Swallowing Flashcards
Swallowing service delivery by an SLP must include, at minimum:
- Determination of pt’s readiness for assessment (chart review)
- Clinical (non-instrumental) ax
- Management (discussion/education)
Valleculae
2 symmetrical pockets btwn base of tongue and epiglottis
Cricopharyngeal muscle
Upper Esophageal Sphincter
Pyriform sinuses
Posterior-lateral to the laryngeal opening
What muscle would be especially important if a pt were trying to swallow a large bolus?
Stylopharyngeus (dilates the pharynx)
Sign of difficulty with tongue base retraction
Residue in the valleculae
Sign of difficulty with pharyngeal propulsion
Residue in the pyriform sinus + above the upper esophageal sphincter
Sign of difficulty with the opening of UES
Residue above UES
Signs of difficulty with laryngeal function
- Absence of laryngeal elevation (decreased UES opening; penetration or aspiration)
- Delay in laryngeal elevation (penetration or aspiration)
- Reduced laryngeal sensation (weak or absent cough)
Tongue pumping - what is it and what is it often a sign of?
Rocking back and forth of tongue during oral phase attempting to propel bolus; involuntary; often associated w/ PD
What is laryngeal penetration?
Part of the bolus passes the epiglottis but stays above the vocal folds
What nerve is responsible for airway protection during swallow?
Superior Laryngeal Nerve (branch of the Vagus X)
Sign at bedside of penetration before swallow
No laryngeal movement
Sign at bedside of penetration after swallow
Delay of about 60 seconds but less than 2 minutes before coughing
A swallow screening can be carried out by ___
Nurse, OT, dietician
One of the following activities should be included in a swallow screening
- ID of risk for dysphagia thru medical chart review
- Recognition of overt signs of swallowing difficulty (e.g. coughing, choking)
- Confirmation of specific clinical observations that are risk factors for dysphagia during physical exam (e.g. reduced level of consciousness, drooling, effortful chewing, pt complains of pain/obstruction, voice change after liquids)
How to measure integrity of MOTOR component of cranial nerve V?
Ask them to resist opening/closing of mouth; side-to-side; clench
How to measure integrity of SENSORY component of cranial nerve V?
Brushing left/right of face, feels same or diff? Which side am I touching?
How to measure MOTOR integrity of CN VII?
Make a seal w/ lips and don’t let me touch teeth
Blow whistle/smile/puff cheeks
How to measure SENSORY integrity of CN VII?
When does an SLP have to get a MD’s interpretation of a VFSS?
- Anatomical anomalies
- Esophageal anomalies (even eventual)
When can an SLP conduct a FEES legally?
In collaboration with an MD or if the act has been delegated to them by MD.
Pros of FEES
- No radiation exposure
- Direct view of laryngeal and pharyngeal structures during swallow (vocal fold mobility + airway protection; VP insufficiency)
- Bedside in typical feeding position
- Secretion management
- Visual biofeedback to pt
Cons of FEES
- Uncomfortable
- Can’t view oral/esophageal phase
- Limited view of pharyngeal phase bc of white out (before and after comparison)
- Fast successive swallows in infants can be difficult to view
- Specialized training needed
- Not good for viewing aspiration, can only suspect it
T/F: You can evaluate a pt who is intubated
False
3 most common causes of solid food dysphagia
- Gastro-esophageal reflux
- Radiation tx
- Dysfunction of cricopharyngeus muscle
Mechanical/structural etiologies of dysphagia
- Head and neck cancer
- Cervical spine osteophyte (spurs/growths)
- Cricopharyngeal bar
- (Zenker’s) diverticulum
Cricopharyngeal bar
Appears btwn C3-C6 (someone else needs to confirm)
Thickened muscle from fibrous connective tissue
Often caused by reflux
Causes increased pressure in the pharynx, narrowed opening to the esophagus
Zenker’s diverticulum
The CP muscle is too strong; pressure build along the pharyngeal wall; the weak point of the throat above caves in
Bc the sphincter is tighter than normal, food enters the diverticulum and causes regurgitation
Difficulty swallowing
Food feeling stuck
Bad breath
Regurgitation
Weight loss
Choking/coughing
Commmon dysphagia symptoms post-stroke
- Longer oral + pharyngeal transit time
- Delayed or absent pharyngeal swallow (holding bolus in mouth bc can’t trigger swallow)
- Weakness = multiple swallows
T/F: Feeding tube is NOT helpful for ppl with dementia
True
Alternative - careful hand feeding (comfort - risk of choking/aspiration)
Why does radiation worsen dysphagia?
