L5 Abnormal Swallow Physiology & Etiology Flashcards
1
Q
T or F: The line between abnormal and normal is always clear
A
False
2
Q
Why is knowing the incidence of dysphagia and your patient population important?
A
- anticipation of clinical caseload will help plan and allocate resources
- use figures to lobby for support from hospital admin
- knowledge of risk factors can improve Ax and Tx of disease via modification of risk factors or earlier detection of disease
3
Q
What is the idea behind the surgical sieve technique?
A
a way to approach thinking about your patients symptoms to make sure you have considered all the contributing factors
4
Q
Why is the surgical sieve technique useful for deglutition disorder clinicians?
A
- forces you to consider all factors
- consider why symptoms are presenting the way they are
- helps consider potential prognosis for return to baseline diet
- consider long, medium and short term prognosis
- helps reason through Tx plan
5
Q
When going through the sieve what types of factors do you include
A
- neurological
- neoplastic
- traumatic
- inflammatory
- congenital
- degenerative
- autoimmune
- idiopathic
- environmental
- metabolic
- endocrinological
- haematological
- anatomical variations
- feeding ability and feeding techniques
- GI tract disorders
- Respiratory disorders
- Iatrogenic
6
Q
Stroke and Parkinsons examples of _________ factors
A
neurological
7
Q
Teeth loss due to aging, dementia and MS are examples of __________ factors
A
degenerative
8
Q
Pierre-Robin Sequence and cerebral palsy are examples of __________ factors
A
congenital
9
Q
The shape of the epiglottis and pyriform sinuses are examples of __________ factors
A
anatomical variations
10
Q
COPD has a _______ course of dysphagia symptoms
A
chronic
11
Q
Pharyngitis has a _________ course of dysphagia symptoms
A
acute
12
Q
Parkinsons, MS and ALS all have a ________ course
A
degenerative
13
Q
After a tongue resection, the dysphagia symptoms follow a ________ course
A
stabilizing
14
Q
T or F: delirium and confusion in patients can affect their swallowing
A
true
15
Q
Overall what are the 2 main etiology courses of dysphagia
A
- recuperative
- degnerative
16
Q
List some examples that fall under recuperative etiology course
A
- stroke
- head and neck cancer
- cervical spine injury
- head injury
17
Q
List some examples that fall under degenerative ethology course
A
- Parkinsons
- Alzheimers
- Multiple Sclerosis
- Huntington’s
18
Q
When assessing dysphagia in stroke, using screening, clinical Ax and VFS, which method is most effective in identifying dysphagia in stroke
A
VFS
19
Q
After first ischemic stroke _____% of individuals have dysphagia alone
A
49%
20
Q
What are the 2 symptoms that co-occur with dysphagia after a ischemic stroke?
A
dysarthria
and aphasia
21
Q
In an MRI study of brain lesions, which brain areas were associated with a high dysphagia
A
- lateral medulla (57%)
- medial medulla (40%)
- poins (43%)
22
Q
Neurologic dysphasia may present in 3 ways. List them
A
1) Known neuro etiology & obvious symptoms
2) Known neuro etiology & no obvious symptoms (less common)
3) Unknown neuro etiology & obvious symptoms
23
Q
List 4 common causes of neurologic related dysphagia
A
- stroke
- head injury
- progressive neurological (AD, PD)
- LMN disease
24
Q
what is the incidence of dysphagia in acute stroke?
A
> 55%
25
What is meant by silent aspiration?
aspiration without any obvious signs of swallowing difficulty, such as coughing or difficulty breathing
26
T or F: the first swallow during a VFS or FEES is a reliable representation of a person's swallowing
False - strange things can happen on the first bolus so we don't push too much weight on the first swallow
27
What are the common dysphagia impairments in stroke
- Prolongation of oral and pharyngeal transit times (>2 sec)
- Delay and/or absent pharyngeal swallow
- Shorter laryngeal closure, UES opening & laryngeal elevation
- Site or side of lesions don't always correlate well with symptoms
28
What are the common dysphagia impairments in head injury
- delayed and/or absent pharyngeal swallow
- reduced lingual control
- reduced pharyngeal clearance
- aspiration during and after swallow
- cognitive deficits impact on safety
29
What is the prevalence of dysphagia in MS?
