Unit 2 Flashcards
1
Q
What is GERD?
A
excessive reflux of gastric contents into the esophagus
2
Q
What patients is GERD most common in?
A
Middle aged people who are overweight or in pregnant women
3
Q
If a patient has prolonged exposure to GERD, what can that lead to?
A
Mucosal inflammation and injury (esophagitis)
4
Q
In severe cases of esophagitis, what can happen to the esophagus?
A
Mucosal inflammation –> narrowing of the esophagus –> bolus getting stuck in the esophagus
5
Q
What is Barretts’ esophagus?
A
The epithelium changes and can become a pre-malignant condition
6
Q
What do patients complain of with GERD?
A
Heartburn
7
Q
What are 6 ways to treat GERD?
A
- Postural maneuvers
- chewing gum to
- medications
- dietary measures
- Dilation of stricture
- Surgery
8
Q
Who do postural maneuvers help GERD
A
Gravity can help or aggravate GERD- do not eat a large meal before laying bed
9
Q
How does chewing gum help GERD?
A
Increased saliva tends to neutralize the acidity in the stomach
10
Q
What occurs in surgery for Barretts’ syndrome?
A
Remove a portion of the esophagus
11
Q
What is achalasia?
A
A motility disorder of the esophagus, characterized by failure of the LES to relax and aperistalsis
12
Q
What are signs/symptoms of achalasia?
A
Food stuck in the esophagus, regurgitation, chest pain, aspiration pneumonia, weight loss
13
Q
How can aspiration pneumonia occur in patients with achalasia?
A
When they regurgitate, a portion of the regurgitated material can go into the airway and eventually result in pneumonia
14
Q
What two ways in achalasia treated?
A
- disrupt LES surgically and by dilation
2. botox injection to LES
15
Q
What is diffuse esophageal spasm?
A
intermittent chest pain and dysphagia for liquids and solids
16
Q
What is diffuse esophageal spasm often confused with?
A
coronary artery disease (CAD)
17
Q
What is a lax cricopharyngeus?
A
A UES that is not tight enough
18
Q
What can a lax criopharyngeus result in?
A
May result in regurgitation back through the UES into the pharynx which can spill into the airway
19
Q
If a lax cricopharyngeus results in aspiration, when does aspiration occur?
A
AFTER
20
Q
What is reduced esophageal peristalsis?
A
The reduced ability to squeeze the bolus through the esophagus
21
Q
What causes reduced esophageal peristalsis?
A
certain neurological disorders, surgery, or radiotherapy
22
Q
What is a diverticulum?
A
a pocket in the esophageal or pharyngeal musculature which collects portions of the bolus
23
Q
What happens when material does not empty from a diverticulum?
A
causes very bad breath
24
Q
How is a diverticulum treated?
A
Surgery
25
What are two etiologies of a partial or total esophageal obstruction?
stenosis or tumor
26
What is a tracheoesophageal fistula?
an abnormal passage from the esophagus to the trachea
27
What is an esophageal cutaneous fistula?
An abnormal passage from the wall of the esophagus to the external skin of the neck
28
When/how does a fistula occur?
tends to occur after surgery due to part of the suture line not healing properly
29
What is odynophagia?
pain with swallowing
30
What is another name for globus pharyngeus?
Globus hystericus
31
What is globus hystericus?
a transitory sensation of a lump in the throat that cannot be coughed up or swallowed
32
If a pt has a cortical stroke with left (dominant) hemisphere involvement, what 3 symptoms may be observed?
1. Contralateral reductions in labial, lingual, and mandibular strength, rate, range of motion, and sensation
2. Delayed pharyngeal swallow
3. contralateral reductions in pharyngeal constriction
33
If a patient has a cortical stroke with right (nondominant) hemisphere involvement, what additional symptom may occur?
reduced orientation, perceptual deficits, attention deficits, impulsivity, errors in judgement, and loss of intellectual control over swallowing
34
If right hemisphere is damaged what additional stage would be in deficit?
