Midterm Study Guide Flashcards
What is the CPG?
CPG: Central Pattern Generator - a biological neural network located in the reticular formation of the brainstem that produces rhythmic patterned outputs WITHOUT sensory feedback (can’t stop pharyngeal swallow once it begins)
CPG is organized into TWO main groups of interneurons: Dorsal Swallowing Group (DSG) and Ventral Swallowing Group (VSG)
CPG is organized into TWO main groups of interneurons: Dorsal Swallowing Group (DSG) and Ventral Swallowing Group (VSG)
DSG: SENSORY; comes first –> ascending → sensory drives motor response; located in nucleus tractus solitarus (NTS) of medulla (brainstem) involved in the triggering, shaping, and timing of the sequential swallow pattern (unstoppable swallow)
VSG: MOTOR; descending –> located in ventrolateral medulla (brain), involved in distributing the motor drive to other motoneurons in the brainstem which execute the motor events; CN V, VII, IX, X, XII and C1-3
What is the difference between screening for dysphagia and a clinical exam?
Screening is not assessment; designed to determine which patients require an assessment; can be administered by anyone; designed to detect presence of overt aspiration (response to overt aspiration is to cough)
Clinical exam is clinician-driven of gathering info including medical history, feed, OSME, observations of swallowing function not good at id’ing pharyngeal abnormalities, competence of airway protection, silent aspiration; enables SLP to form hypotheses that guide diagnostic procedures
What are the parts of a clinical swallow exam?
Core components of CSE:
medical history
swallowing history interviewing
OSMEf
food/liquid trials
documenting plan
T/F silent aspiration is common after CVA. Why?
True
dysphagia in 29-80% of acute stroke -> often show rapid improvement to near baseline function but persistent dysphagia continues in 20-50% of cases
What is an example of a primitive reflex that can affect swallow function? In what type of pt do we often see these primitive reflexes?
tongue pumping, sucking, tongue thrust
TBI can present with primitive reflexes
Does CP usually cause spastic or flaccid presentation?
spastic → high tone due to cortical involvement → most typical in UMN lesion
Polymositis, dermatomyositis, and inclusion body myositis are all examples of what category of disorders?
inflammatory myopathies (peripheral neurogenic causes of dysphagia → infiltration of skeletal muscle by inflammatory cells like t-cells)
T/F - Pt’s with Duchenne’s muscular dystrophy often see recovery of their swallow function
false –> NO recovery
genetic defeat prevents normal muscle protein production; suffer from progressively worsening oral and pharyngeal weakness resulting in post-swallow residue aspiration (type of peripheral neurogenic causes of dysphagia)
Are swallow exercises indicated for a pt with Myasthenia Gravis? Why/why not?
exercise is NOT effective due to muscle fatigue and exercise depletes acetylcholine (ACH) (type of peripheral neurogenic causes of dysphagia)
What is the name for swallow changes that occur as part of normal aging?
presbyphagia (swallowing is NOT inherently impaired in aging)
Name 3 presbyphagic changes that may occur?
- muscle atrophy (aka sarcopenia) of tongue
- mastication and pharyngeal constrictors
- reduced strength and endurance in tongue and lips
- sensory changes like later and lower pharyngeal swallow response ( MBSImp 6)
How do we decide if an elderly person’s pharyngeal residue should be considered “dysphagia”?
dysphagia is impaired safety (aspiration or penetration are present) and efficiency (how much bolus remains indicates increased risk of aspiration → residue is expected due to aging but too much remaining indicates increased risk of aspiration)
What are some common complaints that may lead us to think a pt has esophageal phase dysphagia….
food sticking in throat, difficulty with solids but not liquids, painful swallowing (aka odynophagia), no overt signs of dysphagia
What should you do if you suspect esophageal dysphagia?
not the scope of SLP → GI for esophagram
Name the 4 types of esophageal tests
- esophagram → fluoroscopy with barium to visualize esophagus and stomach performed supine
- Upper endoscopy → endoscope through mouth to visualize esophageal lining, stomach and upper portion of small intestine
- esophageal manometry → tube passed through nose into esophagus; esophageal function assessed during swallow by taking pressure readings of muscle contractions of UES and LES
- ambulatory 24-hr pH probe → small tube through nose into esophagus to LES. pH sensor measures acid exposure to the esophagus for 24 hrs; this test is gold standard for determining acid reflux
What does organ preservation refer to in cancer tx?
keep the structure and treat with chemo/rad instead of removing structure via surgery and rad
T/F pt’s with lip tumor/excision have difficulty initiating pharyngeal swallow
true —> oral incompetence creates difficulty with generating maintaining oral pressures for initiating pharyngeal swallow
Does floor of mouth cancer/tumor removal often result in oral or pharyngeal phase dysphagia?
both → tongue stabilization can impact bolus manipulation and propulsion as well as pharyngeal residue
Which structures, when removed, would you expect to cause pharyngeal residue?
posterior resection of tongue and floor of mouth (mylohyoid CN V3 trigeminal branch 3)
What does TEP stand for?