24-65%
30
What is the prevalence of dysphagia in ALS
83%
31
What is the prevalence of dysphagia in Parkinsons
82%
32
T or F: In parkinsons patients, their report of swallowing difficulties is more sever than their actual dysphagia
FALSE - it Patient report tends to be less severe than their actual dysphagia
33
Describe the swallowing features in Parkinsons
- Oral: lingual rocking, poor bolus containment, incomplete bolus transport
- Pharyngeal: delay in pharyngeal swallow, increased aspiration
- Esophageal: reduced UES opening & airway closure (due to rigidity of lingual movements)
34
What is the difference between laryngeal penetration and aspiration?
- Laryngeal penetration = within laryngeal vestibule, on or above VFs
- Aspiration = below VFs
35
What clinical considerations are important when treating Parkinson's patients?
- dosing of sinemet levodopa/cabidopa
- timing of medication
- deep brain stimulation
- severity of PD
- symptoms
- voicing, coarticulation, respiratory aspects
36
PD patients report swallowing is easier in the _____ phase, and difficult in the _____ phase
on
| off
37
For deep brain stimulation, if an individual has dystonia, rigidity, bradykinesia and tremor, where in the brain is the stimulation?
globus pallidus internal or sub thalamic nucleus
38
Describe how Alzheimers can affect swallowing
agnosia & apraxia for food, resulting in prolonged holding of food in oral cavity
39
Describe how ALS can affect swallowing
- Lingual atrophy, reduction in oral and/or pharyngeal motor strength.
- Respond to aspiration with cough or throat clearing
40
Describe how myasthenia graves can affect swallowing
- swallow hesitancy & rapid fatiguability of all muscles
- masseter weakness, bifacial weakness, poor palate elevation
- also dysarthria, dysphonia & ptosis (eyelids droop)
- liquids > solids, better at start of meal
41
List the common mechanical diseases related to dysphagia
- head and neck cancer
- cervical spine osteophytes
- diverticulum
- CP bars, scars and fibroids
- loss of dentition
42
How do cervical spine osteophytes affect swallowing
- lead to interruption of bolus transport through the pharynx, especially at C3-C6
- will likely have residue and might need multiple swallows for one bolus
43
How does a cricopharyngeal (CP) bar affect swallowing
- interruption of bolus transport through the level of the UES
- high upper esophageal pressure may lead to development of senders diverticulum
44
What is a CP bar?
an overactive cricopharyngeus muscle
45
A CP bar is seen in up to _____% of patients with GERD
50%
46
How does a zenker's diverticulum affect swallowing?
pocketing of food in the out-ouch at posterior intersection between the transverse fibres of the CP muscle and oblique muscles of inferior pharynx
-due to incomplete opening of UES
47
How head and neck cancer affects swallowing depends on what factors
- tumor size
- staging
- location
- location and type of surgical resection/reconstruction
48
Overall, how does head and neck cancer affect swallowing
- obstruction due to bulk or extraluminal compression
- decreased pliability of soft tissue due to neoplastic infiltrate
- direct invasion of nerves leading to paralysis of pharyngeal/laryngeal muscles
- pain
49
If someone had had a partial laryngectomy how can this affect swallowing
delayed resumption of air way protection
50
If someone had a total laryngectomy, how can this affect swallowing
- scar tissue at base of tongue, leading to reduced motion
- stricture or narrowing of esophagus
- poor bolus clearance through pharynx
51
If someone had a mandibulotomy how can this affect swallowing
lip closure problems
52
If someone had a tongue resection how can this affect swallowing?
depending on amount, impaired lingual range of motion, control and strength
53
How can radiation or chemo affect the oral structures?
- xerostomia
- radionecrosis: breakdown of tissue or bone
- fibrosis
- mucositis (thickening of saliva and mucous)
54
What clinical considerations are needed in head and neck cancer
- often times patient is able to communicate
- consent may be easier
- often times mobility is still intact
- aspiration is tolerated to a higher degree than with other patient populations
55
List common causes of iatrogenic dysphagia
- head & neck surgeries
- radiation or chemo
- nasogastric feeding tube
- tracheotomy tube
- medications
56
How can a nasogastric feeding tube affect swallowing
- may interfere with deflection of epiglottis
- hinder UES closure allowing gastric regurgitation into pharyngeal/laryngeal cavities
- in the long term - traumatic friction and pressure along CA joints and cricoid lamina
57
List some possible complications of nasogastric tube
- tube may enter lungs
- may cause trauma as it is passed
- reflux of stomach contents
- can enter the brain or perforate esophagus (Rare)
58
Clinical considerations in NG tube patients
- Consent for placement of the NG tube is taken by the MD (who will rely on SLP & RD recommendations)
- Weighing benefits vs risks of NG tube placement is important for recommendations.
