visual perception
what are the hallmarks of subcortical dementia
- bradyphrenia (slow cognition)
- memory and learning disturbances
- frontal executive syndromes
- motor disturbances
- psychiatric disturbances
- more rapid progression than primary progressive
what are characteristics of pseudodementia
- rapid onset
- minimal effort to perform tests
- cognitive impairment, loss of appetite, difficulty sleeping, social withdrawal
what are direct interventions
restorative treatments that aim at improving or restoring impaired function
what are types of direct interventions
- cognitive stimulation therapy: themebased typically in a small group setting, psychosocial and interactive
- reminiscence therapy: review of life events
- reality orientation: to reduce confusion and increase awareness. Use visual aids to present info for time, person, and place
- external memory aids
- validation therapy: validating values, beliefs and reality of the person to help reduce stress and provide opportunities for them to express feelings
- simulated presence therapy: playing audio recordings of close relatives
what are indirect interventions
- communication skill training: training caregivers to assume some responsibility in communication
- environmental modifications
