Final Flashcards
What is the occurrence in a year of laryngeal cancer in Americans?
~15,000 with 4,200 deaths
What is squamous cell carcinoma most commonly related to?
Smoking
What is cancer staging based on?
- Location of 1st tumor
- Tumor size
- Lymph node involvement
- Cell type and tumor grade (how close to normal cells)
- Metastasis
What does TNM stand for?
Tumor, Nodes, Metastasis
Primary Tumor
Regional Lymph Nodes
Distant Metastasis
What types of head and neck cancer are there?
- Supraglottic
- Glottic
- Subglottic
What types of oral cancers are there?
- Tongue
- Floor of mouth
- Mandible
- Maxilla
- Palate
What dysphagia symptoms due you see post oral cancer?
- Reduced oral sensation
- Reduced mastication
- Reduced bolus formation
- Loss of bolus/drooling
- Nasal regurgitation
- Reduced/delayed a-p transport
- Premature spillage
- Reduced hyolaryngeal elevation (mandible)
- Aspiration BEFORE swallow
What dysphagia symptoms due you see post partial laryngectomy?
- Reduced posterior tongue movement
- Restricted/incoordinated pharyngeal constrictor movement
- Slower swallow
- Poor pulmonary function
- CP achalasia and/or stricture
- Decreased laryngeal elevation
- Recurrence
What does CP achalasia mean?
Failure of the cricopharyngeal sphincter to relax and allow bolus to enter esophagus
What dysphagia symptoms due you see post total laryngectomy?
- Tongue weakness
- Reduced posterior tongue movement
- Restricted pharyngeal constrictor movement
- Reduced transit times
- CP dysfunction
- Esophageal stricture
- Fistula
- Abscess
- Pseudoepiglottis, pseudodiverticulum
- Recurrence
What is a psedoepiglottis or pseudodiverticulum a result of?
Reconstruction after removing larynx.
What dysphagia symptoms due you see with a TEP?
- Aspiration/leakage of food
- Aspiration of prosthesis
- Stenosis
- Stoma and fistula infection
- Spasm
- Migration or fistula enlargement
What dysphagia symptoms due you see post radiation therapy or chemo?
- Xerostomia
- Inflamation (mucositis)
- Pain
- Fibrosis
- Reduced taste
- Loss of appetite
- Decreased tongue and jaw ROM
- Reduced pharyngeal constriction
What is xerostomia?
Dry mouth
Why might a trach be placed?
- Airway obstruction above vf’s
- Upper airway obstruction (edema post surgery)
- Provision of respiratory care
Between what tracheal rings is a trach placed?
Between 3rd and 4th
What parts are make up a trach and what is their function?
- Outter cannula-hold trach site open
- Inner cannula-actual breathing tube in trachea
- Obturator-smooth tip for initial insertion
What signs of aspiration or reflux do you see with a trach?
- Food in trach
- Endotracheal secretions
What types of trachs are there?
- Cuffed
- Cuffless
- Fenestarted
Why might we choose a CUFFED trach?
- Prevents aspiration
- Used with ventilators
- Inflated for positive pressure
Why might we choose a cuffless trach?
- Assists breathing and secretion removal
- Long-term use
NOTE
- Aspiration may occur
- Mary interfere with laryngeal elevation during swallow
Why might we choose a fenestrated trach?
- Smaller
- Used for weaning and decannulation
- Short-term (3-5 days)
What do we need to know before treating a trach patient?
- Pt hx (dysphagia symptoms)
- Type/Name of trach tube and if inflated/cuffed
- Length of time had trach
What do we see in trach patients longer than 6 months?
Scar tissue can restrict laryngeal elevation
With medical clearance, what can we do for inflated cuffs and why?
Deflate the cuffed tube
- inflated cuffs irritate tracheal wall during swallow
- Restricts laryngeal elevation
- Compresses on esophagus
- Reduces laryngeal sensitivity
What needs be done with deflating a cuff?
