Midterm Flashcards
What is dysphagia?
Difficulty swallowing; moving bolus from mouth to stomach
What are etiologies of dysphagia?
Infection, structural malformations, surgery, conditions that weaken/damage muscles and nerves
What are some consequences of dysphagia?
Dehydration, Malnutrition, aspiration pneumonia, and quality of life
What are the different types of dysphagia?
Oral, pharyngeal, oropharyngeal, and esophageal
What is oral dysphagia?
difficulty with tongue movement, lip closure, pocketing, and transport
What is pharyngeal dysphagia?
Difficulty with airway closure, residues, mobility, and upper esophageal sphincter
Define feeding
The placement of food in the mouth before initiation of the swallow (oral prep stage)
Define swallowing
The transfer of food/drink from the mouth to the stomach
What happens during the oral stage of dysphagia?
Mastication, bolus formation, and bolus transport from the oral cavity to the pharynx (time varies with bolus consistency)
What happens during the pharyngeal stage of dysphagia?
-Epiglottis inverts over the laryngeal vestibule
-Larynx and hyoid bone are pulled anteriorly and superiorly to open the pharynx, the cricopharyngeus m. (UES) relaxes and assists the the vocal folds in closing off the glottis
-Bolus is propelled through the pharynx toward the esophagus by action of pharyngeal constrictors
(~1 second)
What happens during the esophageal stage of dysphagia?
-Bolus flows through the esophagus via peristaltic contractions of striated and smooth muscle along the esophageal wall
-Relaxation of LES allows bolus to flow into the stomach
(~10 seconds)
When is the swallow triggered?
When the head of the bolus reaches the pharyngeal faucial pillars.
What muscle makes up the facial pillars?
Palatoglossus m.
What is the dividing point of the pharynx and esophagus?
UES
Define penetration
When the bolus enters the larynx with the vocal folds being the lowest point.
Define aspiration
When the bolus enters the trachea
What are some signs and symptoms of oral/pharyngeal dysphagia?
- coughing/choking while swallowing
- difficulty initiating/delayed swallow
- Food sticking in throat
- Sialorrhea or xerostomia
- Drooling or spillage
- Unexplained weight loss
- Change in dietary habits
- Penetration
- Aspiration
- Recurrent Pneumonia
- Change in voice (wet, gurgly voice)
- Nasal regurgitation
- Tearing and/or nose running
- Sore throat
- Yawning
What is Sialorrhea?
Accessive saliva
What is xerostomia?
Dry mouth
What are signs and symptoms of esophageal dysphagia?
- Sensation of food sticking in the chest or throat
- Chest Pain
- Oral or pharyngeal regurgitation
- Change in dietary habits
- Recurrent pneumonia
- Reflux
- Aspiration
What are s/s of silent aspiration?
- NO cough reflex
- Tearing
- Runny nose
- Yawning
How long does a swallow SCREENING take?
10-15 minutes
What is a clinical bedside/swallowing screening made up of?
- Medical Hx
- Level of alertness
- Pt interview
- Oral Mech
- Assess with SMALL bolus
What s/s do you look for in a clinical bedside/swallow screen?
Spillage, residue, long transit time, cough, throat clear, gurgly voice, tearing, runny nose, wrong sound
What does auscultation mean?
Listening to sound of an organ
What can we NOT do during a clinical bedside/swallow screening?
Cannot assess A and P
What parts make up the diagnostic procedure?
- ID symptoms & explain A and P abnormalities
- Examine physiology
- Examine immediate effects of tx’s
- Imaging (FEES, videofluoro, ultrasound, videoendo, scintigraphy
- Nonimaging (EMG, EGG, Pharyngeal Manometry
What treatments are there for dysphagia?
- Diet Modification
- Compensatory Strategies
- Maneuvers
- Exercises
- Stimulation
- Experimental
- Prosthetic
- Surgery
What are some benefits to doing a clinical bedside/swallow screening?
- Quick
- Non-invasive
- Low risk
- Low cost
T/F Clinical Bedside/Swallowing screenings are 100% accurate.
False
How much (quantity) do you give the patient during a water test in a bedside screening?
3 oz. and time it
What is a false positive in a bedside screen?
Id’d as aspirating but aren’t
What is worse in a bedside screen? false positive or false negative?
False negative because id’d as not aspirating but are
What is the difference between a sign and a symptom?
Signs are what we as clinicians see happening.
Symptoms are what the patients report to us
What is effected if pt complains of something “stuck” high in throat?
Valleculae hesitation/pooling
Base of tongue/epiglottic area
What is effected if pt complains of something “stuck” in middle of throat?
