Test 3 - dysphagia Flashcards
What defines dysphagia?
problems with the oral cavity, pharynx, esophagus or gastroesophageal junction
12 Cranial nn
I. Olfactory - S - smell
II. Optic - S - vision
III. Occulomotor - M - Eye Mm
IV. Trochlear - M - superior oblique
V. Trigeminal - B - Sensory in Face, Mm to chew
VI. Abducens - M - Lateral eye Mm
VII. Facial - B - facial expression, lacrimal and salivary glands
VIII. Vestibulococchlear - S - balance and equilibrium
IX. Glossopharyngeal – B – pharynx for swallowing, posterior third of tongue, parotid salivary glands
X. Vagus – B – sensation from organs, parasympathetic motor regulation of visceral organs
XI. Accessory – B – M that move head, neck and shoulders
XII. Hypoglossal – B – Mm of the tongue
Oral Phase
what happens?
Mm needed?
take in chew, tongue moves bolus, get to stage 2
Lips, mentalis, cheeks, tongue, mandible, Suprahyoid/infrahyoid,
Anterior to posterior contact of midline of tonge withpalate propels bolus backward to pharynx; tongue tipa nd lateral margins maintain contact with anterior and lateral alveolar ridge, sealing bolus on midline of tongue
pharyngeal phase
constriction to propel bolus Stylopharygeus Salpingopharyngeus Palatopharyngeus thyropharyngeus and cricopharyngeus
Valve function and pressure generation VP Closure Laryngeal elvaiton and anterior movement Base of Tongue moave backward to pharyngeal wall Pharyngeal elevation Laryngeal closure CP or UES opening
Esophageal Stage
pharynx through esophageal hiatus of the diaphragm.
Upper 1/3 of esophaguas is striated muscle while lower 2/3 is smooth muscle
carry material to stomach
Peristalic wave pushes bolus ahead of it and continues in sequential manner : 8-20 seconds
Diagnosis typically associated with dysphagia?1
Stroke
Brain Injury
Brain Tumor
Neurological Progressive Diseases: Multiple Sclerosis Parkinson’s Disease Alzheimer’s Disease Myasthenia Gravis ALS
Video swallowing vs . FEES
Video Swallow
-Gold Standard
-Completed in Radiology or
Mobile Unit with Barium
-Pt complaints of oral stage preparation problems; suspicion of aspiration or larynx penetration; complaints of food sticking in throat.
FEES
- Completed at the bedside, clinic or mobile unit
- nose endoscopic
- Does not address oral & esophageal stages
- Pt complaints of choking on food; suspicion of aspiration/larynx penetration
Dysphagia Treatment ideas?
diet modification
exercises
Chin-down posture: Chin is tucked down toward the neck during the swallow, which may bring the tongue base closer to the posterior pharyngeal wall, narrow the opening to the airway, and widen the vallecular space.
Chin-up posture:Chin is tilted up, which may facilitate movement of the bolus from the oral cavity.
Head rotation (turn to the side):Head is turned to either the left or the right side, typically toward the damaged or weak side (although the opposite side may be attempted if there is limited success with the first side) to direct the bolus to the stronger of the lateral channels of the pharynx.
Head tilt: Head is tilted toward the strong side to keep the food on the chewing surface.
sensory stimulation
Dysphagia maneuvers
Describe effortful swallowing - maneuver
Purpose:
increase posterior tongue base movement to facilitate bolus clearance
Directions:
“Swallow and push hard with the tongue against the hard palate” (Huckabee & Steele, 2006).
Describe Mendelsohn maneuver
Mendelsohn maneuver
Purpose:
elevate the larynx and open the esophagus (prolong the width/duration of CP opening) during the swallow to prevent food/liquid from falling into the airway
Directions:
“When you swallow feel your larynx (voice box) move up in your throat. Swallow again and try to keep your voice box up. So hold it up with your muscles for several seconds.”
