Revised Study Guide Deck Flashcards
What is best practice?
Evidence, Experience, and Empathy
What associations/entities define our scope of practice and the rules SLP’s should adhere to when diagnosing and treating swallowing patients??
Entities:
• ASHA
• State boards
• Insurance companies - Medicare; Managed Health Care Companies
• Whoever you receive reimbursements from also define what you can/not do
What are the rules?
Rules:
• Physician must be present when we are conducting a MBS
• We do not have exclusive rights to be the only providers of Dysphagia - OT’s can be the primary providers as well if they’re adequately trained (eval. and intervention are within their scope of practice)
• We cannot dictate what other professions do/cannot control them
Know at least 5 key activities that occur during the pharyngeal stage (in your notes).
· Closure of the velopharyngeal port
· Tongue BASE retraction (contacts and hits pharyngeal wall)
· Elevation of hyoid and larynx
· Closure of larynx
· Relaxation/ opening of the UES (upper esophageal sphincter)
What is the UES?
• Upper esophageal sphincter: known as the Cricopharyngeal opening or the pharyngeal esophageal segment; located at the lower end of pharynx and guards the entrance into the esophagus
What is the UES role in swallowing?
• Role in swallowing:
o Pressure drives it to open, which is caused by the larynx elevating
o Cricopharyngeus muscle opens to permit entry of bolus into esophagus.
o It prevents reflux of esophageal contents into the pharynx to guard airway aspiration.
o This stage is involuntary - occurs in 1 second
What role does the floor of mouth muscles play in swallowing?
The muscles of the floor of the mouth elevate the hyoid and larynx.
What are the methods we utilize to evaluate swallowing (clinical and instrumental)?
Bedside Swallow evaluation, MBS, FEES, Manometry (mostly for research), Ultrasound
What are the 4 categories of swallowing treatment that Groher and Crary -discuss. Give an example of each one.
Behavioral- changing behavior to adapt to the swallowing disorder (i.e., Look left, no straws, slow down)
· Dietary- changing the diet to adapt to the swallowing disorder, chopped meats, blended food
· Medical- medication changes to adapt to the swallowing disorder, N-G tube, botox
· Surgical- surgical procedure to fix the swallowing disorder, Thyroplasty, G-tube
What is the main medical consequence of pharyngeal dysphagia?
Aspiration Pneumonia
Name a few normal changes of swallowing that occur in the elderly as it relates to each of the oral stage.
· Oral stage: hold bolus more anteriorly, increased/ prolonged mastication, reduction in tongue mobility, sensory changes
Name a few normal changes of swallowing that occur in the elderly as it relates to each of the pharyngeal stage.
Pharyngeal stage: Larger volumes to trigger the swallow, slower time for UES/PE segment to relax, triggering of pharyngeal swallow below ramus. Coupling of swallowing separates
Name a few normal changes of swallowing that occur in the elderly as it relates to each of the esophageal stage.
· Esophageal: Transmit may be delayed, higher incidence of reflux and mobility issues
Why are the normal healthy elderly at risk for swallowing problems? (Not looking for “they become weak) Be specific!
· Overall reduction in “reserve” anatomical/ physiological changes
· The uncoupling of oral and pharyngeal events
Where is the main neural control of swallowing located?
- Medulla (brainstem)
- Nucleus Tractus Solitarii (NTS): located in the medulla oblongata which is clusters of nucleii (cell bodies) that regulate sensory and taste;
Define the NTS.
It’s a junction box - coordinates large amount of input and output for sensory/motor (makes sense of sensory info) -including respiratory, gag
• The Vagus nerve in the medulla controls motor information. The NTS controls sensory information (including taste).
· Penetration:
some of the bolus enters the area above the glottis. The larynx and hyoid move up and the trace amount of the bolus is removed from the glottis.
· Aspiration
when the bolus enters the area above the glottis and is not removed. It passes through the vocal folds and into the lungs.
• aspiration can be normal…as long as it it trace (we all aspirate everyone once in fa while!)
nutritive sucking?