The anticipatory stage
35
Patients with a stroke w/ bilateral hemispheric are a higher risk for _______________.
silent aspiration
36
In addition to the symptoms of unilateral hemispheric stroke, what other symptoms would result from a bilateral stroke?
1. bilateral incomplete laryngeal elevation and closure
| 2. UES involvement
37
If the UES is insufficient, what could happen?
may lead to residue in the pyriform sinuses (bilaterally)
38
What is the key symptom that is characteristic of a brain stem stroke?
absent or delayed iniitation of the pharyngeal swallow
39
Which two neurological etiologies have a high risk of silent aspiration?
Brainstem stroke and bilateral hemispheric stroke
40
The symptoms of TBI are interaction between ________________, ________________, and ________________.
cognitive, behavioral, and linguistic impairments
41
Symptoms of TBI vary depending on what...?
location and extent of the head injury
42
What are other symptoms of a TBI?
reduced tongue control, prolonged oral transit, delayed or absent pharyngeal swallow, reduced pharyngeal contraction, laryngeal penetration
43
What could result from long term intubation of a pt w/ TBI?
tracheoesophageal fistula
44
What is myasthenia gravis?
An autoimmune disorder characterized by fatigue and exhaustion of the muscular system caused by impaired conduction at the myoneural junction
45
Explain chewing and swallowing characteristics of pts with myasthenia gravis
Chewing and swallowing deteriorate toward the end of the meal and toward the end of the day
Symptoms become more obvious on repeated swallowing attempts
46
What is postpolio syndrome?
Refers to symptoms experienced by survivors of the poliomyelitis infection
47
What a symptoms of postpolio syndrome?
Infection: symptoms usually begin several decades after recovery from the acute illness and may be progressive
48
How can an acquired immune deficiency syndrome compromise swallowing function (AIDS)?
1. local infection involving the mouth, pharynx, larynx, esophagus, and lungs
2. candidiasis
3. Odynophagia may be one of the first symptoms of an acute HIV infection
49
What is candidiasis?
(thrush)- a fungal infection that commonly causes odynophagia and dysphagia in patients w/ AIDS
50
How does dementia compromise swallowing function?
1. Cognitive deficits may compound the neruomuscular changes of normal aging and interfere with the spontaneous use of compensatory techniques
2. protracted or nonpurposeful bolus processing
51
What are possible symptoms related to dysphagia that are often present in patients with a spinal cord injury?
1. absent or delayed pharyngeal swallow
2. reduced pharyngeal contraction
3. reduced base of tongue elevation
4. reduced laryngeal elevation and/or closure
5. upper esophageal sphincter dysfunction
52
What are two types of MS?
1. fluctuating pattern of remission and exacerbation
| 2. gradual progression
53
What dysphagia symptoms are characteristic of patients with MS?
1. impaired ability to hold the bolus anteriorly and laterally
2. delayed initiation of the pharyngeal swallow
3. reduced pharyngeal contraction
4. reduced laryngeal adduction
54
Symptoms associated with parkinsonism
1. tongue tremor w/ reduced initiation of lingual movement
2. repetitive tongue-pumping action
3. lingual festination (posterior part of the tongue remains elevated, preventing passage of the bolus into the pharynx)
55
What is one symptom associated with ALS?
nasal regurgitation
56
In regards to oral, pharyngeal, and laryngeal cancer, what is usually the main etiology of dysphagia?
the TREATMENT of the cancer; not the actual cancer
57
Swallowing deficits in patients with cancer will depend on...?
1. the amount of ablative surgery
2. the degree of reconstructive surgery
3. the presence of scar tissue
4. the integrity of the remaining oropharyngeal and laryngeal structures
5. potential side effects of pre- and post- operative radiation
58
What are 5 side effects of radiation?
1. hardens tissue (muscle fibrosis)
2. reduces muscle movement
3. osteoradionecrosis (death of bone due to RT)
4. xerostomia & reduced saliva production
5. increases dental caries
6. decreases blood flow resulting in poor tissue healing
59
What are the two primary treatment modalities of head and neck cancer?
1. surgical resection
| 2. radiotherapy
60
What is the purpose of chemotherapy?
