Midterm Flashcards
Oral Preparatory Phase
involves formation of food/liquid into a cohesive bolus; may include oral anticipatory stage including seeing, smelling, and getting ready to taste food items
Oral Phase
stage in swallowing process which involves the transport of the bolus from the front to the back of the oral cavity to the point of entry into the pharynx and initiating the swallow response (A/P transit)
Pharyngeal Phase
stage of swallow which involves the movement of bolus through the pharynx into the esophagus; includes the swallow reflex; squeezing motion of the pharyngeal constrictors; airway protection, and relaxation of the esophagus to permit entry of the bolus
Esophageal Phase
aka pharyngoesophageal phase
when the bolus travels through the esophagus
Importance of Oral Health
If they rely on someone else for oral care, increase risk of pneumonia since they dont get as good of a clean
decayed teeth and higher dental plaque increase risk
mouth has a lot of germs and bacteria so when you aspirate on saliva, germs go into the lungs.
Continuum of Care
There is no guideline
1) referral/screening
2) bedside assessment/ clinical swallow evaluation
- if oral stage is the problem, set treatment
- if pharyngeal involvement, do instrumental assessment
3) instrumental assessment ( also try compensatory strategies)
4) identify and implement habilitative/rehabilitative techniques and compensatory strategies
5) monitor progress via periodic reassessment
6) train others in safe oral intake procedures: patient, care givers
7) discharge from active treatment
8) continue to monitor progress and safety in PO intake
Silent Aspiration
No outward signs of aspiration. Only symptom may be recurrent pneumonia
Overt Aspiration
displays signs of aspiration, like coughing, wet vocal quality, globus sensation, etc.
Lesions in Lower Brainstem
Medulla
significant oropharyngeal impairments,
1st wk post stroke: absent pharyngeal swallow
2st wk post stroke: delay of 10-15 seconds
- often have submandibular tongue base and hyoid movement but not true swallow
- when swallow does initiate, reduced laryngeal elevation and anterior movement with reduced cricopharyngeal opening
- may have unilateral pharyngeal weakness
- some have vocal fold paresis/paralysis
3rd week post stroke: sufficient recovery for functional swallow and full oral intake (maybe modified diet)
Subcortical Stroke
Mild delays in oral transit time (3-5 seconds)
mild delays in initiating swallow response (3-5 secs)
mild to moderate impairments in timing neuromuscular control in pharynx
may demonstrate aspiration before due to delay in initiating swallow or after due to neuromotor control issues in pharynx
recovery to full oral intake may take 3-6 wks
Cortical Stroke - left hemisphere
may result in apraxia of swallow (delay in initiating swallow with no tongue movement in response to presentation of food or mild to severe searching motions of tongue prior to initiating swallow)
mild oral transit delays (3-5 secs)
mild delays in intitiating pharyngeal swallow (3-5 secs)
TBI - General Considerations
swallowing problems can be complex depending on extent and site of head injury, other body injuries, nature of emergency care
swallowing issues more severe the longer patient is in coma
injuries from direct head trauma; contra-coup damage, twisting of brain stem, potential puncture wounds, laryngeal fractures
Usually Tracheostomy (can sometimes be too high and damage larynx, prolonged intubation)
Alzheimer’s
Food agnosia - don’t recognize food as food
feeding apraxia - difficulty in using utensils
swallowing apraxia - holding food in mouths, unable to initiate swallow response
decreased lateral tongue motion for chewing
delay in initiating pharyngeal swallow
bilateral pharyngeal wall weakness
reduced laryngeal elevation
reduced tongue base retraction
ALS - Corticospinal Tract
Carries motor signals from the primary motor cortex in thebrain, down thespinal cord, to themuscles of the trunkandlimbs.
Thus, this tract is involved in thevoluntary movementof muscles of the body.
Slow to develop swallowing problems
reduced velar movement with food in nasal cavity
reduced pharyngeal wall contraction
first sign may be slow progressive weight loss and little/no awareness of a swallowing problem
ALS - Corticobulbar Tract
Carries motor, information from the primary motor cortex to themuscles of the face,headandneck. It does this by synapsing with motor cranial nerves in thebrainstem. Therefore the corticobulbar tract is responsible for innervating the muscles of the face, head and neck, as well as the muscles involved inswallowing, phonation and facial expression.