Nutritive sucking- sucking for nutrition
• Typically 1 suck per second
• There is an apneic period – AIRWAY IS CLOSED
Non-nutritive sucking
· Non-nutritive sucking- sucking for pleasure
• faster than nutritive sucking
• 2 sucks per second
• No apneic period – always breathing (airway is open)
What are the differences in the nose anatomy of swallowing infant versus adult?
*Swallowing is voluntary and involuntary in adults, but it is only involuntary in newborns.
• nose in infants
o smaller nares
o sinuses are not completely formed
What are the differences in the oral cavity anatomy of swallowing infant versus adult?
*Swallowing is voluntary and involuntary in adults, but it is only involuntary in newborns.
Tongue fills mouth
o -Edentulous (no teeth)
o -Tongue rests between lips, sits against palate
o -Sucking pads in cheeks
o -Smaller mandible
o -Sulci (space between gum and inside of cheek) important in sucking for infant
What are the differences in the pharynx anatomy of swallowing infant versus adult?
*Swallowing is voluntary and involuntary in adults, but it is only involuntary in newborns.
o no definite oropharynx so they have less risk of aspiration
o obtuse angle at skull base in nasopharynx
o single line of breathing allowing infants to suck and swallow at the same time
What are the differences in the larynx anatomy of swallowing infant versus adult?
*Swallowing is voluntary and involuntary in adults, but it is only involuntary in newborns.
o ⅓ of adults size o ½ true vocal folds are cartilage o very narrow vertical epiglottis o more forward and higher o thyroid cartilage is round
What are the differences in the esophagus anatomy of swallowing infant versus adult
*Swallowing is voluntary and involuntary in adults, but it is only involuntary in newborns.
o 1.5 cm in length
o LES is still immature, LES keeps acid from coming back up into esophagus – LES is still developing
o Usually matures by 6 months – may take 9-12
o Delayed gastric emptying
o reflux is normal in infants
o 40% regurgitate at least 1x daily
How is the infant’s anatomy customized to prevent aspiration?
• There is no definite oropharynx. The soft palate and epiglottis are squished together, allowing the child to suck and breathe simultaneously.
What is RDS?
• Respiratory Distress Syndrome
o Affects lungs of preterm neonates due to a lack of “surfactant” or (fluid secreted by lungs to stabilize and prevent them collapsing upon exhalation)
o Due to lack of fluid, preemies have difficulty inflating and deflating lungs
How does RDS affect the infant’s swallow?
• RDS affects the infant’s swallowing because they choose to protect their respiratory system through a voluntary refusal to swallow
What are the most important reflexes for the infant?
- -rooting
- -suck/swallow
- -tongue thrust
- -gag reflex
- -cough reflex
What is the suck/swallow reflex and why is it important?
- Infants lips/mouth area are touched, mouth opens and sucking/suckling begins
- its important because it facilitates transition from breast to bottle
When is the right time to introduce an infant to food?
• around 4-6 months when reflexive responses have diminished along with motor development of body and upper extremities- so they can hold a cup
From your textbook, what are some of the clinical signs of reflux in infants? How does this affect their ability to feed?
- Gagging
- Choking
- Apnea
- Halitosis (bad breath )
- Burping
- Frequent swallowing
- Emesis-vomiting
What is failure to thrive and why is it so important?
- failure to grow based on established growth standards for age and gender
- important because children who do not get adequate nutrition MAY NEVER RECOVER from the effects because the central nervous system is still developing
- children may also not be receiving proper nutrition due to poor dentition, medical complications, poor communication, and genetic growth failure
What are the different methods utilized to feed infants who may not be eating by mouth?
- nasogastric (N-G)
- orogastric (O-G)-
- gastrostomy- directly into stomach
- paraenteral -into bloodstream
How does Pierre Robin Sequence affect swallowing?
- respiratory distress when feeding in infancy
- coughing, grunting, sputtering
- u shaped cleft
- glossoptosis
- micrognathia
- retrognathia
What is eosinophilic esophagitis?
- allergic inflammation of the esophagus
* causes food impaction, poor appetite, and reflux
What factors affect preemies swallowing?
- Posture – may be hyperextended which results in higher risk for aspiration and reflux
- Immature respiratory system
- Immature structural alignment
Can SLP’s be feeding therapists also? Defend your answer.