Suction both oral and trach as deflating
-Pooling on top of cuff may otherwise fall into trachea
What can we instruct a patient to do to clear possible airway residues and mimic near-normal trach pressure?
Patient occludes trach with gloved finer or gauze OR 1-Way valve during and several seconds after each swallow
When performing trial swallows with a trach patient, what might we have them do?
- Perform dry swallows first
- Start with easiest consistency for patient with 3-finger test and suction
- Cough
- Phonate sustained vowel after swallow, head turn
How many cc’s do we use during a trial swallow?
3 cc’s
For patients who are ventilator dependent, what happens to their swallow and why?
It usually worsens due to
-Respiration controlled by vent
-Patient can’t lengthen exhalation for swallow (disrupts swallow)
(Cuffed trach tube due to vent)
What treatment might we give a ventilator dependent trach patient?
- Timing of swallow at exhalation
- Blue dye test
- Present a variety of consistencies
What might we see in patients post intubation?
- laryngeal trauma from tube placement
- TE fistula from tube rubbing
Laryngeal Pathologies
Granuloma, vocal fold paresis/paralysis, edema, erythema
How long post intubation do we wait before treating?
1 week
What do we work on first in post intubation patients?
Range of Motion Exercises
Because sensory and motor has changed
What types of feeding tubes are there?
NG-Nasogastric ND-Nasoduodenal NJ-Nasojejunal OG-Orogastric G or GT-Gastrostomy GD-Gastrostomy with dual port to jejunum GJ/PEJ/J-Jejunostomy
What red flags do we see with feeding tube patients?
- Greater than 20% weight loss
- Dehydration
How will we know if a feeding tube patient is dehydrated?
- Rapid weight loss of 4+ lbs/48 hours
- Liquid dysphagia
- Complaint of thirst
- Reduced skin turgor
- Decreased urination
- Hypernatremia (increased serum sodium)
- Elevated BUN (Blood Urea Nitrogen)
Why might we choose an NG tube?
- Short term (months)
- Intact gag reflex
- Normal emptying of stomach
- No uncontrolled reflux
Why might we choose an ND tube?
- Short-term
- Reflux
- Aspiration risk
- Decreased rate of stomach emptying
Why might we choose an NJ tube?
- Longer tube (~43” instead of 36”)
- Placed endoscopically
- Requires radiographic confirmation
- Minimizes dislodgement back into stomach
Why might we choose a GT tube?
- NG route unavailable
- Long term
- Permanent swallowing dysfunction
- Cosmetically pleasing
- Can take homemade purees vs formula
What time of feedings are feeding tubes? (They not oral so they’re…)
Enteral
What dysphagia treaments might we employ?
- Diet Modification
- Positial
- Oral Sensory
- Maneuvers
- Exercises
- Prosthetics
- Surgery
- Experimental/Other
What compensatory techniques do we perform?
- Diet
- Positional
- Oral Sensory
- Prosthetics
- Other (multiple swallows, liquid wash)
T/F compensatory TECHNIQUES do not change motor control of swallow under control of a caregiver.
True
What are compensatory techniques designed to do?
- Eliminate symptoms
- Change time of swallow
T/F compensatory THERAPIES change swallow anatomy/physiology
True
What are compensatory THERAPIES designed to do?
- Change swallow anatomy/physiology
- Increase ROM, control, and strength
Can be direct or indirect
When might we choose diet modification?
As a “last resort”
- Other strategies fail
- Cognitively impaired
- “building block” (Neurom. control/strength and ROM ex’s)
What do diet modification make changes in?
- Bolus volume (size)
- Bolus viscosity (consistency)
- Temperature
- Taste
T/F CVA’s do worse with larger volumes?
False, they do better with larger volumes
What types of diet consistencies are there?
LIQUIDS -Thin -Nectar -Honey SOLIDS -Pudding -Puree -Mechanical Soft -Chopped -Regular
What positional techniques might we employ?
- Sitting upright at 90 degrees
- Sideline
- Chin tuck
- Head rotation
- Head tilt
- Head back
- Present food at midline
What is the rationale for sitting upright at 90 degrees?