A tracheoesophageal voice prosthesis is a device which is positioned between the trachea and the esophagus to allow air from the lungs into the esophagus and out of mouth. The air vibrates and resonates with the pharynx and produces sound in the absence of a larynx. finger occlusion or one-way valve is required to direct air through the TEP
List some acute and long term radiation effects
acute → xerostomia (dry mouth), mucositis (mucosa inflammation)
long term → fibrosis and xerostomia both make swallowing difficult due to reduced ROM and poor bolus lubrication
Why might SLPs advocate for the needs-based placement of G-Tube for HNC pts?
because G-tube placement may cause disuse of swallowing muscles
What is the difference between tracheostomy and tracheotomy?
Tracheotomy is the procedure, tracheostomy is the opening
Should the cuff be inflated or deflated when we place a speaking valve? Why?
deflated, because if cuff is up (inflated) it’s dangerous because air cannot go out of mouth because valve is one way
What is a fenestrated trach?
is a hole in the shaft of the tracheostomy tube to allow for airflow upward and through VFs to help facilitate voicing. also need a fenestration hole in the inner cannula
What does the pilot balloon show us?
is a small plastic balloon with a valve seal attached to the shaft of the trach tube with a lead line attached to the outer cannula near the faceplate. This balloon is used to inflate and deflate the cuff. If the pilot balloon is inflated this is an indication the cuff is inflated well and if the balloon is defeated this is an indication the cuff is likely deflated.
What are some guidelines that tell you a trached pt is ready for instrumental?
instrumental assessment should be completed prior to starting oral feeding → modified CSE to determine readiness including:
- smaller trach size
- deflated cuff status
- able to produce voice/cough
- no overt signs of aspiration
- good O2 saturation
How can someone with permanent mechanical ventilation communicate/swallow?
trach tube with speaking valve can be used to communicate and potentially eat and drink
What are some progressive degenerate diseases? How do we manage these cases?
ALS → aspiration pneumonia present 15%; huge QoL impairment; AAC required baseline is important in guiding treatment and modifications; establish eventual need for non-oral feeding
Alzheimer’s → decline in memory and ability to identify objects interfering with daily life; feeding apraxia and agnosia for food, delayed swallow reflex → might hold bolus in oral cavity for long period of time → initiates swallowing by adding more bolus to oral cavity
Huntington’s → CSE best assessment because VFSS is difficult due to chorea (is a movement disorder that causes sudden, unintended, and uncontrollable jerky movements of the arms, legs, and facial muscles) → gather baseline to see how disease progression and educate on diet modification, bolus size and placement, safe swallowing procedures, and environmental modifications should be discussed to decrease risk of aspiration ad improve swallowing function
Hypoglossal (XII)
MOTOR: innervated all extrinsic and intrinsic muscles of the tongue
- superior longitudinal muscle (tongue tip elevation)
- hyoglossus and stylogossus (posterior tongue depression)
ONLY motor
Vagus (X)
Both motor and sensory
- innervates above and below VFs,
- closes the airway and soft palate,
- constricts the pharynx,
- opens the UES
- propels bolus through the pharynx
> pharyngeal constrictors propel bolus
longitudinal pharyngeal muscles shortens the pharynx to decrease distance bolus travels
Two main branches: Superior Laryngeal Nerve and Recurrent Laryngeal Nerve
Vagus (X): Two main branches: Superior Laryngeal Nerve and Recurrent Laryngeal Nerve
SLN:
- MOTOR: cricothyroid muscle which adjusts length of the VFs (pitch)
- SENSORY: laryngeal muscosa ABOVE the VFs including pharynx and esophagus
RLN:
- MOTOR: VF closure, hyloaryngeal elevation
- SENSORY: laryngeal mucosa BELOW VFs –> trachea
Trigeminal (V)
SENSORY: tactile sensation to face, nasal and oral cavities
-bolus senstation and pocketing (V2 & V3)
MOTOR:
- masseter, temporalis (muscles of mastication)
- tensor veli palatini (tenses velum, eustachian tube opening)
- mylohyoid (floor of mouth) (tongue stabilizers for hyoid elevation innervated by CN V 3rd branch)
Facial (VII)
SENSORY: Taste front of tongue
MOTOR: facial expressions, holds bolus, secretes salvia
- orbicularis oris (oral seal)
- buccinator (pocketing)
- salivary glands
Glossopharyngeal (IX)
SENSORY: taste and sensation for posterior tongue, sensation of soft palate and faucial pillars –> sensory for swallow trigger (tastes and feels for swallow trigger response)
MOTOR : Stylopharyngeus shortens pharynx and secretes salvia
Blue Dye Tests have good _________ but poor ______________
Blue Dye Tests have good _specificity__ but poor ____sensitivity___
T/F – an inflated cuff prevents aspiration
false because the trach tube is below the vocal folds
aspiration may occur when the food sits on inflated cuff and once it’s deflated the rotten food will fall into lungs increasing risk of infection
Is it possible for someone with a total laryngectomy and TEP to aspirate food/liquid? If so, how?
yes, because fistula leaking or alignment issue of TEP can cause risk of aspiration; aspiration is not a risk factor for total laryngectomy
Motor CN involved in swallowing
there are 5
Trigeminal (V)
Facial (VII)
Glossopharyngeal (IX)**
Vagus (X)**
Hypoglossal (XII)*
*motor only
** both make up pharyngeal complex
Trach diagram
16= Faceplate
18=Cuff
14= Outer cannula
20= pilot balloon
22= Fenestration
Endo view of anatomy
Fluoro view of anatomy
VFSS view of anatomy