Describe supraglottic maneuver
Supraglottic swallow
Purpose:
designed to close the vocal folds by voluntarily holding one’s breath before and during swallow in order to protect the airway
Directions:
“Hold your breath. Swallow. And then cough”
Describe - Super-supraglottic swallow maneuver
Super-supraglottic swallow
The super-supraglottic swallow is similar to the supraglottic swallow; however, it involves increased effort during the breath hold before the swallow, which facilitates glottal closure (Donzelli & Brady, 2004).
Purpose:
designed to voluntarily move the arytenoids anteriorly, closing the entrance to the laryngeal vestibule before and during the swallow
Directions:
“Hold your breath very tightly, bearing down. Swallow . Cough.
Define eating
The ability to keep and manipulate food or fluid in the mouth and swallow it
Define feeding
The process of setting up, arranging, and bringing food (or fluid) to the mouth
Depict the stages of normal swallowing
Pre-oral Phase - Moves food or liquid to the mouth.
Oral Preparatory Phase - The oral structures form the bolus by tasting, chewing, manipulation and containment
Oral Phase - Begins when the bolus is in the mouth and ends when the bolus enters the pharynx
Pharyngeal Phase - Begins when the bolus enters the pharynx and ends when the bolus enters the esophagus
Esophageal Phase - Begins when the bolus enters the esophagus and ends when the bolus enters the stomach
Oral prepatory
Interventions
Action
Purpose
Muscles
Cranial Nerves
Lip Closure
Retain bolus in mouth
Orbicularis oris
VII
Cheek
Retain bolus on teeth surfaces and centrally in mouth
Buccinators
VII
Jaw Closure Elevation, closure of mandible and mouth, chewing Temporalis Masseter Lateral pterygoid V V V
Jaw Opening
Open mouth and jaw, chewing
Lateral pterygoid
V
Bolus reception and manipulation
Pull tongue forward, backward, up and down
Extrinsic tongue muscles, genioglossus, hypoglossus, chondroglossus, styloglossus
XII
Bolus manipulation
Change the shape of the tongue during bolus manipulation
Intrinsic tongue muscles; vertical transverse, superior longitudinal, inferior longitudinal
XII
Interventions
Provide cheek and jaw support to facilitate movement for efficiency with breakdown of food
To address weakness of lips and cheeks, and decreased ROM with mouth structures, use tapping, vibration, quick stretch or slow stretch, resistive sucking and blowing exercises
Remember to postural stability- supporting trunk and pelvis before starting feeding
Oral Phase
Interventions
Tongue holds bolus against hard palate
Holds bolus in place before initiating the swallow
Intrinsic and extrinsic tongue muscles
XII
Bolus is propelled posteriorly Moves bolus into pharynx Extrinsic tongue muscles; digastric, mylohyoid, geniohyoid V V XII
Use cold or sour bolus for clients with slow oral transit times
Try thermal stim (cold) to encourage swallow
Utilize positional changes for swallowing such as chin tuck or turning head toward weaker side
Consider swallowing techniques (effortful swallow)
Pharyngeal Phase
cessation of breathing
Hyoid bone elevates and moves anteriorly Elevates larynx, opens upper esophageal sphincter Digastric Mylohyoid geniohyoid Hypoglossus V V XII XII
Posterior tongue elevates
Closes opening between oral cavity and pharynx
Palatoglossus
X
Velum (soft palate) elevates Prevents food material from entering nasopharynx Palatopharyngeus Levator velum palatinum X, XI X, XI
Vocal folds close Keeps food from entering trachea and airway True vocal folds False vocal folds X, recurrent branch Pharynx elevates and shortens Propels bolus through phaynx Palatopharyngeus Stylopharyngeus X, XI IX
UES relaxes as bolus passes through Allows food to pass into body of esophagus Superior constrictor Middle constrictor Inferior constrictor X, XI X X, XI
Esophageal phase
Action Purpose Muscles Cranial Nerves Sequential contraction of esophageal muscle Propels bolus through esophagus Upper 1/3 of esophagus; striated muscles Lower 1/3: smooth muscle Nucleus ambiguus, X Dorsal motor nucleus of X
LES relaxes Allows food to pass into stomach LES Spinal afferents: X Efferents: X