Pyriforms pooling
Just below larynx
What is effected if pt complains of something “stuck” lower in throat or high in chest?
UES dysfunction
Pain in upper chest or inches below larynx
What is effected if pt complains of something coughing or choking when eat?
Aspiration
What percentage of clients silently aspirate?
50%
What do you materials do you need for a bedside clinical exam?
- Laryngeal mirror
- Tongue blades
- cup
- spoon
- straw
- straw
- syringe
- towel/drape cloth
- gloves
- gown
- eye wear/mask
- stethoscope
What do we evaluate in the prep of a bedside clinical exam?
- Chart Review
- Respiratory status/hx
- Dysphagia hx/onset
- Hx of PNA
- Nutritional status
- Medications
What do we look for in the respiratory status of a bedside clinical exam?
- Resp rate at rest
- Time saliva swallows & phase of respiration
- Time/gauge strength of cough
- Time apneic period
- Breathing pattern (mouth or nose)
What do we evaluate in the physical portion of a bedside clinical exam?
- Posture
- Oral Mech (anatomy, physiology-apraxia and abnormal reflexes)
- Laryngeal Function Exam
- Pulmonary Function Testing*
- Pneumotachometry*
What do we evaluate in the trial swallow portion of a bedside clinical exam?
-3 finger positioning
-Cervical auscultation-stethoscope
(pt’s rxn to food, oral mvmts, coughing/clearing, secretion levels. meal duration, resp/swallow coordination, hyolaryngeal excursion, sound of swallow)
What are the results of a bedside/clinical exam?
- Posture for safest swallow
- Best positioning of food in mouth
- Best food consistency
- Hypothesis of swallowing disorder
- Recommendation for dx (direct imaging)
What are indications (why do) an MBS/videofluoroscopy?
- To identify normal and abnormal A and P of the swallow
- evaluate airway protection
- evaluate effectiveness of improving swallow
- provide recommendations for nutrition delivery
- determine therapeutic techniques
- obtain information to collaborate with team
What are the different liquid consistencies?
- Thin
- Nectar
- Honey
What are the different solid consistencies?
- Puree (thin and thick)
- Mech. Soft
- Chopped
- Regular
What are contraindications of MBS/videofluroscopy?
- Medically unstable/uncooperative
- unlikely to change pt’s management
- Pt unable to position
- Size of pt with the device
- Allergy to barium
What are limitations of MBS/videofluroscopy?
- Time constraints from radiation exposure
- Doesn’t fully represent meal time
- Barium increases viscosity
- Limited ability to evaluate fatigue
- Barium is unnatural
What are the benefits of FEES?
- Examines A and P BEFORE and AFTER swallow
- No radiation exposure
- No barium
- Excellent view of vf’s and larynx
What are the cons of FEES?
- No oral or esophageal stages visibl
- “white out” period
- green food dye
What are the oral structures of swallowing?
- lips
- teeth
- maxilla (hard palate)
- velum (soft palate) - shared with oropharynx
- uvula
- mandible
- floor of mouth
- tongue (all but base)
- faucial arches
- palatine tonsils
- sulci
- salivary glands
What are the intrinsic tongue muscles?
- superior longitudinal
- inferior longitudinal,
- transverse
- vertical
What are the extrinsic tongue muscles?
- genioglossus
- hyoglossus
- styloglossus
- palatoglossus
What tongue muscles alter the shape?
Intrinsic tongue muscles
What tongue muscles protrude/retract and elevate/depress the tongue?
Extrinsic tongue muscles
What are the pharyngeal structures of swallowing?
- Pterygoid plates on sphenoid bone (nasopharynx)
- Velum (oropharynx)
- Tongue base
- Mandible
- Hyoid bone
- Pharynx (pharyngeal walls)
- Epiglottis
- Thyroid cartilage
- Cricoid cartilate
- Vallecula
- Pyriform sinuses
What are the suprahyoids/submental muscles?
- mylohyoids
- geniohyoids
- anterior belly of digastric
What is the infrahyoid m?
Thyrohyoid m.
What is the function of the suprahyoids?
To raise and protrude the hyoid
What are the constrictor muscles?
- Superior
- Middle
- Inferior (posterior and lateral walls)
What is the CP and its function?
Circopharyngeus m. inferior constrictor fibers attached to cricoid lamina -Opens for bolus to enter esophagus -Prevents air from entering esophagus -Reduces backflow
What are the laryngeal structures?
- Hyoid bone
- Epiglottis
- Valleculae
- Laryngeal vestibule
- aryepiglottic folds>lateral vestibule walls
- thyroid cartilage
- arytenoid cartilages
- fals vocal folds
- true vocal folds
- ventricales-lateral
What does the PCA’s do?
abducts vocal folds
What do the LCA’s do?
adducts vocal folds
What do the TA’s do?
tilts arytenoids and assists with airway closure
What are the laryngeal strap muscles?
