Neurogenic Dysphagia

Question 1

Sudden or acquired Neurological conditions with at least partial recovery: (9)

Answer 1

1) CVA
2) TBI
3) Spinal cord injury
4) Anterior cervical fusion
5) Neurosurgery
6) Poliomyelitis
7) Guillain-Barré
8) CP
9) Dysautonomia (Riley-Day)

Question 2

Degenerative conditions with gradual decline (10):

Answer 2

1) PD
2) ALS
3) MS
4) MG
5) MD
6) Alzheimer’s
7) Werdnig-Hoffman
8) Postpolio
9) Dystonia
10) Dermatomyositis

Question 3

Other types of Neurological conditions (not sudden or degenerative):

Answer 3

1) RA

2) COPD

Question 4

Neurologic Dysphagia S+S:

Answer 4

1) Decreased sensation to aspiration (SILENT)
2) Weak cough (if any)
3) Anosognosia (lack of awareness, deny they are having problems)
4) Cognitive probs
5) Language probs
6) Fatigue

Question 5

Neurologic Evaluation of Swallowing: Comatose PT

3

Answer 5

1) 5 finger test (5-10 minutes) or sEMG
2) Stimulate pharyngeal swallow (stroke faucial pillars)
3) Videofluoro if able (99.9% not gonna happen)

Question 6

Neurologic Evaluation of Swallowing: Noncomatose (Acute but good comprehension) PT:

3

Answer 6

1) Oral exam, oral mech
2) Bedside w/3cc (or 9oz for acue CVA) – minute amts
3) Videofluoro

Question 7

If pt is intubated, wait _____ after extubation.

Answer 7

~1 wk

Question 8

Sudden Neurologic Disorders

CVA-Medulla (lower brainstem)

Answer 8

Absent/weak pharyngeal swallow (1st wk post-stroke), severely delayed pharyngeal swallow (after 1st wk post), valleculae & U pyriform residues, reduced laryngeal excursion, reduced CP opening, U vf paresis

Question 9

Sudden Neurologic Disorders

CVA-Pontine (high brainstem)

Answer 9

Pharyngeal hypertonicity, delayed/absent pharyngeal swallow, pharyngeal wall paresis/paralysis, reduced laryngeal elevation, cp dysfxn

Question 10

Sudden Neurologic Disorders

CVA-Subcortical

Answer 10

Delayed oral transit time, delayed pharyngeal swallow, incoordination/ lack of neurom. control for pharyngeal swallow

Question 11

Sudden Neurologic Disorders

CVA-Cerebral Cortex (L or R)

Answer 11

LEFT: apraxia (delayed oral, no tongue motion/fasciculations), delayed triggering of pharyngeal swallow
RIGHT: oral transit delay, pharyngeal delay, delayed laryngeal elevation

Question 12

Sudden Neurologic Disorders

CVA-Multiple Strokes

Answer 12

Delayed oral, repetitive tongue mvmts, delayed triggering pharyngeal, reduced laryngeal elevation & closure, pharyngeal & pyriform residues on weak side

Question 13

Sudden Neurologic Disorders

TBI (11)

Answer 13

1) Delayed/absent triggering of pharyngeal swallow
2) Reduced lip closure
3) Reduced tongue ROM
4) Poor bolus control
5) Abnormal oral reflexes
6) Reduced tongue base motion
7) Reduced vp closure -nasal regurgitation?
8) Reduced laryngeal elevation
9) Reduced laryngeal closure
10) Reduced cp opening
11) Unilateral or Bilateral pharyngeal wall paresis/paralysis

*Other issues: pt putting too much food in mouth, cognition, sensation

Question 14

Sudden Neurologic Disorders:

Spinal Cord Injury (6)

Answer 14

1) Delayed triggering of pharyngeal swallow
2) Reduced laryngeal excursion
3) Reduced cp opening
4) Reduced tongue base motion
5) U or B pharyngeal wall dysfxn
6) Reduced airway closure (intubation/prolonged trach)

*May need a brace or a halo to stabilize while they heal

Question 15

Sudden Neurologic Disorders:

Anterior Cervical Fusion (5)

Answer 15

1) U vf paralysis (reduced closure) –>due to damage to the RLN during the surgery
2) reduced laryngeal excursion
3) reduced cp opening
3) U or B pharyngeal wall dysfxn
4) oral dysfxn
5) delayed triggering of pharyngeal swallow

Question 16

Sudden Neurologic Disorders:
Neurosurgery

Medulla (2)

Answer 16

1) Absent pharyngeal swallow

2) Tongue & tongue base “struggle”

Question 17

Sudden Neurologic Disorders:
Neurosurgery

CN (cranial nerves?) (5)

