Midterm Flashcards
Define and provide an example of dysphagia.
Dysphagia is an impairment in swallowing. It is often a comorbidity of other disorders. Dysphasia can contribute to malnutrition, aspiration, aspiration pneumonia, death, reduced quality of life, and longer hospital stays with a higher likelihood of readmission. Some disorders include stroke, brain injury, dementia, ALS, etc.
Describe the oral preparatory phase of swallowing.
Takes place in the oral cavity
Mastication of the bolus, mixing it with saliva and dividing the food for transport
Mastication occurs in a rotary motion with the tongue moving laterally to push the food around
Information is gained about bolus size, consistency, taste, pressure and temperature to help guide this phase
Saliva from the three salivary glands (Parotid, submandibular, sublingual) containing amylase to digest starch and mucous for lubrication, lubricates and dilutes the bolus to a consistency suitable for swallowing
What are the motor actions of the oral prep phase?
Labial seal
Buccal and facial tone
Adaquate and appropriate tongue movement
Lowering the velum, raising the posterior tongue
When necessary, mastication of the material with lateral and rotary motion of the mandible
What are the three sensory components of the oral prep phase?
Taste
Temperature
Pressure of the bolus, which provides information in order to stimulate saliva production and determine the pressure required to manipulate the bolus
Describe the oral phase of swallowing.
Takes place in the oral cavity
- Tongue tip raises to the alveolar ridge
- Posterior tongue drops to open the back of the oral cavity and soft palate elevates
- Tongue surface moves upwards, gradually expanding the area of tongue-palate contact from anterior to posterior, squeezing the bolus back
- Swallow is triggered when the bolus hits the anterior faucial pillars
What are the steps of the pharyngeal phase of swallowing?
- Bolus hits anterior faucial pillars
- Suprahyoid muscles contract, causing the hyoid to move supriorly and anteriorly
- Airway protection
- Pharyngeal muscles contract, raising the pharynx
- Tongue base retracts to PPW
- Pharyngeal constrictors are activated in rostral-caudal direction, causing pharyngeal peristalsis
- Thyrohyoid contracts, causing the larynx to move towards the hyoid, creating a negative pressure below the bolus to suck it towards the esophagus
- Epiglottis inverts
- Layngeal and pharyngeal elevation pull cricoid away from PPW, opening the UES
- If labial and nasopharyngeal seal are intact, UES opening creates more “suction force” that combine with driving force of the tongue and pharyngeal stripping wave to enhance bolus efficiency
- Completed when soft palate returns to original position and larynx reopens
What can modify the pharyngeal phase of swallowing?
Can be modulated in part by how the bolus is transported in the preceding phase Timing of trigger can be impacted by texture, taste, and volume
Describe the esophageal phase of swallowing.
Relaxation of UES lasts 0.5-1.2 seconds, just long enough for bolus to pass
UES returns to contracted state to avoid any retrograde bolus entry into the hypopharynx
Esophageal peristalsis is then activated and the bolus is propelled to the LES and stomach
Wave travels inferiorly, squeezing the bolus through the esophagus
After hypopharyngeal pressure peaks, LES is triggered to relax and bolus is squeezed into the stomach
Any residue is cleared via secondary waves up to two hours after
Transit times vary with age, bolus size, and texture (8-13 seconds in healthy adults)
Describe the mechanisms of airway protection.
Vocal fold closure (true and false): ceases respiration and seals off airway to prevent aspiration
Epiglottic deflection: tip of the epiglottis to the arytenoids
Elevation of the aryepiglottic folds/larynx
Anterior hyolaryngeal excursion
Describe the mechanisms of UES opening.
Intrabolus pressure: via tongue and pharyngeal muscles
Build up of positive pressure int eh pharynx/negative pressure in the esophagus
Cricoid elevation
What are some indications to give an instrumental exam? Provide at least four.
