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Dysphagia Steph > Lecture 5 > Flashcards

Lecture 5 Flashcards

1
Q

What are the goals of a clinical swallowing assessment?

x6

A

Determine the presence, nature, severity of dysphagia
Collect baseline data
Judge swallowing safety & potential risks
Enable the development of a management plan
Consider impact of dysphagia on QoL
Determine need for onward referral

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2
Q

What are the benefits of a bedside evaluation?

A

Cheap, quick, less invasive, ethical, fewer resources required

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3
Q

What are the limitations of a bedside evaluation?

A

Does not detect silent aspiration, less detailed, more subjective

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4
Q

What are the elements of a clinical swallowing assessment?

(x9)

BGCCOOIRR

A 
Background information
General observation
Communicaiton, cognition, behaviour
Case history
OME
Oral trials
Overall impression and diagnosis
Recommendations/management plan
Referral for other assessments
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5
Q

Background information - generally obtained from medical file or MDT team

A 
Age and gender
Relevant medical history/diagnosis
Current medical and chest status
Nutritional status
Medications
Cultural/client-specific information
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6
Q

General observation

A 
Alertness - can they be roused?
Mobility status and posture
Ability to manage secretions (are they drooling)
Ability to self feed (are there movements e.g. paralysis, chorea, cognitive impairments)
Respiratory status (is patient wheezing)
Client state (comfort/distress)
Support system/family
Do they appear healthy/nourished?
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7
Q

Communication

A

Ability to follow instructions
Insight and awareness into role of SP
Need for communication support/device

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8
Q

What are the goals of a dysphagia case history interview?

MDCBCS

A
  • Gather information: medical diagnosis/status, nutritional status, complexity of the problem
  • Determine if dysphagia is present (nature & extent)
  • Determine causal factors
  • Area of breakdown: Determine functional abilities and impairments
  • Gather information about client (cultural, religious etc.)
  • Determine level of stress/concern regarding swallow
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9
Q

Areas to probe via case history

OSPDCMP

A
  • Onset of the problem (gradual/sudden, progressive/improving, fluctuating/stable)
  • Symptoms of dysphagia (main difficulties, factors that exaccerbate/improve)
  • Pain associated with the swallow
  • Duration of meals
  • Consistencies that are difficult/easy to swallow (inc. medications)
  • Modified diet (food currently being avoided/modified to aid swallowing)
  • Food preferences (cultural, religious, personal).
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10
Q

What is the purpose of an OME?

A
  • Provide information about the appearance, strength, speed, coordination, and range of movement of the facial musculature (and associated cranial nerves)
  • Opportunity to assess receptive language abilities (following directions)
  • Allows clinician to determine patient state (cooperative/agitated)
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11
Q

What are the characteristics of an UMN lesion?

A

With an UMN lesion, voluntary control of ONLY the LOWER muscles of facial expression on the side CONTRALATERAL to the lesion will be lost.

The ability to raise the eyebrows suggests an UMN lesion

Voluntary control of muscles of the forehead will be spared due to the bilateral innervation of the portion of the motor nucleus of CN VII that innervates the upper muscles of facial expression.

The lower face receives UMN from the contralateral cortex, whereas the upper face receives bilateral UMN innervation

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12
Q

Which approach is appropriate for an OME? What does this involve? Which areas do we assess, in what order?

A

The “up-down-front-back” approach starts at the top of the face and works down, progresses to the inside of the mouth and then works to the back of the mouth.

  • Upper face
  • Lower face (lips and cheeks)
  • Jaw
  • Oral cavity inspection
  • Tongue
  • Oropharynx
  • Soft palate
  • Vocal folds
  • Hyolarngeal excursion
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13
Q

How would you assess the motor function of the upper face region? What cranial nerve(s) are involved?

A
  • Observe symmetry at rest/facial droop
  • Ask the patient to raise their eyebrows, frown, open and close their eyes (model these if difficulty understanding)
  • CN VII (Facial) - motor function of facial muscles (gives information about chewing ability)
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14
Q

How would you assess the motor function of the lower face region (lips and cheeks)? What cranial nerve(s) are involved?

(Symmetry, strength, range, coordination)

A
  • Observe symmetry at rest/facial droop
  • STRENGTH: puff up cheeks (lip seal), hold tongue depressor between lips
  • RANGE: Retraction (smile/”ee”) and pucker (“oo”)
  • COORDINATION: alternate between ee-oo
  • CN VII (Facial) - motor function of facial muscles (gives information about chewing ability)
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15
Q

How would you assess the sensory function of the face? What cranial nerve(s) are involved?