Yes! But we split the job w/ OTs. • Oral motor skills-SLP • Mealtime behaviors-SLP • Reaction to food types/textures -SLP • self feeding and posturing--OTs
Know the differences between swallowing and feeding disorders in infants.
Feeding Disorders
• Often behaviorally motivated
• Results in aversion or refusal of foods/liquids
Swallowing Disorders
• Reduced function of oral, pharyngeal, and esophageal structures
CRITERIA FOR REFERRAL for a probable SWALLOWING DISORDER
- SUCKING AND SWALLOWING INCOORDINATION
- WEAK SUCK
- BREATHING DISRUPTIONS OR APNEA DURING FEEDING
- EXCESSIVE GAGGING OR RECURRENT COUGHING DURING FEEDS
- NEW ONSET OF FEEDING DIFFICULTY
- DIAGNOSIS OF DISORDERS ASSOCIATED WITH DYSPHAGIA OR UNDERNUTRITION
a. Cleft palate, cerebral palsy, craniofacial disorders - Weight loss or lack of weight
- Severe irritability or behavior problems
- History of recurrent pneumonia
- Concern for possible aspiration
Criteria for a probable feeding disorder
- Food aversion or refusal
- Failure to advance to age appropriate foods
- Excessive Vomiting
- Negative Mealtime Behaviors
- Failure to Thrive
- Gagging or Choking
How do you know if the infant is having a sensory issue?
- Unable to sort solids and liquids
- Holds food under tongue and cheek
- Demonstrates nipple confusion with breast-feeding and bottle feeding
- hyperreactive-extreme response to taste/temp.
- hypoactive- diminished response to taste/temp-need strong flavors
Why is posture so important?
- Oral phase → then tongue would be retracted, poor lip seal, and reduced lingual movement, and higher risk for aspiration.
- pharyngeal phase →
- esophageal phase → higher incidence of reflux because of gravity helping reflux so if child is hyperextended you want them to be more forward
How do you know that a premie is ready to eat?
- Cardiac, respiratory status
- Bowel sounds adequate
- Feedings can be done with minimal respiratory distress
- Tolerance of bolus feedings
- Infants need to be OFF the ventilator to even consider oral feeding.
- suck/swallow/breathe needs to be regulated
What is OST?
Oral Sensorimotor Treatment→ using sensory stimulation to improve eating and drinking. You are trying to desensitize pt from different components (lips, tongue, jaw, etc.). Not giving them anything edible, just stimulating their senses
Why are there differences in bottles and nipples for infants? Explain your answer.
- infants have different needs.
- Dr. Brown’s → reduces air, makes sucking easier
- syringe bottles → controls volume
- chu chu→ for cleft palates
- wide neck nipples → improves lip closure
What are the goals of behavior treatment?
- basically counseling! -least intrusive treatment
- addressing importance/impact of lighting and family dynamics
- educating, reducing stress, create best environment possible, providing resources!
- operant conditioning to let child know they can receive rewards when they eat
Operant Conditioning
o Rewards throughout when child reaches food goals
o When they reach a certain food goal, increase complexity of food
Systematic desensitization
• Playing games and activities with child with food and increasing complexity
Upper motor neurons and Lower motor neurons control which nervous systems?
- UMN: Central Nervous System
* LMN: Peripheral System
The degree of cortical impairment depends on a variety of factors…..name at least 3
- Location of damage
- Extent of damage
- Type of damage (trauma vs blunt force)
- Unilateral vs. Bilateral
What swallowing deficits (be specific) would a lower brainstem stroke exhibit?
- Difficulty triggering the pharyngeal swallow
- absent pharyngeal swallow
- delayed pharyngeal swallow
- Reduced laryngeal elevation
- Reduced UES opening
- Information regarding taste, cough, and gag reflexes
- Can GROSSLY aspirate, can have absent cough reflex
What is oral apraxia?
happens from LH stroke. voluntary movement disorder of sequencing (inability to sequence motor movements).
As a swallowing therapist, the goal is two fold…..
to achieve that the patient swallow safely but also maintain or maximize NUTRITION
Many Dementia and Alzheimer patients exhibit oral agnosia. What is it? Give an example.