Patient’s signs and symptoms are inconsistent with findings on the clinical examination
Need to confirm a suspected medical diagnosis and/or assist in the determination of a differential medical diagnosis
Confirmation and/or differential diagnosis of the dysphagia is needed
There is either nutritional or pulmonary compromise and a question of whether the oropharyngeal dysphagia is contributing to these conditions
The safely and efficacy of the swallow remains a concern
The patient is identified as a swallow rehabilitation candidate and specific information is needed to guide management and treatment
What are some methods of radiation safety?
Step to the sides and backwards, as clinician exposure is highest immediately in front of the patient
Take a position 6ft away from the source = should be a zero exposure location
Lead vest and collar for clinician with lead napkin for client
Dosimeters on collar and waist
Always have a plan going in to minimize exposure time, ensuring location and posture of client is good, etc.
Patients should cover reproductive organs
Name the different types of motor speech disorders and their sites of impairment.
Flaccid: Cranial nerves and brainstem, LMN (primarily LMN)
Spastic: cerebral cortex, white matter tracts, or bilateral UMN (Specifically pyramidal and extrapyramidal systems)
Ataxic: cerebellum
Hypokinetic: basal ganglia system (Typically parkinsons)
Hyperkinetic: basal ganglia system
Apraxia: left hemisphere, most likely broca’s area or primary motor cortex
Differentiate UMN and LMN based on strength, reflexes, atrophy, and presence/absence of fascinations.
Strength: reduced weakness (UMN), weakness (LMN)
Reflexes: hyperreflexia (UMN), hyporeflexia (LMN)
Atrophy: n/a (UMN), Yes (LMN)
Fasciculations: n/a (UMN), Yes (LMN)
What are some advantages and disadvantages of an electrolarynx? Provide at lease two for each.
Pros:
- Can use immediately post-surgery
- Easy to learn
- Communicate in noisy environments
- Can use at different locations in the neck
Cons:
- Sounds mechanical
- Expensive and needs to be charged or uses batteries
- Can breakdown
- Success can be impeded by hearing loss or hand tremors
What are some advantages and disadvantages of TEP speech?
Pros: - Quick and easy to learn - More natural and dynamic voice - Hands free option - Reversible Cons: - May not be a candidate due to surgery and effects of radiation - Cleaned and care for daily - May need more surgery (Secondary puncture vs. primary) - Cost
What are some advantages and disadvantages of esophageal speech?
Pros: - Natural sounding voice - No electronic aids, prostheses, or hands to help with communication - No cost Cons: - Tension and stress can impede speech - Hard to learn (1-2 years for complete proficiency) - Need to be highly motivated - Poor voice dynamics
Provide 5 things to keep in mind when training on an electrolarynx.
- Need a good seal between device and skin
- Requires good or over-articulation
- Speak slower but maintain normal prosody
- Speak in shorter sentences
- On/off timing important at start of sentence and at the end
- Avoid stoma blast
Provide 5 things to keep in mind when training on an TEP.
- Relax!
- Occlude the stoma by prasing finger or thumb over it and gently pushing from the diaphgram
- Maintain good seal on the stoma
- Do not push from the upper chest, neck, or shoulders
- Start with an ah sound or counting one to ten
List the key head and neck structures of the oral prep phase.
Obicularis Oris (CN VII) – closing the lips
Buccinator (CN VII) – counter force to the tongue to facilitate proper bolus control
Masseter (CN V) – elevates the mandible (closes the jaw)
Temporalis (CN V) - elevates and retracts the mandible (closes the jaw)
Medial pterygoid (CN V) – closes the jaw by raising the mandible against the maxilla
Lateral pterygoid (CN V) – assists in opening the mouth by drawing the condyle and articular disk forward
Tongue muscles (CN XII):
- Intrinsic: superior and inferior longitudinal, vertical, and transverse
- Extrinsic: genioglossus, styloglossus, hyoglossus, and palatoglossus (CN X)
