Final Exam Flashcards
3 stages of swallowing
- Oral stage–mastication, tongue control, swallow initiation, etc.
- Pharyngeal stage–hyolaryngeal excursion, PPW movement, epiglottic inversion, BoT retraction, UES opening
- Esophageal stage–LES opening
Muscles of mastication (muscles and innervation)
Innervated by trigeminal nerve
- Lateral and media pterygoids
- Buccinator
- Masseter
Muscles of the lips (8, plus innervation)
Innervated by facial nerve
- Orbicularis oris
- Levator labii superioris
- Zygomaticus minor
- Zygomaticus major
- Levator angularis oris
- Risorius
- Mentalis
- Depressor labii inferiors
- Depressor anguli oris
Muscles of the palate (4 plus innervation)
- Levator veli palatini (vagus)
- Tensor veli palatini (trigeminal)
- Musculus uvuale (vagus)
- Palatopharyngeus (vagus)
Suprahyoid muscles (for hyolaryngeal excursion)
- Geniohyoid (hypoglossal)
- Mylohyoid (trigeminal)
- Digastric (trigiminal)
- Stylohyoid (gacial)
Tongue muscles
- Styloglossus
- Genioglossus
- Hyloglossus
- Palatoglossus
Relation between oral hygiene and swallowing
No direct relation; however, individuals who aspirate and have poor oral hygiene have an increased risk for pneumonia.
Salivary glands
- Parotid (thin saliva)
- Sub-mandibular (both kinds, most saliva)
- Sublingual (thick saliva)
Xerostomia
Dry mouth
Innervation of the tongue
Anterior 2/3: Facial
Posterior 1/3: Hypoglossal
Glossopharyngeal nerve
Sensory: Taste for posterior 1/3 of tongue, mucous membranes, upper pharynx
Motor: Pharyngeal constrictors
Trigeminal nerve
Sensory: Anterior 2/3 of tongue, mucous membranse, cheek, gums
Motor: Muscles of mastication, tensor veli palatini, mylohyoid and anterior belly of dygastric
Facial Nerve
Sensory: Taste anterior 2/3 of tongue
Motor: Buccal, lip muscles
Vagus nerve
Sensory: Internal branch of SLN, general hypopharynx, larynx
Motor: Velum, pharynx, larynx, esophagous
Hypoglossal
Motor: tongue muscles except palatoglossus
Causes of dysphagia in infants
- Maternal disease (diabetes, substance abuse, preeclampsia)
- Structural abnormalities (macro/microcephaly, CL and CP)
- Neurological causes (PKU, hydrocephalus, intracranial hemorrhage, seizures, infections, neuropathies, myopathies)
Tracheoesophageal fistula/Esophageal atresia
When the esophagus is attached to the trachea; when the esophagus suddenly ends before reaching the stomach
Differences between infant swallow and adult swallow
High hyoid position, more curve in nasophayrnx and hypopharynx, tongue is larger than adults
Main difference between nutritive and non-nutritive sucking
Apneic period
Parkinson’s Disease and dysphagia
Pocketing of food/saliva, nasal/oral regurgitation, excessive secretions, poor lingual control of bolus, limited pharyngeal constriction, diminished hyolaryngeal excursion
ALS and dysphagia
UMN and LMN affected; drooling, penetration/aspiration, residue, etc. may occur but sensory functions are in tact; eventually NPO
Changes in typical aging
- Reduction in muscle mass
- Reduced range, speed, and strength
- Diminished senses
- Respiratory compromise
- Some penetration acceptable
Symptoms of impaired bolus prep
- Prolonged mastication
- Residue and pocketing
- Premature spillage
- Prolonged oral transit time
Symptoms of delayed swallow initiation
- Pre-swallow pooling
2. Penetration/aspiration before the swallow
Symptom of impaired BoT Retraction
- Residue in valleculae
Symptoms of impaired UES opening
- Penetration/aspiration after the swallow
2. Residue in the pyriform sinus
Symptoms of impaired pharyngeal stripping
- Pharyngeal residue
2. Prolonged pharyngeal transit time
Postural change for prolonged oral transit
Head back
Postural change for delayed swallow initiation
Chin tuck
Postural change for poor BoT retraction
Chin tuck
Postural change for unilateral laryngeal dysfunction
Head rotation to impaired side
Postural change for unilateral pharyngeal/pyriform sinus residue
Head rotation to impaired side
Postural change for unilateral oral/pharyngeal dysfunction
Head roataion to unimpaired side
Cuffed v. cuffless trachs
Cuffed trachs close off the upper airway, only allowing breathing through the trach. Cuffless trachs allow breathing both through the trach and through the mouth/nose
Passy-Muir Valve
Allows speech with a trach–DO NOT USE ON A PT WITH AN INFLATED CUFF
Swallowing with a trach
Reduced subglottal pressure, reduced laryngeal elevation, reduced upper airway sensitivity, general muscle weakness
Reasons why surgery may cause dysphagia
- Damage to nerves
- Edema
- Surgery for cancers
- Damage to brainstem
Dysphagia due to medication
Antipsychotics, anticonvulsants, antidepressants; cause xerostomia and tardive dyskinesia
Clinical Bedside Exam Procedure
- History
- Cranial nerve exam
- Trial swallows (thin, 5 mL, 10 mL, 20 mL, continuous sips; puree/pudding; solid)
Observations during clinical exam
- Hyolaryngeal elevation
- Timeliness of swallow
- Vocal quality
- Coughing
- Oral residue
How to test trigeminal nerve
- Palpitate facial muscles
- Test facial sensation
- Corneal reflex
How to test facial nerve
- Look for asymmetry during oral mech
2. Check taste in anterior 2/3 of tongue
How to test glossopharyngeal nerve
- Palatal elevation
- Gag reflex
- Taste in posterior 1/3 of tongue
How to test vagus nerve
- Voluntary cough
2. Vocal quality
How to test hypoglossal nerve
- Note atrophy or fasciculations of tongue
Dye test
Tests silent aspiration in pt with a trach
Risk factors for H&N cancer
