Module 3 Flashcards
Complications of Dysphagia
RESPIRATORY:
Asphyxiation
Lobar collapse
Infection
SECRETION MANAGEMENT:
Drooling
Dehydration
Psychosocial
Social Isolation
Depression
Nutrition/ Hydration
Malnutrition
Malaise
Etiology & Conditions
Neurogenic
Neurological, Vascular, Brain injury
Structural
Cancer, Stricture, Web
Metabolic
Encephalopathy, Infections Iatrogenic Caused by intervention or treatment Surgery related, medication related, Radiation Congenital Clefts, Tracheal issues Mechanical Trauma, Intubation, Acute Inflammation, Cervical Osteophyte
S/sx Oropharyngeal Dysphagia: ask during evaluation
Coughing / Choking Throat Clearing Difficulty initiating swallow Drooling Unexplained weight loss Increase in RR Increased congestion Lower lobe infiltrate Change in diet
Requirements for Oral Prep / Oral Stage
Lip Seal: prevents anterior leakage / spillage
Buccal tension: keeps food from lower buccal cavities
Lingual ROM: keeps food from slipping out of control – holds bolus against hard palate; prevents posterior spillage; aids in mastication
Hard Palate: provides roof to control and manipulate bolus
Soft Palate Seal: prevents nasal regurg and posterior spillage
Oral Prep / Oral Stage Impairments
Can result due to changes in motor and / or sensory function
Typically result from impairment of the tongue’s or lips’ ability to control the bolus May also have difficulties with: Mastication Initiating swallow Labial and facial control
Due to tongue motor / sensory issues:
Cannot form a bolus due to reduced range of tongue motion or coordination
Cannot hold a bolus due to reduced tongue shaping of bolus and coordination of bolus
Residue on tongue due to reduced tongue ROM or strength or poor sensation
Adherence of food to hard palate due to reduced tongue elevation or poor strength
Poor bolus movement anterior to posterior due to reduced lingual coordination
Due to jaw issues:
Unable to align teeth due to reduced mandibular movement Reduced mastication because of this difficulty with solids Due to dentition issues: Poor ability to masticate solids Due to palatal issues: Nasal regurgitation Premature spillage: Spills down your throat
Due to facial / labial issues:
Oral pocketing due to reduced labial tension or tone
Loss of bolus anteriorly due to reduced lip closure
Global changes
Delayed oral onset due to reduced oral sensation
Premature spillage of bolus into pharynx- likely due to poor bolus control as well as poor seal between the tongue and the soft palate resulting in premature leakage into the pharynx
Oral Prep / Oral Stage Terms:
Anterior spillage Poor bolus control Poor bolus cohesion Poor bolus movement anterior to posterior Decreased / Prolonged mastication Buccal pocketing / Oral residue Tongue pumping Premature spillage
ASK: Oropharyngeal Dysphagia
Coughing / Choking Throat Clearing Difficulty initiating swallow Drooling Unexplained weight loss Increase in RR Increased congestion Lower lobe infiltrate
Pharyngeal paresis/paralysis
Look for movement of the PPW, lateral pharyngeal walls
Asymmetry of bolus movement
Strong side pushes the bolus across midline to the weaker side, so the bolus passes down the weak side
Usually due too neurogenic issues
Hyoid Elevation and Laryngeal Movement
Abnormal elevation:
No elevation
Poor elevation
Elevation occurs, but unable to be sustained
Epiglottic Inversion
Normal epiglottic tilt is a 2 step process
- Passively moves horizontally by hyoid elevation and posterior movement of the tongue
- Contraction of the thyroepiglottic muscle further inverts the epiglottis
Delay
Sensation issue Swallow triggers “lower down” than typically noted Mild: Vallecula Moderate: Vallecula / Pyriforms Severe: Pyriforms Prolonged pooling in these areas = delay
Premature spillage =
Incompetence of the palatoglossal seal and is characterized by movement of the bolus posteriorly, without cohesive organized intent, prior to the onset of a swallow reflex.
Premature spillage is attributed to weakness and / or poor coordination of the posterior tongue or the soft palate or both
Delay =
Typically sensation related “hold the food in your mouth until I say swallow” Residue Mild, moderate, or severe amounts (SLP subjective) of the bolus can retained in the vallecula or pyriforms after the swallow, or posterior pharyngeal wall Can be due to: Weakness Poor base of tongue retraction Reduced pharyngeal constriction Poor pharyngeal coordination Poor UES opening Penetration Entry of the bolus into the laryngeal vestibule above or to the level of the vocal folds DOES NOT pass through the vocal folds
Levels of Penetration
Highest to lowest
Epiglottic
Tip of the epiglottis, inferior surface
Aryepiglottic folds, False vocal folds
True Vocal Folds
Penetration Can Occur:
Before the Swallow: ----Due to premature spillage or delay During the Swallow: ----Due to poor coordination, laryngeal closure issues After the Swallow: ----Due to residue
Aspiration
Entry of the bolus BELOW the level of the vocal folds- into the airway
Occurs if there is failure of the laryngeal protective mechanisms
Hyolaryngeal elevation, epiglottic inversion, laryngeal closure
Aspiration Can Occur:
efore the Swallow
—–Due to premature spillage or delay
During the Swallow
—-Due to laryngeal incompetency and closure issues
i.e. TVC issues, poor epiglottic inversion
After the Swallow
—–Due to residue or reflux
How is Aspiration Normally Prevented?