A

Use a light touch with a cotton swab with the patient’s eyes closed. Have the patient tell you where they are being touched (e.g. right cheek).

  • CN V (Trigeminal) - sensory function = general somatic sensation of the face, cheeks, jaw, lips.
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16
Q

What is the importance of the jaw in swallowing?

A

The jaw is important for containing the food/liquid/saliva bolus. In addition, when the jaw is closed correctly, the tongue can be brought into a position to manipulate the bolus for chewing/reaching the palate.

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17
Q

How would you assess the motor function of the jaw? What cranial nerve(s) are involved?

(Symmetry, strength, range)

A
  • Observe habitual position at rest (Is it hanging open? Is it symmetrical?) - an open mouth position may indicate weakness.
  • STRENGTH: Ask patient to bite their teeth together and palpate the masseter. Place your hand under jaw and ask the patient to open against your resistance.
  • RANGE: have patient move their jaw up and down/side to side/rotatory movement.
  • CN V (Trigeminal) - jaw movement is governed by the motor component of the trigeminal nerve (i.e. CN V controls the “muscles of mastication” e.g. masseter).
  • During chewing, involvement of CN V will show a deviation of the jaw TOWARDS the side of the lesion when the mouth is opened.
18
Q

How would you assess the oral cavity? What cranial nerve(s) are involved?

A
  • General inspection (should be moist and pink).
  • Look at the symmetry of the tongue in the mouth at rest (CN XII). Are there any white patches (may = oral thrush) or fissuring (may = dehydration) on the tongue
  • Look at the symmetry of the soft palate in the mouth at rest (CN X).
  • Are the tonsils evident? Are they impinging on the amount of opening to the oropharynx?
  • Is there any food residue? Could indicate sensory issue (CN IX).
  • Look at state of gums and dentition. Are teeth discoloured/broken/display holes?
  • Type and quantity of saliva (could indicate dehydration and/or poor oral hygiene).
19
Q

What is the importance of the tongue in swallowing?

A

The tongue is critical for oral manipulation and containment of the bolus (glossopalatal seal).
It is the primary force for projecting the bolus into the pharynx (oral transit)
It is important for initiating the pharyngeal swallow (BOT to PPW approximation).

20
Q

How would you assess the tongue? What cranial nerve(s) are involved?

(Symmetry, bulk, strength, range, coordination)

A
  • SYMMETRY: Ask the patient to stick out their tongue. Observe symmetry.
  • BULK: Observe presence of atrophy/fasciculations (brief spontaneous muscle movements, may indicate MND).
  • STRENGTH: Ask patient to push each cheek out using their tongue (feel the strength and symmetry of the movement). Ask the patient to press against the tongue depressor.
  • RANGE: Have the patient point their tongue upwards towards their nose, down towards their chin, and then lick all around their lips.
  • COORDINATION: have patient say “ka la ka la” to observe alternating movement.
  • CN XII (hypoglossal) provides motor function for the extrinsic and intrinsic muscles of the tongue.
21
Q

You have asked the patient to stick out their tonge. It sticks out to one side.

If the tongue deviates to the SAME side as the known lesion, does this represent a UMN, unilateral LMN, or bilateral LMN dysfunction?

A

Unilateral LMN (ipsilateral innervation)

22
Q

You have asked the patient to stick out their tonge. It sticks out to one side.

If the tongue deviates to the OPPOSITE side to the known lesion, does this represent a UMN, unilateral LMN, or bilateral LMN dysfunction?

A

UMN (contralateral innervation)

23
Q

You have asked the patient to stick out their tonge. It has very limited protrusion and does not deviate to either side.

Does this represent a UMN, unilateral LMN, or bilateral LMN dysfunction?

A

Bilateral LMN

24
Q

What is the importance of the soft palate in swallowing?

A

Plays a role in separating the oral and nasal cavities during swallowing. It creates a tight seal in the oral chamber and prevents nasal regurgitation.

25
Q

How would you assess the soft palate? What cranial nerve(s) are involved?

A

Observe symmetry at rest using a torch.
Ask the patient to say “ahhhh” for 3-5 seconds.
Ask the patient to as “ah-ah-ah”. Look for differences in symmetry and strength.
Note resonance and nasal emission during voicing.

26
Q

Which side does a weak soft palate deviate to? Why?