Tobacco, alcohol, GERD/LPR, Epstein-Barr virus (nasopharyngeal), HPV (oropharyngeal), poor oral hygiene, poor nutrition
Assessment in H&N Cancer
Pre-op is mostly counselling–do both a clinical and instrumental exam. Discuss post-op outcomes
Reasons for post-op dysphagia in H&N cancer
- Removal of structures
- Scar tissue
- Would dehiscence
- Decreased movement and sensation
- Presence of trach
Effects of radiation therapy
Nausea, fibrosis, skin irritation, nerve damage, peripheral neuropothies, damage to salivary glands, reduced range of motion, reduced sensation
Effects of chemo
Nausea, occasional mucositis, xerostomia, loss of apetitie, oral cavity infection
Achalasia
Insufficient LES relaxation causes food to be stuck in the esophagus; causes chest pain, regurgitation, and dysphagia
Diffuse Esophageal Spasm–“Cork-screw esophagus”
Spasms throughout the esophagus reducing the ability for food to travel to the stomach
Strictures
When lumenal diameter is less than 15 mm
Schiatzki Ring
Narrowing of lower part of esophagus
Esophageal Diverticula
Pouch in pharynx where food builds up…leads to bad breath, regurgitation, cough, and repeated pneumonia
Scleroderma
Connective tissue disorder that weakens the LES
Supraglottic maneuver
- Hold breath
- Swallow
- Cough
Super Supraglottic
- Hold breath
- Bear down
- Swallow
- Cough
Mendelsohn
- Have pt swallow while feeling laryngeal elevation
2. Have pt hold out laryngeal elevation for as long as possible
Shaker
- Lie down (or sit up)
2. Lift head (or push head against resistance)
Masako
- Hold tongue between teeth
2. Swallow
Effortful swallow
Instruct patient to “swallow hard”
Infant swallowing and cardiopulmonary diseases
Blood-oxygen saturation is low, which affects respiration and therefore suck-swallow-breathe pattern
Types of feeding disorders in children
- Insufficiency–eats too little or too slowly
- Overselectivity–does not eat a wide enough variety of foods
- Refusal
- Feeding delay
Suckling timeline
Begins in 18th-24th week of gestation, sufficient for feeding in some healthy infants by 34 weeks
Infant feeding timeline
0-4/6 months–breast/bottle feed only
6-9 months–spoon feeding with thin purees, finger feeding of meltables, holds own bottle
9-12 months–cup drinking, finger feeding for melatbles and lumpy, mashed foods
12-18 months–self-feeding with utensils and holding cup with 2 hands
Clinical signs of infant dysphagia
Inefficient extraction, disorganized ssb pattern, anterior spillage, emesis, coughing, wet cry, decreased latching
Infant dysphagia interventions
Change positioning, change bottle/nipple, frequent burping, cheek support, chin support, external pacing
Compensation v. Rehabilitation
Compensation–techniques that allow safe swallowing without changing the underlying problem
Rehabilitation–addresses the physiological aspects to create safe swallows
Cyclical ingestion
Compensatory strategy of alternating food and drink while eating
Dry/repeated swallow
Compensatory strategy to clear residue
Passive oral motor exercises
Icing, brushing, vibration, manipuation of structures in the oral cavity; thermotactile stimulation
Types of active oral motor exercises
- Range of motion
- Resistance
- Chewing and swallowing exercises
Therabite
Handheld unit used to stretch a patient’s jaw
IOPI
Visual feedback device to measure tongue and lip strength using inflated bulb placed in mouth
Neuromuscular electrical stimulation
Sends electrical pulses through the muscles to stimulate and strengthen them. Little research evidence, best when used with other therapy techniques.
Non-oral feeding methods
- NG tube
- PEG tube
- PEJ tube (goes directly into intestines; requires pre-digested formula)
Strategies for dementia
- Offer softer foods
- Cut food into smaller pieces to aid/reduce mastication time
- Thicken liquids
- Compensatory maneuvers (train into habit)
- Serve smaller meals throughout the day
- Use environmental triggers
Free-water protocol
Patient is allowed to drink purified water as long as good oral hygiene is maintained to prevent dehydration and increase quality of life
LSVT and swallowing
LSVT may improve VF and laryngeal vestibule closure and pharyngeal transit
ESMT and swallowing
Improves cough and airway protection
Myofascial release and swallowing
Beneficial to patients with fibrosis
Beckman Oral Motor Treatment
Uses assisted movement and stretch reflexes to increase functional response to pressure and movement–does not require cognitive participation
McNeil Dysphagia treatment
Systematic exercise-based therapy for dysphagia in adults. Incorporates a single swallowing technique (i.e. hard swallow) with a hierarchy of feeding tasks.
Advantages of FEES over VFSS
- Portable
- No radiation
- More cost-effective
- No need for radiologist
- Visualization of anatomy–can see mucosal and structural abnormalities
- Visualization of glottic closure
- More flexibility in the evaluation
Advantages of VFSS over FEES
- Visualization of entire swallow
- No whiteout period
- Less invasive to patient
Seeing aspiration during a FEES
Before: bolus falls into airway before swallow is initiated
During: bolus is not in airway before whiteout period but is immediately after
After: bolus falls into airway after whiteout period. residue is usually visible
Observing hyolarygeal elevation with FEES
Whiteout period=good hyolaryngeal elevation
Complications of FEES
Laryngospasm, sneezing, gagging, vasovagal response, epistaxis (nosebleed)
