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Dysphagia > HC 4 Radiography + DSS > Flashcards

HC 4 Radiography + DSS Flashcards

1
Q

How do we assess the pharynx by radiography?

A

= (modified) barium swallow or Dynamic Swallowing Study (DSS)

  • accomplished by videofluoroscopy of video radiography:
  • recording of the fluoroscopic image
  • spatial resolution is not so much, but is generally adequate for most studies
  • less radiation exposure
  • easier manipulation of the images
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2
Q

What is a esophagram?

A

= radiographic examination of the esophagus

= barium meal or swallow

  • often combined with examination of the stomach and duodenum
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3
Q

Which other equipment is used in radiography? Explain

A

•Rapid sequence digital radiography

−6 frames per second

−Excellent spatial resolution & easy manipulation of the images

−Relatively low radiation exposure

−Disadvantage: too few frames for some studies

•Cine-MRI and turbo- FLASH MRI:

−less or no radiation

−Not commonplace

•Videofluoromanometry:

−Dynamic and functional structural information

−Provides insights to bolus flow and pressures

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4
Q

What are our concerns regarding radiation exposure and safety?

A
  • ALARA principle: As Low As Reasonably Achievable (there is no safe dose of radiation)
  • balance between an effective study and minimizing long-term radiation risk: in the elderly the risk to health in missing aspiration or swallow impairment is far greater than the cumulative risk from low-dose radiation
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5
Q

When is it indicated to perform radiography?

A
  • suspicion for silent aspiration
  • Persistent dysphagia
  • Odynophagia
  • Aspiration
  • Pulmonary pathology
  • Chronic cough
  • Regurgitation
  • Weight loss
  • Reflux or esophageal pathology
  • After surgery or radiotherapy to the head and neck
  • Full assessment of pharyngeal and esophageal phases
  • Tailored
  • Testing maneuvers or strategies
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6
Q

Why is DSS the optimal radiographic procedure?

A

−Provides information regarding transit and pathway bolus through oropharynx, hypopharynx, pharyngoesophageal segment and esophagus

−Ability to demonstrate motion

−Is general available

−From oral cavity, base of the tongue, valleculae, epiglottis, piriform sinuses, to pharyngoesophageal segment and cervical esophagus

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7
Q

What’s the difference between a lateral and a anterior posterior view?

A
  • lateral view: better view on epiglottis and cricopharyngeus muscle
  • anterior posterior view: better view
  • on valleculae and piriform sinuses
  • on asymmetries (unilateral weakness)
  • on some pathologies e.g. Zenker’s diverticulum
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8
Q

What are possible observations during radiography?

A

−Penetration

−Aspiration

−Hyolaryngeal elevation

−Esophagus: abnormalities in anatomy and motility problems

−Epiglottic folding back

−Residue: valleculae and piriform sinus

−Stream (Posterior cricoid findings)

−During esophageal screen (large bolus of barium, barium tablet): transit time, completeness of bolus transfer, reflux, stasis, constrictions of the stream, presence of hiatal hernia

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9
Q

When is it indicated to perform DSS?

A

When complaints, signs/symptoms and/or histories

suggest

oral, pharyngeal, laryngeal or pharyngoesophageal dysfunction

to identify risks to

respiratory/pulmonary and nutrition/hydration health

and to target potential

behavioral, surgical or medical interventions more precisely and effectively

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10
Q

What are DSS’ limitations?

A

−Limited length of observation and repetition

−Technical limitations (e.g. two-dimensionality)

−Radiation exposure

−Dependence on the quality of images obtained

−Good positioning of the patient may be difficult

−Lack of attention to or experience with Fluoroscopic swallow study

−No information on pressures

−No information on sensation of tissues

−Inability of some patients to undergo the study

−Conditions can have an effect of swallow performance (e.g. not similar to real-life eating)

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11
Q

What are DSS’ contra-indications?

A
  • when moving the patient is dangerous
  • when rapid fluctuations
  • when positioning is not possible
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12
Q

What does DSS attempt to do?

A

−Determine risks to respiratory system during eating/drinking

−Clarify and characterize variables that lead to such risks

−Modify variables (if possible)

−Elaborate patient’s potential for oral eating

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13
Q

Which variables could influence the patient performance and study success with DSS?