Contributes to gravity to direct bolus down
What is the rationale for using sideline?
Eliminates gravitational effect on pharyngeal residue
What is the rationale for using the chin tuck?
- Widens valleculae (to prevent penetration)
- Narrows airway entrance and increases laryngeal elevation and vocal fold closure
- Pushes tongue base backward toward pharyngeal wall
- Pulls epiglottis in a more protective position
What is the rationale for using head rotation and which way do they rotate towards?
To WEAKER side
-Closes off damaged side and directs bolus down stronger side
What is the rationale for head tilt and which way do they tilt towards?
To STRONGER side
-Directs bolus down stronger side (by gravity)
What is the rationale for head back?
Uses gravity to clear oral cavity
What positional strategies are good for unilateral issues?
Head rotation and head tilt
What oral sensory techniques might we employ?
- Downward pressure of spoon against tongue
- Sour bolus
- Cold bolus
- Bolus requiring chewing
- Suck-swallow
How do we perform thermal-tactile stimulation and why?
Vertically rub anterior faucial arch 3 fast times with a cold laryngeal mirror, ice stick, or cold spoon
-Heightens oral awareness and triggers pharyngeal swallow
How do we measure oral techniques?
- Duration from command to swallow
- Oral transit time
- Pharyngeal delay time
How do we perform suck-swallow technique and why?
Vertical tongue-jaw sucking with lips closed
-Triggers pharyngeal swallow, draws saliva to back of mouth
What prosthetics might we suggest?
- Dentition
- Palatal Lowering (hard palate)
- Soft Palate
- Lingual
What do dentition prosthetics do?
Increase mastication, appearance, and denture retention
What do palatal lowering prosthetics do?
- Decreases volume of oral cavity
- Increases bolus transit and tongue-palate contact
What do soft palate prosthetics do?
- Restores contact between palate and posterior tongue to maintain bolus control and direct bolus
- Aids in mastication
- Avoids pharyngeal spillage (slows down transit)
- Avoids nasal regurgitation during swallow
What do lingual prosthetics do?
- Decrease oral cavity size (and pooling)
- Increases tongue-soft palate contact (bolus control)
- Increasing eating
- Increases articulation and resonance
Even though we can’t make prosthetic, what might we be asked to do medically?
Evaluate prosthetic during/with swallow
What do we need to know when treating a patient with prosthetics?
Do they have
- Dentures/appliances
- Glasses
- Hearing Aids
What maneuver therapies might we use?
- Effortful Swallow
- Supraglottic Swallow
- Super-Supraglottic Swallow
- Mendelsohn
Describe an effortful swallow maneuver and what it does.
- Squeeze hard with all of your muscles
- Swallow with “squeeze”
Increases posterior tongue base and epiglottic movment and decreases pooling in valleculae
Describe the supraglottic swallow maneuver and what it does.
- Inhale and hold breath
- Place bolus in position (at back of tongue)
- Swallow while holding breath
- Cough after swallow before inhaling
- Swallow again to clear material expelled by cough
Voluntary breath hold that closes vocal folds before and during swallow (longer apneic period)
Describe the super-supraglottic swallow maneuver
- Inhale and hold breath
- Place bolus in position (at back of tongue)
- Swallow while holding breath and :bear down”
- Cough after swallow before inhaling
- Swallow again to clear material from cough
Effortful breath hold that tilts arytenoids forward, closing vocal folds before and during swallow (quickens closure)
What is the super-supraglottic swallow maneuver also called?
Valsalva Maneuver
Describe the Mendolsohn maneuver and what it does.
- Push tongue hard up against roof of mouth
- Several dry swallows while feeling thyroid lift
- Hold thyroid up for several seconds
- Prolonged laryngeal elevation opens and prolongs UES to decrease pyriform pooling
- Normalizes/coordinates timing of pharyngeal swallow events
What exercise therapies might we use?