Prevention of premature spill
Prompt and organized transfer of food through the oral cavity and pharynx owing to timely and forceful contraction of the posterior tongue and the sequential contraction of the pharyngeal muscles and prompt opening of the UES as part of the sequential swallow
Coordination of swallowing with respiration
Protective reflexes against aspiration including:
Laryngeal elevation, lifting up and forward movement of the larynx so as to move out of the way and “hide” under the epiglottis and the tongue during a swallow
Reflexive closure of the larynx true and false vocal cords along with the AE folds
Epiglottic inversion helps direct bolus around the airway during swallowing
If these fail and the bolus enters the trachea, a strong cough reflex is normally triggered.
Airway clearance can also be achieved later by the mucociliary elevator (cillia)!
Laryngeal Adduction Reflex
Audible Aspiration
Both penetration and aspiration are “audible” in the normal population
Clinically indicated by a reflexive cough or throat clear
Silent aspiration
Not all penetration and aspiration is audible, voice, neurogenic, ventilator, teach
Typically, do not know they are aspirating because they do not cough or clear their throat
Clinical prediction of silent penetration/aspiration is notoriously inaccurate!
voice quality, breathing, caught
Factors to Consider about aspiration Quantity
Larger quantities of material is riskier than aspiration of smaller, more minute quantities
Depth
How far does aspiration travel down trachea?
Just below vocal folds? Into distal airways?
Further down aspiration = more dangerous
Physical Properties of the Aspirate
Thin liquids easier to clear
Solids can obstruct airway and be fatal
Acidic material from reflux is dangerous (lungs highly sensitive to caustic acid=pnemonia)
Aspiration of saliva from oral cavity can be dangerous if saliva contaminated with infectious organisms (poor oral care)
Lungs can tolerate aspiration of water much better than anything else
Pulmonary Clearance Mechanism
Strong and productive cough?
Other pulmonary issues?
Bed bound? Walkie-talkie?
Smoker?
Penetration / Aspiration Scale
Score Description of Events
1 Material does not enter airway
2Material enters the airway, remains above the vocal folds, and is ejected from the airway.
3 Material enters the airway, remains above the vocal folds, and is not ejected from the airway.
4Material enters the airway, contacts the vocal folds, and is ejected from the airway.
5Material enters the airway, contacts the vocal folds, and is not ejected from the airway.
6Material enters the ariway, passes below the vocal folds, and is ejected into the larynx or out of the airway.
7Material enters the airway, passes below the vocal folds, and is not ejected from the trachea despite effort.
8 Material enters the airway, passes below the vocal folds, and no effort is made to eject.
Esophageal Stage Impairments
Can result in retention of the bolus in the pharynx or esophagus
May be a result of:
Mechanical obstruction CP bar, stricture, osteophyte Weakness Motility Disorder Impairments of the UES or LES
S/sx Esophageal Dysphagia
Globus sensation Change in dietary habits Reflux Coughing up particles of undigested food Pyriform sinus pooling Diverticulum Unexpected weight loss Recurrent pna Difficulties with pills increased mucus production trachesophageal
CP Bar
The UES is an area that is longer than the cricopharyngeus and consists of a zone of high pressure consisting of some fibers of the inferior constrictor muscle, the cricopharyngeal muscle, and some circular fibers of the proximal cervical esophagus.
fails to relax and open, the bolus may have difficulties passaging from the pharynx to the cervical esophagus
Opening is the physical separation of the walls (of the sphincter), whereas relaxation is loss of tension or loosening
CP Bar
UES is seen videofluoroscopially as “sticking out” posteriorly – known as a CP bar
Thumb-like indentation
Can be obstructive or nonobstructive
Diverticulum
An “outpouching” of the tissue forming an opening for material to gather in the esophagus
Usually forms in an area of weakness
Zenker’s most common
Zenker’s most common
Manifests itself as:
Dysphagia
Globus sensation
—–May fill up with food, causing the person to cough up partially ingested food into the mouth
Halitosis
—-Potential infection of the pharyngeal areas due to food stuck
Involuntary gurgling noises when swallowing
Rarely causes any pain
Cervical Osteophyte
More than half of the people over the age of 60 have osteophytes, or bone spurs
Osteophytes in the spine are a normal sign of aging and are not a cause for concern unless they result in pain or neurological symptoms
Cervical osteophytes
are bone spurs that grow on any of the seven vertebrae in the cervical spine
Cervical Osteophyte formation
Typically occurs when ligaments and tendons around the bones and joints in the cervical spine are damaged or inflamed.
The inflamed or damaged tissue abnormally influences surrounding bone growth (though hard, bones are constantly renewing, like fingernails and hair).
As a result, new bone cells are deposited where they would not normally grow.
Frequently Used Terms
Retrograde bolus movement Slowing of the bolus Posterior prominence (CP bar) Obstructive in nature Congruent with (osteophyte, narrowing of the esophagus, etc.) Backflow Reduced clearance Stasis Outpouching