Answer 17

1) U pharyngeal wall paresis/paralysis
2) U vf paralysis
3) U soft palate weakness
4) U tongue paresis
5) Delayed pharyngeal swallow

Question 18

Sudden Neurologic Disorders:

Poliomyelitis (Polio)

Answer 18

1) Reduced lingual control
2) Reduced mastication
3) Reduced bolus propulsion by tongue
4) Reduced pharyngeal contraction
5) Reduced vp closure (nasal regurgitation)
6) U pharyngeal paralysis

Question 19

Sudden Neurologic Disorders:

Guillain-Barré

Answer 19

1) Weak oropharyngeal swallow
2) Reduced tongue
3) tongue base
4) larynx ROM

Question 20

Acquired Neurologic Disorders:

CP

Answer 20

1) Oral dysfunction (reduced lip closure, inappropriate oral reflexive behaviors, non-cohesive bolus, incoordinated tongue mvmts)

2) premature spillage
3) pharyngeal delay
4) reduced tongue base retraction
5) reduced laryngeal elevation, pharyngeal residue

Question 21

Acquired Neurologic Disorders:

Dysautonomia (Riley-Day)

Answer 21

Tongue incoordination, reduced tongue base contraction, reduced pharyngeal wall contraction, delayed pharyngeal, LES dysfxn (reflux), reduced esophageal motility

Question 22

Degenerative Neurologic Disorders:

PD

Answer 22

Tongue pumping or rolling, delayed pharyngeal swallow, reduced pharyngeal wall contraction, reduced tongue base motion, valleculae & pyriform residues (increasing w/ each swallow), reduced laryngeal elevation & closure (bowed vf’s), cp dysfxn, tremor

Question 23

Degenerative Neurologic Disorders:

ALS

Answer 23

Corticobulbar tract
Reduced tongue mobility, tongue fsciculations, loss of bolus control, reduced lip closure, vp weakness, reduced laryngeal elevation

Corticospinal tract
Reduced velar mvmt, reduced pharyngeal wall contraction

Question 24

Degenerative Neurologic Disorders:

MS (7)

Answer 24

1) Reduced lingual control
2) reduced chewing
3) delayed oral transit
4) reduced tongue base mvmt
5) reduced pharyngeal wall mvmt
6) reduced laryngeal fxn
7) delayed pharyngeal

Question 25

Degenerative Neurologic Disorders:

MG (5)

Answer 25

1) Tongue weakness
2) velar weakness
3) lack of chewing
4) laryngeal dysfunction
5) progressive use reduction of pharyngeal contraction

Question 26

Degenerative Neurologic Disorders:

MD (4)

Answer 26

1) Myotonic dystrophy
2) Prolonged contraction of cp & muscles of mastication
3) Oculopharyngeal dystrophy
4) Reduced pharyngeal contraction, cp dysfunction

Question 27

Degenerative Neurologic Disorders:

Alzheimer’s (6)

Answer 27

1) Agnosia for food (continue to cue to keep chewing etc.)
2) feeding & swallowing apraxia
3) oral tactile agnosia
4) delayed oral & pharyngeal
5) pharyngeal weakness
6) reduced laryngeal elevation

Question 28

Degenerative Neurologic Disorders:

Werdnig-Hoffman (pediatric motor neuron disease) (3)

Answer 28

1) Pharyngeal dysfxn (delayed pharyngeal swallow
2) severely reduced pharyngeal wall contraction
3) reduced laryngeal elevation

Question 29

Degenerative Neurologic Disorders:

Postpolio (polio in 1950’s epidemic) (3)

Answer 29

1) Pharyngeal wall weakness
2) reduced tongue base retraction
3) reduced laryngeal elevation & closure

Question 30

Degenerative Neurologic Disorders:

Dystonia (5)

Answer 30

1) Reduced labial seal
2) premature spillage
3) delayed oral transit
4) incoordinated lingual propulsion
5) usually normal pharyngeal swallow (besides the delay)

*mostly an oral issue

Question 31

Degenerative Neurologic Disorders:
Dermatomyositis (DM) (2)

*skin condition tht can effect the muscles of swallowing

Answer 31

1) Reduced pharyngeal contraction

2) cp dysfxn

Question 32

Other Disorders:
Rheumatoid Arthritis (RA) (3)

Answer 32

1) Cricoarytenoid joint>reducing arytenoid mvmt (reduced glottic closure), airway residues
2) Cervical vertebrae>pharyngeal wall impingement
3) Temporomandibular joint>painful/reduced chewing

Question 33

Other DIsorders:

Chronic Obstructive Pulmonary Disease (COPD) (2)

Answer 33

1) Airway closure problems

2) incoordination/weak respiration/dyspnea (wear, clavicular breathers, need help with deep breathing)