Review Swallow Flashcards
If observe repetitive tongue pumping in oral stage swallow, could be sing of?
Parkinsons
Signs of aspiration during swallow trials
5
- absent swallow
- reflexive cough after swallow/choking
- difficulty handling secretions
- change of voice
- pulse oxymetry
Why look at range of motion of tongue in OME?
bc odds of liquid aspiration are ++ higher for individuals w/ reduced lingual ROM
(Leder et al, 2013)
why do a cog-ling screen?
bc odds of liquid aspiration are ++ higher for Pts not oriented to person, place and time.
odds of liquid + puree aspiration are ++ for Pts who can’t follow 1 step commands
(Leder et al, 2009)
why consider dysarthria in dysphagia Ax?
bc presence of dysarthria is ++ associated with increased aspiration risk in individuals w stroke (Daniels, 2005; Muccolloug, 205)
what can voice quality tell you in clinical beside eval?
- dysphonia (breathiness, hoarseness, harshness) is predictive of aspiration
- wet vocal quality (hard to perceive)
- reduced pitch elevation is predictive of higher penetration-aspiration scale scores
do gag reflex in clinical swallow?
The absence of a gag reflex does not appear to be a predictor of dysphagia (Leder, 1996)
what do you hear with cervical auscultation?
(hearing sounds of swallow with stethoscope)
should hear 2 bursts (bolus entrance into pharynx, leaving pharynx) ; 3rd small burst in some (glottal release)
delay in hearing these sounds could signify swallow abnormality
why do pulse oximetry w clinical bedside?
- measure oxygenation of peripheral blood flow (measures amount of light absorbed by blood in tissue, which varies w/ oxygen content)
95-100% normal rance, <90% suggests problems
some studies suggest 2% drop in SPO2 are not related to aspiration events but are more likely to be found in Pts symptomatic for dysphagia
can clinical swallow tell us who aspirates?
no. clinical swallow gives us information on Pts who are at risk for aspiration and/or dysphagia. no info on bolus flow or swallow physiology (always remember natural variation).
what is important to note about dentition?
missing teeth
decay
dentures
(+ ask about impact on swallow (fit well?, etc.))
importance of cranial nerve 5 (trigeminal)
- motor for muscles of mastication/jaw (masseter, temporal, medial pterygoids, lateral pterygoids) + 2 extrinsic larynx muscles (mylohyoid, anterior belly of digastric) + 2 tensors (tensor veli palatini, tensor tympani)
- sensory for face (3 branches, top lip V2 and bottom lip V3)
innervation of tongue
motor = all intrinsic and extrinsic muscles of the tongue is hypoglossal nerve (CN XII) EXCEPT palatoglossus (vagus nerve - CN X)
sensory =
anterior 2/3rds of tongue : taste VII, sensation V3
posterior 1/3rd of tongue : taste and sensation IX
base of tongue : sensation X (superior laryngeal branch)
importance of cranial nerve VII (facial)
motor for face (bilat superior, unilat inferior) + 2 extrinsic laryngeal muscles (posterior bello of digastric, stylohyoid)
special sensory (taste) for anterior 2/3rds of tongue.
importance of cranial nerve IX (glossopharyngeal)
motor for stylopharyngeus (only motor component of IX)
special sensory (taste) for posterior 1/3rd of tongue
importance of cranial nerve X (vagus)
motor for velopharyngeal muscles (levator veli palatini, salpingopharyngeus, palatoglossus, palatopharyngeus, superior middle and inferior pharyngeal constrictors) + cricothyroid + intrinsic laryngeal muscles
sensory for pharynx and back of throat (gag reflex) + for larynx
importance of cranial nerve XII (hypoglossal)
motor for all extrinsic and intrinsic muscles of tongue, except for the palatoglossus (X vagus)
what could involuntary movements of structures during clinical swallow be a sign of?
hyperkinesia
what signs of parkinsons would be observable in OME of face?
- “mask” face
- lips tremor
why make raise eyebrows during OME?
bc absence of forehead wrinkling = can differenciate UMN (bilat) vs LMN damage (unilat)
what’s the name of restriction in opening of the jaw
trismus
role of changes in pressure within oro-pharyngeal structures in a normal swallow?
allows the bolus to move rapidly from zones of high pressure to zones of low pressure.
(for example, laryngeal elevation creates negative zone of pressure in pharynx in region of PES)
cranial nerves responsible for salivation?
VII - submandibular and submaxillary glands (autonomic aspect of nerve)
IX - parotid gland (autonomic aspect of nerve)
which cranial nerve would be most important for swallow initiation and sensory protective mechanisms of upper airway?
superior laryngeal nerve (CN X vagus)
description of events of oral stage of normal swallow (10)
- tongue tip occludes at alveolar ridge (holding bolus on palate)
- edges of tongue dorsum contain bolus laterally.
