Swallowing disorders Flashcards
Swallowing as a complex act requiring:
o Integration of 6 cranial nerves (V, VII, IX, X, XI, XII)
o Synchronization of muscle patterns
o Domination of the respiratory system (stop breathing when swallowing)
o Invocation of the autonomic system
Swallowing = patterned response (not a traditional reflex)
o Large scale distributed swallowing neural networks
Swallowing as a series of pressure changes = 2-pump system
Oropharyngeal propulsive pump: • Lingual and velopharyngeal dynamics • Positive pressure Hypopharyngeal suction pump: • Hyolaryngeal excursion opens UES • Negative sub-atmospheric pressure
Oral Stage of Swallowing
Preparatory phase
• Saliva mixed with material
• Enzymes break down solid material
• Interaction of tongue, lips, jaw, teeth, facial muscles → bolus
Oral transport phase
• Bolus moves from front of oral cavity to oropharynx
• Propelled by lingual force
• Intrinsic tongue muscles = facilitate containment
• Extrinsic tongue muscles = facilitate bolus transport
Pharyngeal stage of swallowing
Velopharyngeal closure
• Velopharynx = junction including soft palate, lateral and posterior pharynx
• Prevents nasal regurgitation
Backward thrusting of tongue base to pharyngeal wall
• Creates pressure on bolus
• Drives bolus from valleculae to esophageal inlet at cricopharyngeal region
Elevation and forward movement of hyoid bone and larynx
• Assists with UES opening
Epiglottis moves downward
• Due to hyolaryngeal elevation and anterior movement, bolus pressure, tongue base retraction
• Epiglottis covers laryngeal vestibule
• Elevates the bolus laterally around airway = airway protection
Laryngeal closure
• From true vocal folds up to false vocal folds and laryngeal entrance at aryepiglottic folds and epiglottis
• Protects airway
UES relaxation and opening
• From upward and forward traction of hyo-laryngeal complex
• Permits passage of food through esophagus
Contractile wave downward = peristalsis
• Follows bolus
• Cleans up residue
Esophageal stage of swallowing
- Bolus moved from UES through LES into stomach
- Mostly by gravity and peristalsis
Sphincter opening:
• LES: remains open for duration of swallow (relaxes and remains open until peristalsis wave passes)
• UES: opens and closes with each swallow
Identify the health-related consequences of oropharyngeal dysphagia.
- Mortality
- Pneumonia (pulmonary complications) malnutrition
- Dehydration
- Decreased rehabilitation potential
- Decreased QOL
- Increased length of hospital stay
- Increased cost
At risk = all age groups (from 1 or more underlying disease or condition):
o Infants = premature, syndromes
o Children = cerebral palsy, head injury
o Adults = aging Baby Boomer
Symptoms of oropharyngeal dysphagia:
o Drooling o Residue in mouth o Difficulty chewing o Choking o Lump in throat sensation o Leaving food on plate o Changes in eating habits o Does not accept food o Weight loss
Symptoms of aspiration (entrance of material below level of true vocal folds)
o Coughing during or after meals o Throat clearing o Increased secretions o Wet/gurgly voice o Fever (infection starting) o Chest sounds o Reduced oral intake
Distinguish the specific disorders that disrupt oropharyngeal swallowing.
Neurogenic Stroke • 25-70% of stroke patients have dysphagia • 50% of these silently aspirate (from superior laryngeal nerve innervation, severely impaired cognition) • Relative risk for pneumonia post-stroke is 6.95x higher for aspirators • Pneumonia = 35% of post-stroke deaths Parkinson’s disease Tumors Head injury Oculopharyngeal dystrophy Muscular dystrophy Myasthenia Gravis Multiple Sclerosis Post-polio syndrome Progressive supranuclear palsy Amyotrophic Lateral Sclerosis
- Immunologic
- Iatrogenic
- Obstructive
- Psychiatric
- General deconditioning
Plan the optimal methods to diagnose and evaluate treatment of oropharyngeal dysphagia.
Screening = refer if have: o Diagnosis of new stroke, head and neck cancer, or TBI o Modified texture diet/eating maneuvers o Unable to follow commands o Wet/gurgly voice o Drooling while awake o Tongue deviation from midline
Diagnosis
Clinical evaluation of swallowing
• Cannot rule out aspiration
• Cannot determine why or where there is impeded bolus flow
Radiography (videofluoroscopy)
• Focuses on mouth, pharynx, larynx, and cervical esophagus
• Most frequently used technique
Allows for determination of:
• Underlying physiologic or anatomical factors
• Analysis of bolus flow
• Response to treatment
Fiberoptic Endoscopic Evaluation Protocol includes • Evaluate anatomy and function of nasopharynx, pharynx, and larynx • Assessment of secretion management • Sensitivity testing • Food administration • Biofeedback training
o Manometry
o Ultrasound
o Scintigraphy
Treatment of oropharyngeal dysphagia
Medical • Disease specific (e.g., levodopa) • Antacids • H2 blockers • Proton Pump Inhibitors (e.g., omeprazole, lansoprazole) • Promotility Agents (e.g., cisapride)
Surgical
• Correct glottal insufficiency
• Tube placement = bypass oropharyngeal dysphagia
Prosthetic devices for certain disorders
• Ex: velar insufficiency
Behavioral
Compensatory methods =Circumvents problem using indirect strategies to alter bolus flow
• Postural adjustments (chin tuck, head turn, head tilt)
• Maneuvers: Supraglottic, Super-supraglottic, Mendelsohn
• Diet modifications (ex: thicken liquids)
Eating strategies
• Eating slowly
• Alternating liquids and solids
Rehabilitative = Change swallowing physiology to restore function
• Exercise regimens
Identify team members who may participate as part of a dysphagia team.
- Need coordinated team due to inherent complexities of dysphagia
- Includes: neurologist, speech language pathologist, otolaryngologist, gastroenterologist, cardiothoracic surgeon
