FINAL EXAM Flashcards
The degree of cortical impairment depends on __
Location of damage
Extent of damage
Type of damage (trauma vs blunt force)
Unilateral vs. bilateral
what swallowing deficits would a lower brainstem stroke exhibit?
difficulty triggering the pharyngeal swallow
absent pharyngeal swallow
delayed pharyngeal swallow
reduced laryngeal elevation
reduced UES opening
medulla is affected
What is oral agnosia?
inability to visually recognize food or liquid
What oral agnosia may be exhibited in Dementia and Alzheimer’s patients?
The patient may not eat the food because they don’t realize it is food
May not know what to do with it or refuse to eat the food
Patient may need a feeding tube to maintain nutrition
why can patients with TBI be difficult to treat for dysphagia?
behavioral issues such as impulsive, poor attention and awareness
cognitive issues such as in and out of alertness, making it hard to counsel them and feed them
cannot eat or swallow if not alert
What swallowing deficits are associated with Parkinson’s?
oropharyngeal - poor bolus control
random tongue movement
tongue pumping/lingual rolling
delayed swallow initiation
pharyngeal residue
drooling (increases risk of silent aspiration)
incoordination of swallow and respiration
swallow as progressive as disease
Generalized treatments for Parkinson’s
Early Parkinsons’: exercises
Moderate Parkinson’s: sensory changes/input
Severe Parkinson’s: counseling on enteral nutrition/maximizing nutrition
quality of life as it’s a progressive, non-curable disease
Neurological disorders causing dysphagia: Dementia
causes dysphagia due to structural changes and chemical changes affecting neurological control
Neurological disorders causing dysphagia: TBI
external physical trauma to head
causes dysphagia due to changes in posture and muscular tone in muscles needed for swallowing
cognitive and behavior changes
Neurological disorders causing dysphagia: Parkinson’s disease
neurodegenerative disorder that occurs due to a disorder basal ganglia and causes slowed movements (bradykinesia) rigidity and tremors
rigidity and bradykinesia impacts swallow initiation time, UES relaxation, and pharyngeal residue
Neurological disorders causing dysphagia: Brain Tumor
causes dysphagia due to neurogenic changes, cranial nerve deficits, sensory/motor changes, cognitive changes
Neurological disorders causing dysphagia: ALS
progressive neuromuscular degenerative disease
Side effects of radiation; how does it effect swallowing
the scatter effect
mucositis - inflammation of mucous membranes
xerostomia - dry mouth in relation to decreased production of saliva
odynophagia - painful swallowing
edema - swelling
dental changes
fibrosis - scarring of tissue; changes into excessive fibrous connective tissue
may cause patient a lot of pain or discomfort when swallowing which leads to feeding tubes
why is dry mouth/xerostomia a problem in head and neck cancer patients?
causes patient to swallow less and less, which can lead to lack of nutrition, energy, weight loss, and insertion of feeding tube
this in turn can cause atrophy of pharyngeal muscles
this can also cause psychological and emotional problems as well such as depression
when should swallow treatment begin for a head and neck cancer patient?
the sooner therapy is initiated after cancer treatment, the better the outcome.
there is no consensus regarding the optimal time after treatment to begin dysphagia therapy
head and neck cancer before, during and after treatment
pre-treatment - establish baseline, protocols, START exercises and counseling
during - monitor, exercises, counseling
post - monitor for change, continue exercises, counseling
Why is it important to keep a head and neck cancer patient swallowing EVEN if they are aspirating?
Helps limit this buildup of residue and allows them to continue to exercise the structures to avoid worsening swallow inefficiency and atrophy of pharyngeal muscles
What is trismus?
Problems opening mouth, lockjaw
Reduced ability to open the mouth secondary to tonic/tight contraction of the muscle
What is a total laryngectomy-how does this affect swallowing?
physical separation of the GI tract from the respiratory tract; removal of the larynx, OR separation of the airway from the esophagus
This affects swallowing because there is no elevation because there is no larynx or hyoid bone
What specific swallow changes would you see in an oral cancer patient?
Limit mastication, bolus formation and containment, bolus control, and bolus transport from the front to the back of the mouth.
What specific swallow changes would you see in a laryngeal cancer patient?