A

−Position

−Postural stability and flexibility

−Respiratory sufficiency

−Stamina and endurance

−Lubrication

−Bolus characteristics

−Competing behaviors and states

−Environment

−Adaptability

−Views

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14
Q

Why does the position of head/neck influence the swallow performance?

A
  • alters the effect of gravity
  • changes the relationships of structures and shapes of the chambers
  • e.g. rotation -> increase/decrease size of piriform sinus
  • e.g. neck flexion (buiging) -> changes shape of valleculae
  • e.g. neck extension -> alters relationship between hyoid movement direction and the PES
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15
Q

Why does the postural stability and flexibility affect the swallow performance?

A
  • Fine movements depend on a stable support structure (eg. airway)
  • flexibility in posture is needed to apply compensatory strategies
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16
Q

Why do the bolus characteristics influence the swallow performance?

A

Size, thickness, taste, texture, viscosity and temperature facilitate or complicate timing, valving and clearing

17
Q

Why do competing behaviours influence the swallow performance?

A

Any distraction can affect the swallow: gagging, sneezing, hiccupping, laughing, crying, speech, startle, fear,…

18
Q

Why does the environment influence the swallow performance?

A
  • some circumstances promote interest in eating or drinking, or not
19
Q

Why does the adaptability influence the swallow performance?

A
  • number & complexity of variables affecting swallow => adaptability needed to protect: cough, early lingual retraction, early laryngeal closure,…
  • so awareness of real or potential swallow failures is needed
20
Q

DSS consists of 2 parts. Which ones? Explain

A

1. Start with standardized part: same set of tasks, in the same way to every patient:

  • tasks that all patients are likely to be capable of
  • then advance in terms of volumes and consistencies
  • stop when excessive risk

2. Patient-tailored part. Strategies designed to:

  • facilitate bolus flow
  • or improve airway protection

3. attempt to replicate the patient’s specific complaint

21
Q

Which advantage has the uniform protocol in DSS?

A

Comparison:

  • over time or treatment
  • with other patients or patient populations
  • with normative data
22
Q

Which strategies may be explored during DSS?

A

Compensation and facilitation techniques (maximizing intact components and minimizing failures):

  • changing the size and relationships of pharyngeal spaces and structures
  • changing the effects of gravity on bolus flow
  • increasing effort to increase range, timing and strength
23
Q

What can be said about the effectiveness of the strategy?

A
  • compare with performance on the task where failure is noted
  • effectiveness can only be assessed if the goal of the strategy is clear
  • the strategies depend on cognition, sensory integrity, anatomy, range of motion, control, strength, respiratory health, upper body postural stability and control
24
Q

Which compensatory taks or tools are available to the clinician when the ability to control and propel the bolus in the oral cavity is poor?

A
  • bolus consistency
  • bolus placement
  • gravity
25
Q

Which strategies/compensations are available if the linguapalatal valve fails?

A
  • problem with swallow initiation: enhancing sensory information by manipulating the characteristics of the bolus (size, temperature, texture, taste)
  • slow or deflect the bolus (limiting the amount of the bolus falloing into the piriform sinuses)
  • facilitate bolus flow by head/neck extension, followed by flexion
26
Q

Which compensations/strategies are available when there are problems with the pharyngeal chamber?

A
  • if incomplete pharyngeal clearing (residue): head/neck rotation or flexion, prolonged and increased laryngeal elevation, repeated swallows, post-swallow clearing
  • if pharyngeal wall stiffness: effort strategies that aim at early, prolonged and vigorous laryngeal closure
27
Q

Which compensations/strategies compensate for velopharyngeal valve problems?

A
  • Closure: head/neck rotation, bolus size and/or viscosity
  • Opening: increasing time allowed for respiration between swallows à limiting size and viscosity, rate of bolus presentatioin, number of boluses
28
Q

Which compensations/strategies are available to compensate of ineffective laryngeal closure?

A

•head/neck flexion/rotation, prolongation of laryngeal closure/elevation, upper body side-lying

29
Q

Which compensations/strategies are available if the PES valve fails?

A
  • compensate for decreased opening: repeated swallow on 1 respiration, increased/prolonged elevation hyoid and larynx, head/neck rotation/flexion/extension, upper-body reclining, restricting bolus size
  • compensate if PES never closes completely: slowing the rate of bolus presentation, precautions

Dysphagia (10 decks)

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