Speech & Language Therapy in ENT Flashcards
In general, When are patients referred to SLT in the realm of ENT?
Swallowing difficulties
Communication difficulties
Honours: hearing diffivulty hence speech
What is the general workup of a patient with dysphagia
Clinical assessment of swallow
Evaluation of swallow: VFFS/FEES
What examination is involved in the clinical assessment of swallow. Briefly outline what is being assessed
Oro-facial examination with !Bulbar Assessment! assessing the three domains of speech, swallowing, and salivation including structure and function of face and mouth as well as cough and gag reflexes.
Voice assessed
What instruments are used in the evaluation of swallow?
Either VFFS (Videofluoroscopy) or FEES (Fiberopticendoscopy).
These are used to assess all the stages of swallow in detail including lip closure, propulsion of bolus, residue/bolus cohesion, timing and coordination of swallow, movement of oral and laryngeal structures, coordination of swallowing and breathing, signs of penetration and/or aspiration, severity of swallowing difficulties
You have been called to assess a patient with dysphagia, what clinical (5) and medical (4) indicators would lead you to believe the patient was in fact having dysphagia.
Clinical:
Coughing before/after swallowing
Drooling-especially during meals
Difficulty chewing
Gurgling wet voice during/after eating/drinking
Throat clearing during/after meal
Repeated episodes of choking
Medical/surgical:
Post-op Head and neck area
Radiation therapy to head and neck area
Tracheostomy
Unexplained weight loss
Frequent chest infections/pneumonia
Unexplained vomiting
Tracheostomy
General fatigue/deterioration
COPD
SOB
What are the 4 stages of swallowing?
1) Oral Preparatory Phase: Presentation of food on spoon/fork into mouth and chewing or mastication begins forming bolus
2) Oral Phase: food bolus is propelled backward by tongue
3) Pharyngeal phase: Food travels from back of tongue through pharynx to the esophagus
4) Oesophageal phase: Food travels down oesophagus to lower esophageal sphincter via peristalsis.
During assessment of swallow via Videofluoroscopy or fiberopticendoscopy, Penetration and aspiration are checked for to ensure they dont occur. What is meant by each?
Penetration: Food entering above level of vocal cords
Aspiration: Food enters airway/lungs below level of vocal cords
This is not referring to how the food gets there. It is referring to how deep into the airway the food reaches. Aspiration is what leads to infection directly and more quickly which is why its lower down, below the levels of the vocal cords
Give some implications of swallowing difficulties
Dehydration
malnutrition (same issues as malnutrition in dietetics)
increased risk of aspiration/chest infections/pneumonia
delayed/failed/complicated discharges
Increased need for follow-up and review
Increased costs
Deterioration in QoL
Mortality
The aim of dysphagia management is to eliminate or minimise food or fluid entering the lungs so as to prevent resp complications as well as to aid quality of life and promote independence. What management strategies are employed by SLT in the management of dysphagia?
SLT => not considering “treating the underlying cause”
Oromotor and swallow rehabilitation
Therapeutic trials
Compensatory strategies
What compensatory strategies are employed by SLT in the management of a patient with dysphagia
Utensils
Positioning (e.g. positioning of cup to prevent oral leakage)
Postures
Low-risk feeding strategies
LAST: Modifying food and fluid textures
What advice would you give a patient suffering from swallowing and speech difficulties as a result of facial palsy
!!!Eye care. Protect eye with lubricant as well as eye protection at night as they have trouble closing eyes
Advice:
Oral hygiene: Ensure that all food is cleared after meals with regular oral care and rinsing
Speech: Support weak cheek with hand to aid in speech and swallowing.
Massage BOTH sides of face to aid in recovery
Taste changes may be expected.
A patient presents with difficulty swallowing post-op thyroidectomy. She continues to lose considerable weight. You call for Speech and language therapy who tell you that on Bulbar assessment, it was found that the patient experiences pain throughout with restriction on opening the jaw. What is this sign?
Trismus
Define Trismus
Give common causes of Trismus
How would you screen for Trismus if suspected?
You have a patient with suspected trismus, what will you do?
Muscle spasm in the temporomandibular joint resulting in restricted/reduced opening of the jaw, typically with pain and most commonly associated to head and neck surgery or radiotherapy for head and neck cancer
Other causes: Injection on lower jaw, trauma to temporomandibular area/displacement, muscle stress due to prolonged opening
Screen: Patient unable to fit 3/4 fingers between top and bottom teeth
Next steps: Report, document, and refer to SLT. SLT inpatient and outpatient tx will be provided and range of motion exercises with Therabite will help. (no need to say all this, just the first part)
A patient is about to receive radiotherapy as part of her treatment for her Head and Neck cancer. You want to warn them about the possible side-effects and complications of this. From the point of view of ENT and SLT (without the immunocompromised bit), what will you inform them?
Reduced movement of muscles in the area
Solids may be hard to swallow, liquids easier
Xerostomia (dry mouth)
Odynophagia
Reduced sensation
Aspiration => Chest infections
Patients with dysphagia are always encouraged to continue with swallowing exercises and attempting to eat foods as much as possible rather than depending on feeding tube. Patients who both eat and exercise have the highest rate of return to a regular diet and shortest duration of feeding tube dependence. Why is this encouraged given the risk of aspiration, choking, and dental hygiene?
This is encouraged to prevent fibrosis and atrophy. Proper compensatory strategies as well as oral hygiene will prevent the majority of complications and the benefits of maintaining use of muscles of mastication far outweigh the risks here. Encourage patients to do this for as long as it is safe to do so (i.e. not if high choking risk)
SLT is responsible in laryngeal communication/voice restoration post-laryngectomy. It is involved in pre- and post-surgical support of the patient in both swallow and voice function. They select patients for Surgical Voice Restoration (SVR) and select appropriate voice prosthesis for patients. Low and high tech devices such as gestures, alphabet charts, and electric larynx have been used to aid these patients but should only be given to those who have failed the techniques. What are these techniques?
Electrolarynx technique: Battery-operated hand-held device that uses vibration of air in the oral cavity when held to neck/mouth to produce a mechanical voice quality. Requires a lot of training
Oesophageal speech: tongue press to inject air into esophagus which is then released to produce sound.
SVR - Surgical Voice Restoration
What is involved in SVR - Surgical voice restoration?
Surgical implantation of voice prosthesis allowing air to flow from trachea to esophagus. Tracheostoma valve or finger used for operation. This enables a patient to produce sound after laryngectomy/tracheostomy
Normal phonation (speech) occurs with air exhaled from lungs draw vocal cords creating a vibration sound. Sound is transmitted up to the mouth where it is articulated to shape words. Patients with a tracheostomy have a disruption to this process as well as suffer from xerostomia, dehydration and dysphagia. Trachrostomies can either be cuffed or uncuffed. How does each affect a patient’s voice?
Non-cuffed: Air tends to escape from the easiest exit => out of tube => reduced airflow over vocal cords => reduced voice
Cuffed: Cuff prevents air from passing up to vocal cords unless there is a fenestration (opening) => Complete aphonia with possible voice leakage if fenestration
A patient with a tracheostomy/laryngectomy is ready to commence weaning. State the stages of weaning
Stage A: Cuff Deflation - patient upright, oropharyngeal suction, synchronized suction and cuff deflation
!Trial Finger Occlusion - ensures deflation is tolerated
Stage B: Speaking Valve - placed on tracheostomy tube. This is skipped if faster weaning needed
Stage C: Decannulation Cap - placed on tube
Stage D: Decannulation
Throughout this process, vitals including HR, RR, sats are monitored of course.