A

A weak soft palate from UNILATERAL damage will show the uvula deviating towards the UNAFFECTED side, as there is insufficient muscle tension from the affected side to hold it in place.

27
Q

What two areas are assessed to assess airway production?

A
  1. Vocal fold adduction (glottal closure)

2. Hyolaryngeal excursion (dry swallow)

28
Q

How would you assess vocal fold adduction? What cranial nerve(s) are involved?

A

Observe voice quality - is is clear/gurgly/hoarse/breathy/ strained?
Observe the strength of the volitional cough

CN X (Vagus) - the motor component of the Vagus nerve controls vocal fold adduction and is therefore important for the closure of the glottis

29
Q

How would you assess hyolaryngeal excursion? What cranial nerve(s) are involved?

A

Palpate the larynx during a dry swallow to feel for hyolaryngeal excursion:

  • Time how long it takes for the reflex to be initiated
  • Observe the extent to which the larynx elevates

CN V, VII, XII (Trigeminal, Facial, Hypoglossal) - the motor component of each CN controls the suprahyoid muscle group, which assists in hyolaryngeal excursion.

30
Q

What are indicators that a patient is suitable for oral trials?

A
  • Conscious and alert
  • Able to be positioned optimally for oral intake
  • Show some ability to protect the airway
  • Have sufficient stamina for the trial
31
Q

What should you check before commencing oral trials?

A
  • Palpate the dry swallow first

- Check for oral hygiene

32
Q

Which level of fluid does the oral trial NORMALLY start on? How much of this fluid should be presented?

A

Start with thin fluids and use WATER as it is pH neutral and least likely to cause harm to the respiratory system if aspirated.

Start with a teaspoon amount, then work up to dessert spoon, small sip from a cup.

Work from thin to thick, so that fluids are only thickened to the level that is absolutely necessary for swallowing.

33
Q

What factors help you to determine the level of diet and fluids to start with during oral trials?

A 
Background information
Medical status
Aspiration risk factors
OME findings
Oral hygiene
34
Q

What is the purpose of oral trials?

A

To determine the safest consistency food and/or fluid for that particular patient to swallow.

35
Q

What must be assessed during the oral trials?

A
  1. Palpation (promptness of swallow initiation, range and strength of hyolaryngeal excursion)
  2. Check voice quality after swallow
  3. Observe physiology at each stage of the swallow
  4. Check for oral residue
  5. Note any changes to client state (e.g. breathing rate)
  6. Judge stamina/fatigue
  7. Seek feedback from client
  8. Observe any compensations (e.g. tiny bites, chin tuck)
36
Q

When observing the physiology of each stage of the swallow, what should be observed?

A
  1. Ability to open mouth and accept the bolus
  2. Ability to close mouth and contain bolus
  3. Ability to chew bolus (if required)
  4. Evidence of prompt swallow initiation (vs delayed/effortful)
  5. Presence/absence of hyolaryngeal excursion
  6. Coordination of respiration and swallowing
  7. Phonatory changes post swallow
  8. Need for multiple swallows
  9. Any instances of coughing/throat clearning post swallow
  10. Any reports of pain or discomfort
  11. Oral residue post swallow
37
Q

What should you look for during the oral stage?

A 
Impulsivity/shovelling of food
Increased oral preparation time
Impaired bolus formation
Oral scatter
Piecemeal swallows
Tongue pumping
Anterior oral escape
Oral residue/pocketing
Grimacing/discomfort
38
Q

What should you look for during the pharyngeal stage?

A

Delayed, effortful, or inconsistent swallow initiation
Reduced or inconsistent hyolaryngeal excursion
Signs/symptoms of pharyngeal residue
- Multiple swallows
- Throat clearing
- Reports of food sticking in throat
Signs of laryngeal penetration/aspiration (coughing, throat cleaning, moist voice quality)
Grimacing/discomfort

39
Q

What must you judge in your overall impression of the swallow?

A 
Swallowing function and safety
Aspiration/choking risk
Ability to commence/continue oral intake
Ability to meet nutritional/hydrational needs (is a dietitian referral needed?)
Severity and nature of dysphagia
40
Q

What must be determined in your recommendations/plan?

A

Is it safe for client to commence/continue oral intake?
What consistency of diet/fluid?
Can the person self feed?
Is supervision needed?
Positioning issues?
Is it safe for patient to take medications orally?
Special instructions to staff/carers/family?
Oral hygiene issues?
Other assessments/referrals required?
Suitability for rehab/treatment? What tx options are appropriate?

Dysphagia Steph (6 decks)

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