- your recommendations should be in line with patient’s goals of care.
- Knowing when NG tube is contra-indicated especially for end- of-life scenarios is important otherwise a potentially harmful/ futile treatment could be given.
59
How long should NG tubes stay in?
should ideally not stay in longer than 4-6 weeks after which other complications may arise (eg ulceration along the GI tract, infection, sepsis).
60
Why is it common for someone who had endotracheal intubation to have dysphagia afterwards?
because the epiglottis and VFs were held open for a long period of time
61
What are some post-intubation dysphagia clinical considerations
- diagnosis of patient and comorbidities
- reason for intubation
- respiratory status
- alterness and motivation
- ability to manage secretions
- demonstrated ability to tolerate being off ventilator (within 24 hours)
- OPE results
- goals of care
62
What is a tracheotomy?
the surgical creation of an opening in the trachea, performed to create a patent airway and provide a means of pulmonary toilet
63
What happens if a patient has been on a ventilator for a week, an they still need support what is the course of action?
will transfer them from a ventilator to a trach
64
What is the difference between surgical and percutaneous tracheostomy?
- Surgical: cutting a large hole incision layer by later
| - Percutaneous: puncture a small hole through trachea and use dilators to slowly make hole bigger
65
What are the parts of a tracheostomy tube?
- outer cannula
- inner cannula
- flange
- obturator
- cuff
- cork
66
Why is the inner cannula of a tracheotomy tube changed around every 3 hours
There is a risk that it can get blocked with secretions
67
Why is the cuff of a tracheostomy tube important?
used to create an airtight seal in the trachea
68
What is the difference between tracheostomy and tracheotomy
- tracheostomy - an artificial airway, trachea diverted into a stoma
- tracheotomy - the surgical creation of an opening in the trachea
69
What are the 2 types of tracheostomy tubes?
non-fenestrated
| fenestrated (little holes)
70
What are possible complications of tracheostomy?
- tube obstruction
- tube misplacement
- hemorrhage
- infection
- tracheal granuloma
- tracheomalacia
- trachial stenosis
- obstruction of esophagus or feeding tube
- tethering of larynx?
71
Describe the ideal tracheostomy patient
- downsized to size 6 or 4
- has an uncuffed tube
- commenced corking trials or tolerating a speaking valve
- Uses less than 51 O2
- saturating well 90+
- Resp rate not higher than 40 BPM
- Able to stay alert and focused
- Reason for trach is not one that preclude patient fro eating/drinking
72
What goal in corking trials indicates that the patient is ready for decannulation?
they last 2 days with the cork in the trachea (breathing through mouth)
73
What types of medications can affect swallowing?
- neuroleptics
- sedatives
- antihistamines
- diuretics
- anticholinergics
74
What are common side effects of medications?
- drying of mucosa/ dry mouth
- drowsiness
- thirst
- reduced appetite
75
-How can medications be part of the swallowing problem?
- shape of medication can affect how easily they are swallowed
- size
- liquid vs. solid
76
-What considerations must be taken in regards to medication format?
- Our guidance is very useful to reduce medication format alteration to a minimum and ensure all considerations have gone through pharmacy
- Establish a good relationship with pharmacist on the unit
- Nurses may not be sure whether or not a drink has been thickened to the appropriate consistency- suggest an item that is readily given at the correct texture
- Explicitly state medication format suggestions in a way that is helpful to pharmacy and team
77
What systemic disease affect swallowing
- diabetes
- AIDS
- rheumatologic & connective tissue disease
- malnutrition and dehydration
- prolonged illness/ post op
- iron and B12 deficiency
- Sjorgen's syndrome
78
What are some psychogenic disease that can affect swallowing
- Phagophobia - fear of swallowing
- Globus sensation NYD
- Insufficient and prolonged manipulation of foods - may aspirate
79
What are some clinical considerations for psychogenic related dysphagia
- Don’t say: “don’t worry it’s not real”
- Reassurance may be of little value
- Affirmation may be more effective
- Mindfullness techniques
80
Describe the clinical 'to do list'
- Take a careful history
- Mention which factors you think are contributing to main symptoms of dysphagia
- Mention how this relates to prognosis for return to baseline diet
- Refer on to appropriate team members for areas of concern
- Always consider whole GI tract
81
The goal of intervention at end of life is not __________ but rather __________
rehabilitative
| facilitative