- Shaker
- Masako
- Oral Motor
Describe the Shaker exercise and what it does.
- Lay flat on your back on the floor or a bed
- Without lifting your shoulders, hold you head off the floor and look at your feet for 1 minute
- Relax your head back down for a 1 minute break
- Repeat sequence 2 more times
- Raise your head 30 more times and look at your toes (don’t sustain head lifts)
- Repeat entire exercise 3 times/day
Head lift exercise to increase UES opening and decrease hypopharyngeal intrabolus pressure
What does the Masako exercise do?
Anterior posturing of the tongue to strengthen pharyngeal constrictors
-Done ONLY with dry swallows
What types of oral motor exercises might we do?
- ROM
- Resistance
- Bolus (maintenance, prep, manipulation, propulsion)
Lip seal, jaw strengthening, tongue strengthening
What surgeries might be used for dysphagia treatment?
- CP myotomy (slice to remain open)
- Diverticulectomy (take pocket off)
- Dilation (balloon out stricture)
- Palatopexy (palate muscles changed)
- VF medialization (Augmentation/injection or thyroplasty)
What experimental treatments are being used?
- DPNS Deep Pharyngeal Neuromuscular Stimulation
- NMES Neuromuscular Electrical Stimulation
- Myofascial Release
- Botox
What “other” strategies might we use?
- Food presentation
- Multiple swallows (to clear)
- Liquid wash
- Adduction techniques (cough, throat clear, LSVT, hard glottal attack, sustained phonation)
- EMST Expiratory muscle strength training
What is the order of interventions we should use?
- Posture changes/oral sensory
- Maneuvers/exercises
- Diet modifications
- Prosthetic
- Surgery
What treatments do we use for a partial glossectomy?
- Head tilt (to stronger side) before food is placed in mouth
- Placement of food onto existing posterior tongue surface
- Head tilt back
- Thermal stim
- Oral motor (tongue-palate ROM/resistance)
- Oral motor (chewing - wet gauze)
- Speech sounds /d/, /t/, /g/, k/k
What treatments do we use for a hemilaryngectomy?
- Chin tuck
- Head tilt (strong side)
- Head rotation (to the weak side)
- Super-supragottic
- Adduction
What treatments do we use for a laryngectomy?
- Oral motor (ROM/resistance)
- Plosives (/p/, /t/, /k/)
- Neck stretches
What treatments do we use for ALS?
- NO MANEUVERS OR EXERCISES!
- Compensatory only (thermal-tactile stim, positional, diet modifications)
- G-tube placement
What treatments do we use for strokes?
- Thermal-tactile stim, pressure, sour
- Head rotation (to weak side)
- CHin tuck
- Mendelsohn
- Supraglottic
- Super-supraglottic
- Oral motor (ROM) - indirect
- Adduction - indirect
- Larger bolus size (3 oz = ~90 cc/ml)
What treatments do we use for PD?
- oral motor (ROM) for tongue, lips, larynx
- Effortful
- Supraglottic
- Super-supraglottic
- Mendelsohn
- Adduction (LSVT)
- EMST
What treatments do we use for TBI?
- Counsel family members/caretaker
- Postural changes
- Thermal-tactile stim
- Oral motor (ROM/resistance)
- Increased viscosity
What treatments do we use for MS?
- Oral sensory (thermal-tactile stim)
- Postural changes
- Oral motor (ROM)
What treatments do we use for Alzheimer’s?
- Counsel caretaker/family members
- Oral sensory
- Strong taste, increase bolus size
- Postural
- Exercises (early)
- Diet modifications (late)
- Enteral feeding (end stage)
What treatments do we use for post-neurosurgery?
- Aggressive oral motor (ROM/resistance for lips, tongue, tongue base, larynx)
- Adduction
- Effortful
- Super-supraglottic
What treatments do we use for cervical injury/fusion?
- Positioning (as close to 90 degrees as possible)
- Mendelsohn
- Supraglottic
- Super-supraglottic
- Adduction (LSVT)