Reduced laryngeal elevation
Reduced glottal and laryngeal closure
Reduced UES or PES opening
Reduced pharyngeal wall contraction
True/False. SLPs can diagnose esophageal dysphagia
FALSE. SLPs cannot diagnose – but they can perform esophageal SCREEN during MBS
Esophageal dysphagia can impact….
oropharyngeal function
The esophagus is……
Innervated by CN X (Vagus)
Proximal 1/3 - striated muscle; Distal 2/3 - smooth muscle
Hollowed muscular tube; Collapsed at rest; distends when food/liquid/air is swallowed
what is peristalsis?
a series of muscular contractions
what are the three different types of peristalsis?
primary - rapid movement of cervical esophagus; slow movement of mid/distal esophagus; shortens
secondary - distends
tertiary wave - not peristaltic; disordered
symptoms of esophageal dysphagia
Food sticking in throat (globus sensation), coughing during/after meals – Common
Chest pain, shortness of breath, respiratory symptoms, odynophagia – less common
Patient sensation is often inaccurate
Referred sensation – sensation of something stuck in throat, but actually stuck in esophagus 2/2 esophageal innervation by vagus nerve
different kinds of structural disorders of the esophagus
esophageal stenosis/stricture
schatzki’s ring
esophageal web
malignancy/obstruction
diverticulum
what is esophageal stenosis/stricture?
narrowing of esophagus
schatzki’s ring
distal/lower esophagus and usually symmetric
see a slow progression of symptoms
esophageal web
upper 1/3; usually asymmetric
malignancy/obstruction
usually from esophageal tumors or Barrett’s esophagus (premalignant condition 2/2 severe/chronic GERD)
progresses rapidly - usually advance by time detected
diverticulum
pouch/sac branches off esophagus 2/2 bulging from esophageal pressure
regurgitation
zenker’s diverticulum - common and develops at UES
cricopharyngeal bar - failure of muscle to distend (stretch)
motility disorders of esophagus
- GERD - LES muscle relaxation results in backflow of stomach acid into the esophagus
- Laryngopharyngeal Reflux (LPR) - backflow of stomach acid into laryngopharynx
- Achalasia - incomplete/absent relaxation of LES and bolus can’t move into stomach; absent peristalsis
- Eosinophilic Esophagitis - allergic inflammatory disease
treatments of esophageal disorders
myotomy
dilation
fundoplication
botox
supplemental oxygen types for respiratory dysphagia
nasal cannula
BiPap
CPAP
non-rebreather
what is the endotracheal tube?
oral intubation; long/plastic tube placed through mouth - vocal folds - trachea; cuff on the end can be inflated/deflated; connected to ventilator; patient sedated
What are the risks associated with the Endotracheal tube?
- granuloma
- hematoma
- ulcers
- edema
- vocal fold paralysis
- deconditioning
- delayed swallow response time
what is a tracheostomy tube?
a hole created in neck to the trachea
allows patient to wean sedation, initiate mobility, possibility for speaking/swallowing, deflated to allow air to flow to oral cavity
risks of tracheostomy tube
- decreased taste/smell
- increased risk of aspiration
- 2/2 deconditioning from medical condition requiring trach placement
what is a cuffed trach and associated risks?
- inflated to maintain air from vent to lungs, prevent aspiration
- increased risk of silent aspiration if cuff inflated
speaking valve
- Allows air in through trach during inhale and closes during exhale; moves air around trach tube through vocal folds and into oral cavity
- Improves upper airway secretions, ability to cough/clear secretions and improves speech
what is COPD?
group of progressive lung diseases (emphysema and chronic bronchitis)
chronic obstructive pulmonary disease
COPD risks
Increased risk of aspiration 2/2 decreased hyolaryngeal excursion, delayed oral/pharyngeal initiation, deconditioning, swallow on inhale cycle, and earlier and longer apneic periods
what is iatrogenic dysphagia?
difficulty swallowing that is caused by medical treatment or intervention (surgeries)
True or false: head and neck surgeries increase risk of dysphagia
false
what surgeries can cause dysphagia?
thyroidectomy
carotid endarterectomy (CEA)
cardiovascular surgery
skull base surgery
Possible complications of surgeries
damage to vagus nerve
unilateral vocal fold paralysis
intubation
deconditioning
what are possible complications of cervical spine surgery?
prevertebral edema, esophageal injury, vagus nerve injury
what is cervical osteophytes and possible complications?
- Bony outgrowth of the cervical vertebrae; narrows pharyngeal space
- Possible complications: Obstructive dysphagia, most symptomatic at C3 and C6
what is an esophagectomy and possible complications?