- Thyrohyoid
- Sternothyroid
- Sternohyoid
What does the thyrohyoid do?
elevates and lowers larynx
What does the sternothyroid do?
suspends larynx and trachea in neck
What does the sternohyoid do?
lowers and stabilizes hyoid
What are the esophageal structures?
- UES (CP and PE segment)
- Esophagus
- LES
How long is the esophagus?
~25 cm
What is the function of the UES/CP?
- allows bolus to enter esophagus
- keeps air out of esophagus
- keeps contents swallowed from coming back up
What is the function of the LES
keeps contents in stomach
What are the 2 layers of the esophagus?
-Inner circular
-Outer longitudinal
(striated and smooth muscles for peristaltic movements)
What happens during the oral stage of dysphagia?
- labial movement/sensory receptors/nose breathing
- Mastication
- Bolus formation
- Bolus transport
What happens during the pharyngeal stage of dysphagia?
-Velum elevates and retracts for VP closure
-Bolus transport with the tongue base and pharyngeal wall contraction
-Epiglottis inverts
-Hyolaryngeal elevation and protraction
-Closure of larynx
-CP opening
-Transport of bolus by pharyngeal constrictors
CP closure/larynx rests
What are the stages of esophageal dysphagia?
- Bolus flows through the esophagus via peristaltic contractions of striated and smooth muscle along the esophageal wall
- Relaxation of LES allows bolus to flow into stomach
What is different in the AandP of young normal people?
- higher hyoid and larynx (better protection)
- Lower velum/shorter pharynx
- Uvula in epiglottis, pocketing valleculae
- Pharyngeal swallow is triggered at anterior faucial arch
What is different in the AandP of older normal people?
- ossification of cartilages and hyoid bone
- pharyngeal swallow triggered when bolus head reaches middle of tongue base
- 70+ larynx lower
- Arthritis in C vertebrae impinge on pharyngeal wall
- “Dippers”
- Delay, residue, penetration
- Reduced hyolaryngeal excursion, plateus at CP opening
- Reduced CP opening flexibility
What are some neurologic AandP variations in the swallow?
Pharyngeal swallow triggered when bolus head reaches middle of tongue base or when falls into pyriforms
What does cranial nerve V do for motor?
Trigeminal
-mastification
What does cranial nerve VII do for motor?
Facial
- lips
- face
- salivary glands
What does cranial nerve IX do for motor?
Glossopharyngeal
- Pharynx
- Gag reflex
What does cranial nerve X do for motor?
Vagus
- Trachea
- Larynx
- Pharynx
- Cough reflex
What does cranial nerve XI do for motor?
Accessory
- Uvula
- Palate
- Pharyngeal constrictors
What does cranial nerve XII do for motor?
Hypoglossal
-Tongue
What does cranial nerve V do for sensory?
Trigeminal
-Sensation of anterior 2/3 of tongue
What does cranial nerve VII do for sensory?
Facial
-Taste of anterior 2/3 of tongue
What does cranial nerve IX do for sensory?
Glossopharyngeal
-Taste and sensation of posterior 2/3 of tongue
What does cranial nerve X do for sensory?
Vagus
-Mucous Membrane of pharynx, larynx, brochi, lungs, esophagus, and stomach
What does cranial nerve XI do for sensory?
Accessory
Nothing (trick question)
What does cranial nerve XII do for sensory?
Hypoglossal
-Sensation, mucous membranes of pharynx, palate, posterior tongue, and tonsils
What is the CPG? Function? and Location?
Central Pattern Generator
-Automatic/reflexive swallowing
Location: Medulla
When does the apneic period occur?
During the pharyngeal stage and lasts ~1 second
What could cause the apneic period to increase?
Increased volume of bolus
T/F the apneic period/swallow is safest on inhalation
False
Mostly during exhalation at end or near end of swallow
T/F Many dysphagia patients swallow at wrong time of breathing or have an incoordination of swallowing?
True
What aging differences in 80+ normal swallowers will you see?
- muscle atrophy/reduced lingual propulsion
- hardening of flexible cartilages/ossification
- Sagging of the larynx (laryngoptosis/presbylaryngeus)
- Transit times are increased/delayed
- Residue increased
- UES opening reduced
- Timing of swallow response/start delayed
- Frequent penetration into the airway
- Reduced sensations and cough reflex
- Piecemeal deglutition
T/F Penetration and aspiration into the airway is frequent in presbylaryngeus?
False
Frequent Penetration normal but NOT ASPIRATION