Xerostomia
Fibrous soft tissue
Cuff inflated –> air goes ___
Directly out the stoma
**can cause increased pressure on esophagus and make it harder to swallow
Common effects post-extubation (7)
- Trauma to muscles (tube irritating)
- Dysphagia
- Stenosis (narrowing of trachea)
- Disuse atrophy (relearning how to swallow)
- Mucosal inflammation
- Temporary VF paralysis (hoarse)
- Reduced laryngeal sensation
Compensatory strategy for premature spillage into pharynx –> delayed initiation of swallow
Chin tuck
- Keeps bolus contained within oral cavity until ready to swallow
- Protects airway by narrowing opening (more likely to go into esophagus)
Compensatory strategy for penetration/aspiration before swallow (bolus spilling into pharynx) / reduced tongue base retraction
Chin tuck
- Increases contact btwn tongue base and PPW
- Protects airway (narrowed opening)
- Keeps bolus contained within oral cavity
When would we use the chin up/head tilt back strategy?
- If we know they have good airway protection and just oral dysphagia only
- Difficulty propelling the bolus during oral transport
- Facilitates posterior propulsion but often used incorrectly by pts – usually reserved for pretty extreme oral phase impairment
When we use head turn towards weaker side?
- Unilateral VF abduction
- Unilateral pharyngeal weakness/residue accumulation
Turn toward impaired side approximates VFs.
Forces gravity to direct toward stronger side.
Describe the supraglottic swallow maneuver and why we would use it
- Breathe in through nose, hold breath, swallow while breath hold, cough, then swallow again
Promotes laryngeal valving prior to swallow; faster closure of VFs during swallow
Prolongs the pharyngeal swallow so the bolus has more time w/ the VFs closed to clear into esophagus
Describe the Mendelsohn maneuver and why we would use it
Swallow normally and feel Adam’s apple move. Swallow again, once at max height, squeeze muscles and hold for 3 seconds before releasing.
- Targets the elevation of larynx for a prolonged period
- Used for pts with a slowed transfer of bolus through pharynx (UES closes before bolus completely transfers) or incomplete UES opening
Describe the effortful swallow and why we would use it
Tongue against roof of mouth and swallow hard (exaggerate movement)
- To increase tongue base retraction
- To increase pharyngeal driving pressure
IDDSI levels
7 - regular
7 Easy to Chew
6 - soft and bite sized
5 - minced and moist
4 - puree - extremely thick
3 - liquidized - moderately thick
2 - mildly thick
1 - slightly thick
0 - thin
Requirements for swallow maneuvers
- Active participation
- Good movement control
- Proprioceptive sense
- Ability to learn
Environmental Modifications for dysphagia management
- Reduce distractions so they don’t forget about the food in their mouth
- Increase cues to help pt awareness (e.g. coloured paper under plate)
- Rate limiting cup or straw
Masako maneuver and why we would use it
Protrude tongue between teeth and swallow saliva while biting down.
- Improves pharyngeal weakness by strengthening contact with base of tongue; PPW bulges forward to meet it
Shaker maneuver and why we would use it
Lying on the back, elevating head to see one’s toes without moving shoulders
- Increases UES opening and helps with anterior excursion of larynx
When would we recommend EMST?
Any patients with weakened cough (e.g. PD, ALS)
More powerful cough to clear aspirated material and improve VF adduction
Is pharyngeal residue ever normal?
No, healthy person swallows a bolus as a whole unit in a single swallow with no residue
Pharyngeal residue may reflect:
- A bolus that is especially thick or sticky
- Poor tongue strength for propulsion
- Poor pharyngeal constriction behind the bolus (**strongest link)
- Problems with diameter or duration of UES opening
Patient’s facial nerve VII is damaged. How will this affect their swallow?
- Dry mouth - less saliva
- Poor lip seal
- No taste in front 2/3 of tongue
Patient’s glossopharyngeal nerve IX is damaged. How will this affect their swallow?
- Inability to trigger pharyngeal phase
- Diminished or absent cough reflex / gag
- Reduced pharyngeal dilation
- Reduced laryngeal elevation
Patient’s vagus nerve X is damaged. How will this affect their swallow?
Overall difficulty with oral and pharyngeal phase bc innervates soft palate, base of tongue, pharynx.
- Nasal regurgitation
- Reduced or absent gag reflex
- Insufficient laryngeal closure
- Opening of UES segment (so food flowing through before ready?)
Patient’s hypoglossal nerve XII is damaged. How will this affect their swallow?
Inability to coordinate mvmt of tongue in oral phase; result in pocketing
Insufficient pressure generation to propel bolus