- removal of esophagus or portion of esophagus
- Possible complications: vagus nerve injury, changes to esophageal motility, stricture, pharyngeal/esophageal dysphagia
what are possible complications of thermal burn trauma?
inflammation
intubation/trach
anoxic BI
sedation
Postural maneuvers & compensation techniques for dysphagia: head tilt
directs bolus to good/strong side
Postural maneuvers & compensation techniques for dysphagia: head turn
closes weak side
Postural maneuvers & compensation techniques for dysphagia: chin up
improves anterior-posterior oral transit; use only with good pharyngeal phase/airway closure
Postural maneuvers & compensation techniques for dysphagia: chin tuck
improves oral containment, increases BOT/PPW contact, decreases laryngeal vestibule diameter
Postural maneuvers & compensation techniques for dysphagia: supraglottic swallow
improves laryngeal vestibule closure
Postural maneuvers & compensation techniques for dysphagia: super-supraglottic swallow
tighter laryngeal vestibule closure
Postural maneuvers & compensation techniques for dysphagia: effortful swallow
increases BOT/PPW pressure, pharyngeal pressure, improves UES opening and hyolaryngeal excursion
Postural maneuvers & compensation techniques for dysphagia: repeat swallows
can clear pharyngeal residue
Postural maneuvers & compensation techniques for dysphagia: mendelsohn maneuver
improves hyolaryngeal excursion/UES opening, improved coordination but difficulty to teach
associated risks with chin tucks
can increase risk of aspiration with delayed initiation, pyriform sinus residue
what are compensation techniques that are modifications?
Small bites/sips, slow rate, alternate liquids/solids, no straws, etc.
Liquid modifications – thin, nectar/mildly thick, honey thick/moderately thick liquids
Carbonated/sour/cold bolus – immediate effects of timing, but no long-term improvement
Frazier free water protocol – thickened liquids (as indicated) at meals, free water between meals (Strong oral care required)
Diet modifications – national dysphagia diets, IDDSI, clear or full liquids
benefits of liquid modifications?
slows bolus transit
reduces aspiration; but no strong evidence it decreases pneumonia rates
possible decreased fluid intake
exercises principles for swallowing rehabilitation include..
- gradual progression of intensity
- frequency (Number Of Training Sessions Per Unit Of Time)
- load
head and neck muscular swallowing rehabilitation is specialized for
speech > force
effortful swallow
targets lingual/palatal pressure, lingual strength, oral manipulation, pharyngeal pressure, hyolaryngeal excursion/UES opening, BOT/PPW pressure
tongue-hold/masako
works on BOT/PPW contact and pharyngeal constriction
head-lift/shaker
targets laryngeal elevation, hyolaryngeal excursion/UES opening
CTAR (chin tuck against resistance)
targets laryngeal elevation, hyolaryngeal excursion/UES opening
mendelsohn maneuver
targets laryngeal elevation
EMST (expiratory muscle strength training)
targets buccinator strength, BOT/PPW contact, hyolaryngeal excursion, laryngeal vestibule closure, cough strength, breath support
MDTP (McNeil Dysphagia therapy program)
possibly targets pharyngeal response and hyolaryngeal excursion
jaw opening
targets laryngeal elevation, UES opening
Effortful pitch glide
targets laryngeal elevation, hyolaryngeal excursion, pharyngeal contraction/shortening
sEMG (device)
adjunctive therapy and biofeedback
NMES (neuromuscular electrical stimulation)
possibly targets pharyngeal response time, pharyngeal transit time, hyolaryngeal excursion
IOPI (device)
targets lingual/palatal pressures, bolus/pharyngeal transit, BOT/PPW contact
swallow strong/tongueometer
targets lingual/palatal pressures; biofeedback
true or false: there is no evidence to support thermal-tactile stim
true
biofeedback
sEMG - visual representation of muscular effort placed during swallow response; patient can visualize effort and increase/decrease with feedback provided
what are two swallowing prevention techniques?
Pharyngocise – various exercises included to be completed prior to or during XRT for head/neck cancer
Therabite – device used to improve/maintain jaw opening
Targets muscle preservation, trismus, saliva production, taste
Head/neck development in normal infant/child development
- oral cavity/jaw smaller
- oral cavity filled by tongue
- large/fat buccal pads
- uvula/epiglottis in contact at rest
- larynx/hyoid bone higher in neck
- Eustachian tubes shorter and run horizontal
gut development for infant/child
anatomic completed by 20 weeks; physiologic function late in gestation
lung development for infant/child
latest to develop; 28 weeks - surfactant development
neurological development for infant/child
- 1st trimester - spinal cord beings to develop
- 2nd trimester - brainstem matures, breathing/sucking/swallowing being to emerge
- 3rd trimester - brainstem most highly developed, primitive cerebral cortex
fetal development
- 7 weeks lips form
- 13 weeks swallowing
- 18 weeks sucking
- 32 weeks suck/swallow coordination
- 37 weeks suck/swallow/breathe coordination
infant swallowing phases
oral prep
oral transit
initiation of pharyngeal swallow
pharyngeal phase
esophageal phase
what is the purpose of adaptive reflexes and what are they?