- respiration ceases, arytenoids approximate
- retraction of tongue (mainly by extrinsic tongue muscles - digastric + mylohyoid (V), geniohyoid (XII)
- positive pressure to bolus tail by tongue base against velum/posterior pharyngeal wall
- velum sealed by levator veli palatini
- palatopharyngeal folds pulled medially to allow bolus passage
- larynx pulled up and forward
- epiglottis descends over airway
- bolus deflects through valleculae at tongue case, away from airway
which muscles responsible for hyoid movement?
2
geniohyoid - most responsible for anterior displacement of hyoid (CN XII)
mylohyoid - most responsible for superior movement of hyoid (CN V)
(Pearson, 2011)
when does pharyngeal stage of swallow begin?
when bolus is at level of valleculae. ends when PES closes.
role of CN IX in PES opening?
parasympathetic signals from CN IX to brainstem relax PES muscles, to allow for hyolaryngeal movements to open them
other name for PES/UES (muscle)
cricopharyngeal muscle (part of lower pharyngeal constrictor)
innervation inside the mouth?
V - mucosa of cheeks, nasopharynx, soft palate, hard palate, buccal floor + gen sensory for anterior 2/3rd of tongue
VII - taste for anterior 2/3rds of tongue
IX - taste and gen sensory for posterior 1/3rd of tongue + gen sensory for oropharyngeal mucosa (tongue base, palatine tonsils - swallow initiation)
X - mucosa of pharynx, epiglottis, larynx, oesophagus
height of UES compared to C?
C5-C6
dysphagia symptoms reported by Pt
(11)
H = hidden/subtle symptomes (5)
- difficulty chewing (decreased mastication efficiency - slowed down chewing) H
- drooling (lip/tongue weakness)
- nasal regurgitation
- difficulty initiating swallow (dry mouth, lip/tongue weakness)
- blockage (food doesn’t pass through)
- frequent cough/choke (laryngeal penetration)
- delayed cough H
- throat clear H
- residue H
- odynophagia (pain)
- weight loss H
dysphagia signs observed by clinician
9
- drooling (infrequent swallow of saliva ; weakness of labial closure ; frooling of saliva or bolus)
- lack of swallow initiation
- cough
- throat clear
- residue
- delayed cough
- delayed swallow initiation w/o cough (potential silent aspiration)
- sign hidden by Pt
- regurgitation
preparatory phase symptoms (3) and related signs (3 - 1 - 6)
- drooling
(drooling saliva/bolus ; weakness in labial closure ; infrequent saliva swallows) - xerostomy
(dry lips/tongue/palate) - difficulty chewing and/or changing diet to softer foods
(drooling food ; slow chewing even for soft foods ; teeth decay ; misadjusted dentures ; weakness of tongue/jaw/lips ; lack of coordination of tongue/jaw/lips)
pharyngeal phase symptoms (5) and related signs
- effort during swallow/difficulty initiating swallow
(delayed laryngeal elevation ; penetration/aspiration of bolus before swallow initiation on VFSS) - blockage/globus (sensation of ball)
(residue on VFSS - sometimes oesophageal) - cough/choking
(penetration/aspiration on VFSS) - wet cough
(aspiration of saliva during VFSS) - regurgitation in oral cavity/pharynx
(bolus not swallowed)
causes of oesophageal dysphagia
(4 categories | 4 + 2 + 2 + 2)
+2
structural disorders, motility disorders, LES abnormalities, PES abnormalities
structural
- esophageal stenosis (narrowing of lumen - can be peptic from GERD)
- esophageal rings/webs (Schatzki’s rings)
- tumors
- esophageal diverticulum (bulge in weak spot on esophagus)
motility
- nutcracker oesophagus (increased esophageal pressure - spasms)
- diffuse esophageal spasm
LES abnormalities
- achalasia (mega-oesophagus)
(non relaxing of LES preventing passage to stomach)
- Barrett’s esophagus
(stomach cells replacing esophageal mucosa)
UES abnormalities - Zenker's diverticulum (posterior pharyngeal wall at Killian's dehiscence) - cricopharyngeal bar (UES muscle not distending)
- esophagitis
- GERD / LPR
if bad breath constant… sign of?
residue somewhere, for example zenker’s diverticulum.
difference between bulbar and spinal ALS presentation?
Bulbar (25%) –
speech and swallow first. AAC early. Other motor later. Rapid deterioration.
Spinal (75%) –
motor limbs first. Dysarthria later. AAC later. Slow progression. (Can have total paralysis, but ability for speech/swallow)
potential quality of life impacts of dyphagia
5
- reduced enjoyment of eating/drinking from fear of doing so safely (anxiety) or increased effort
- embarrassment may change the places in which a person is willing to eat and
limit social activities - slow and fatigue in eating may impact effectiveness of eating
- diet changes/restrictions may decrease satisfaction of eating
- time and expense of special diets
4 general quality of life impacts of dysphagia
- fear of choking (anxiety)
- discomfort/pain while eating
- social insecurity
- less enjoyment eating