- inability to recognize food - tactile stimuli from the face, lips, and oral mucosa are not functioning so they may not be able to tell that a non-food item is something they’re not supposed to eat
- May try to eat the silverware because they think it is food since they’re putting it in their mouth
Why can patients with TBI (traumatic brain injuries) difficult to treat for dysphagia?
Behavioral Issues: Impulsive, poor awareness (no awareness of deficits or what has happened to them), attention issues
What are some of the specific clinical features of Parkinson?
- resting tremor
- bradykinesia- slow movement
- mask expression
- cogwheeling- muscles jerk when force is applied to them
- “Pill rolling”- moving fingers like rolling a pill
- dysarthria
- poor oropharyngeal control (bolus control)
- tongue pumping
- weak swallow reflex
- incoordination of swallow and respiration
- drooling (increased risk of silent aspiration)
Name the generalized treatments for Parkinsons-all stages.
• dietary o thicken liquids o chop up meats • behavioral o small portions o small and frequent meals o exercises • adaptive equipment • Early PD: exercises • moderate parkinsons: o sensory changes/input • severe parkinsons: o enteral nutrition-provides nutrients directly into the GI tract/maximizing nutrition
What affect does anti-psychotic medication have on the stages of swallowing? WHY?
o Causes Idiopathic/Iatrogenic Dysphagia - —these drugs are meant to slow down the CNS (brain) and over time it will slow down the swallow
o This is important because choking and psychomatic dysphagia can result from being on these meds for an extended period of time
Name a lower motor neuron disease and the effects on swallowing.
• amyotrophic lateral sclerosis • Effects on swallowing o reduced tongue base movement o reduced pharyngeal wall constriction o reduced laryngeal elevation o decreased labial closure
What are the side effects of radiation?
• side effects o mucositis (inflammation of mucous membranes) o edema o trismus o odynophagia (painful swallowing) o xerostomia o dental changes o fibrosis (scarring of tissue)
• how does radiation affect swallowing?
o becomes extremely difficult due to xerostomia, odynophagia, and potential fibrosis (radiation is like getting an extreme sunburn inside your body)
Why is dry mouth (xerostomia) a problem in head and neck cancer patients?
• because salivary glands are radiated
When should swallow treatment begin for a head and neck cancer patient?
• need to build up muscle strength before the event so they come out where they were pre-treatment
Why is it important to keep a head and neck cancer patient swallowing EVEN if they are aspirating? (Think what changes in the muscles occur)
- if they don’t keep swallowing they will develop fibrosis
- DO NOT LET THE MUSCLES ATROPHY AND TURN FIBROTIC, KEEP THEM SWALLOWING!
- DO NOT MAKE THEM NPO!
- If they don’t swallow, those muscles will turn to scar (fibrosis), the more they don’t use it, the more the muscles will turn to stone (become fibrotic).
What is trismus?
- Inability to open the mouth very much
* muscle spasms in the jaw that keep the mouth clenched shut
What is a total laryngectomy
• Physical separation of GI tract from the respiratory tract or removal of larynx OR separation of the airway from the esophagus.
how does a total laryngectomy affect swallowing?
• affects swallowing because of reduced laryngeal clearance o additional problems related to swallowing include: • pseudoepiglottis • backflow of material into pharynx • poor pharyngeal pressure • nasal regurgitation • fistula (can cause retrograde aspiration) • pouch formation • reduced hyolaryngeal excursion • reduced UES or PES opening • reduced pharyngeal stripping wave • complaints of food sticking
What specific swallow changes would you see in an oral cancer patient?
— Reduced tongue/bolus control — Reduced tongue elevation — Slowed oral transit with disorganized tongue movement — Delayed pharyngeal swallow — Reduced tongue base retraction — Reduced pharyngeal wall contraction — Reduced Laryngeal Elevation — Reduced UES/PES opening — Reduced velopharyngeal closure — Reduced epiglottic inversion
What specific swallow changes would you see in a laryngeal cancer patient?
— Reduced Laryngeal Elevation
— Reduced Glottal and Laryngeal Closure
— Reduced UES or PES opening
— Reduced Pharyngeal Wall contraction