direct feeds to gut
rooting, suckling, sucking
nutritive vs nonnutritive suck
Nonnutritive suck – suck/swallow ratio 6:1 to 8: 1, twice as fast as nutritive suck
Nutritive suck – integrates suck/swallow/breathe; suck/swallow 1:1 ratio
(Immature (3-5 sucks/burst), transitional (5-10 sucks/burst), mature (10-30 sucks/burst))
what is the purpose of protective reflexes and what are they?
airway protection
tongue protrusion, phasic bite, gag, tongue lateralization, cough, laryngeal chemoreflex
infant/child disorders that cause dysphagia
- Respiratory disorders (newborn apnea, pulmonary hypoplasia, RDS, BPD, laryngomalacia)
- Cardiac disorders (tetralogy of fallot, transposition of great arteries, VSD, patent ductus arteriosus)
- GI deficits (NEC, Hirschsprung’s disease, esophageal atresia, GERD, EoE)
- Neurological disorders (hydrocephalus, TBI, CP, intraventricular hemorrhage, seizures)
- Cleft Lip/Palate (lip only, lip and palate, hard and/or soft palate, velopharyngeal insufficiency)
- Congenital (Pierre Robin sequence, Moebius syndrome, Down syndrome)
- Material Conditions (FAS, NAS)
- Prematurity (difficulty with state control, stress, postural control, oral motor control, gut maturity/health, physiological control, respiratory rate, heart rate, endurance, suck/swallow/breathe)
- Tongue Tie (tight lingual frenulum, creates heart shaped tongue when protruded, can affect breast feeding (poor latch), treatment with frenulotomy)
- Sensory processing (hypersensitivity, hyposensitivity, oral sensitivity)
- Autism Spectrum (usually demonstrate oral motor delay, sensory sensitivity or desire for sameness)
- Any of these deficits can result in nutrition/hydration/energy concerns
child treatment for dysphagia
- Oral sensory – motor therapy; determine if skill deficits, learned behavior or both
- Special Feeding equipment – teething toys, gum brushes, food nets, nosey cups
- Oral motor toys – chewy tubes, bite blocks, tongue depressors
- Specialty spoons – textured, maroon
- Positioning – important, feed/back/ trunk/head support
- Behavioral Feeding Therapy
what is the purpose of behavioral feeding therapy?
- Increase desirable behavior - accepting foods offered, eat acceptable amount, eat variety of foods, quality over quantity
- Decrease undesirable behavior - refuse foods, verbal/physical protests, withdrawal or refusal
infant treatment for dysphagia
- Side-lying – changes direction of gravity, milk diverted to cheek
- Flow rate – slow flow to improve coordination of suck/swallow/breathe, improves ability to control flow
- External Pacing – tip bottle downward to allow fluid into bottle, but leave nipple in baby’s mouth
- Thickened liquids – slows flows, decreases regurgitation, use caution with commercial thickeners
- Chin/Cheek support – improves seal on nipple; used as a cue not a crutch
- Quality over Quantity – support positive experiences; negative experiences can create stress and eventually learn to avoid eating or develop bad patterns
what is cue based feeding?
involves following the infants cues to drive feeding
what does quality vs quantity mean in infant feeding?
priority is feeding performance over amount taken in
what are the signs of stress in infant feeding?
- change in state/alertness
- change in tone/postural control
- raised/furrowed brows
- pull head back
- turn head away
- hand/arm extension
- finger splay
- gulping, gurgling, milk spilling out of mouth
- coughing/choking, gagging
- Change in cardio-respiratory behavior
what are the sings of disengagement in infant feeding?
- pushing nipple out
- no active rooting/sucking,
- unable to re-alert
- use of weak suck
what is involved in a child/infant evaluation for dysphagia?
Swaddling – important to regulate state, improves coordination; midline flexion – arms/legs to chest
Treatment strategies are used during evaluation to compensate for deficits if noted
Caregiver focus
If dysfunction or risk of aspiration present, pursue MBS or FEES