Decreased tongue mobility; less able to control material in oral cavity
unable to increase tongue pressure to handle thicker foods (reduced lip closure)
reduced velar function
reduced tongue base retraction with reduced pharyngeal contraction resulting in residue in pharynx
delay in initiating pharyngeal swallow
reduced laryngeal elevation and reduced cricopharyngeal opening
complete laryngeal closure is impaired with laryngeal penetration
respiratory compromise
Parkinson’s Disease
Typical repetitive anterior to posterior tongue rocking pattern in oral transit; hallmark behavior for Parkinson’s
slight delay in initiating swallow response
decreased tongue base retraction
reduced laryngeal wall contraction with residue in pharynx and pyriform sinuses after each swallow
reduced laryngeal closure, incomplete vocal fold closure
some cricopharyngeal dysfunction may occur
end stage of disease may include dementia and severe rigidity making postural changes difficult
(may improve after medication)
Multiple Sclerosis
multiple plaques from cortex to brainstem and cerebellum to corticospinal tracts
delay in triggering pharyngeal swallow, reduced tongue base retraction, reduced pharyngeal contraction with residue in valleculae
depends on CN
CN 12 - reduced lingual control, reduced control of chewing and oral transport of bolus
CN 10 - reduced tongue base movement; reduced pharyngeal wall movement; reduced laryngeal function
CN 11 - reduced triggering of pharyngeal swallow
Some have no issues
Muscular Dystrophy
muscle deterioration
reduced pharyngeal wall contraction
Myotonic dystrophy - prolonged contraction and difficulty relaxing involved muscles, UES, muscles of mastication
Oculopharyngeal dystrophy - selectively involves ocular and pharyngeal muscles, reduced pharyngeal contraction,dysfunction of muscular portion of UES (doesn’t relax)
COPD
airflow limitations; failure to exhale sufficient amount of CO2
No aspiration found but there are differences
aspiration may occur during periods of exacerbation, may swallow on inhale
experience more GERD, aspiration due to reflux
COPD does not cause dysphagia
Uvula
no direct function but can help identify anterior faucial arches
Valleculae
space between tongue and base of tongue
pyriform sinuses
base of the pharynx
if food sits here, its right next to the opening of the airway
laryngeal vestibule
area in larynx about true vocal folds
Peristaltic Action/Wave
wavelike squeeze
Penetration
bolus above level of vocal folds
deglutition
acts associated with bolus transfer and transport of food from the mouth to the stomach
Pharyngeal pocketing
food lodging/remaining in the pharynx after the swallow reflex is completed
sulci
anterior spaces between lips and gums where food may collect; lateral spaces between cheecks and gums where food may collect
Iatrogenic Etiology
problems secondary to medial interventions, side effects of medication/treatment
Anatomic Etiology
structural problems, too much or too little tissue, tumors, birth defects, scar tissues, calcium deposits
Physiologic Etiology
problems with how structures function; neurological problems
Cortical Stroke - Right Hemisphere
mild oral transit delays (2-3 secs)
pharyngeal delays (3-5 secs)
once swallow is initiated, slight delay in laryngeal elevation
Slower recovery than left CVA due to inattention and difficulty sequencing-following multiple step commands even with tactile cues and physical prompting
CVA Considerations
tracheostomy - inflated cuffs with traces reduce laryngeal elevation due to “drag” resistence of cuff on tracheal wall; if longer than 6 months reduces laryngeal closure due to limitation of air flow on vocal folds reducing stimulation to sensory receptors
medications may worsen swallow; dry mouth, antidepressants slow coordination
Visual Neglect
TBI - Swallowing Considerations
reduced lip closure/tongue range of motion
poor bolus control
abnormal relfexes
reduced laryngeal elevation
reduced closure of the airway entrance
Unilateral/bilateral pharyngeal wall paresis or paralysis
Tracheoesophageal fistula
reduced velopharyngeal closure
reduced laryngeal and reduced cricopharyngeal opening
TBI - Other Considerations
impulsivity - tend to put too much in mouth too quickly
cognitive difficulties - decreased understanding of swallowing maneuvers
Reduced sensation - reduced awareness of swallowing issues
Issues with Compliance with treatment
seem to be able to tolerate aspiration at first but will eventually create problems for them
Cervical Spinal Cord Injury
delay in initiating pharyngeal swallow
reduced laryngeal elevation
reduced cricopharyngeal opening
reduced tongue base retraction
decreased unilateral or bilateral pharyngeal wall functioning
problems with vocal fold closure secondary to traumatic airway management or to prolonged tracheostomy
Usually pharyngeal or oropharyngeal stage issues
Oral Swallowing Concerns
apraxia of swallow concerns
trismus - reduced mouth opening, often a side effect of radiation
reduced lip strength
reduced labial tension (bolus in sulci)
reduced buccal tension - bolus in sulci
reduced tongue range of motion/strength
reduced tongue coordination
reduced tongue-palate contact
residue in oral cavity related to scar tissue
poor dental status
Pharyngeal Swallow Concerns
Esophageal Swallow Concerns