Chemotherapy is used as an adjunct therapy; used in combination w/ surgical resection and/or radiotherapy to control metastasis
61
Small tumors are treated with...
radiotherapy or surgery alone
62
Large tumors are treated with..
a combination of modalities
63
What is the general rule of surgical removal of tumors?
the malignant tumor must be resected along with a margin of at least 1.5-2cm of normal tissue
64
2 types of surgery
1. simple resection
| 2. composite resection
65
What is a simple resection?
one structure is involved in the surgery
66
What is a composite resection?
More than one structure is involved
67
What is the MAJOR rule of cancer surgery?
no ablative surgical procedure should be compromised because of the desire to maintain the patient's function
68
How are tumors staged?
SIZE and LOCATION
69
What are the 3 components of tumor staging?
tumor size, nodal status, and presence of absence of metastisis
70
What are reasons for tumor staging?
understanding the location and size, planning treatments, what combination of treatments is appropriate, prognosis and recovery
71
How is tumor size measured?
T: 1-4
1= smallest lesion
4= largest lesion
72
How is nodal status measured?
N followed by a number representing the # of nodes involved
73
How is metastisis measured?
M is assigned 0-1 if there is or is not presence of metastisis
74
What are the two main types of reconstruction in cancer surgery?
1. Primary closure
| 2. Flaps
75
What is primary closure?
The remaining soft tissues are pulled together and sutured
Sometimes, primary closure is not achievable if there is not enough soft tissue left
76
What is a flap?
Surgeon takes tissue from another area and puts it in the defect area
77
What are the two types of flaps?
1. Local
| 2. Distant
78
What is a local flap?
tissue is taken from an adjacent area
79
What is a distant flap?
tissue is taken from another area to close the gap
80
What are 6 general principles of swallowing therapy with treated ORAL cancer patients?
1. couseling
2. swallowing therapy including oral motor exercises when the surgeon indicates that there is no danger to suture lines
3. aggressive program of tongue and jaw ROM exercises
4. swallowing tx is begun when pt. is still in the hospital with ng tube
5. therapy continues until the pt.'s swallowing has reached a point where the therapist and pt. agree that maximum goals have been attained.
6. consistent support of nursing and physician involvement is important
81
After the oral cancer surgery, what part of therapy must be stopped immediately?
ROM exercises for about 10-14 days in order for the sutures to heal
82
For small tumors in the larynx, what is the frequent treatment of choice?
radiotherapy
83
What are the 3 areas of the larynx?
Supraglottis
Glottis
Subglottis
84
What is the most frequent area of the larynx for cancer?
glottis (65%)
85
What is the rarest laryngeal cancer location?
subglottis (5%)
86
What is the % of supraglottic tumor occurrence?
35% (2nd most common)
87
What are the 2 types of laryngeal surgeries?
1. Total laryngectomy
| 2. Partial laryngectomy
88
What are the 4 types of partial laryngectomies?
1. laryngofissue
2. Hemilaryngectomy (vertical)
3. Supraglottic laryngectomy (horizontal)
4. Partial laryngopharyngectomy
89
What is removed in a total laryngectomy?
hyoid, epiglottis, larynx, upper 2 tracheal rings, strap muscles
90
What happens to the trachea in a total laryngectomy?
It has to be shunted out in order for the patient to breathe
91
Where is the lower pharynx attached?
upper esophagus
92
Are patients with a total laryngectomy at risk for aspiration?
NOPE
93
What may be one swallowing related side effect of a total laryngectomy?
Stenosis of the pharynx
94
What is a laryngofissure?
They surgeon opens the larynx from the front with cordectomy
95
What is removed in a laryngogissue?
One of both true vocal folds and false folds
96
What are advantages of a laryngofissue?
1. can breathe through the mouth
2. laryngeal elevation in tact
3. epiglottis is not removed and will still invert
97
What problems may be associated with laryngofissue?
1. Could result in aspiration DURING the swallow due to reduced laryngeal closure
2. breathy voice
98
What is removed in a hemilaryngectomy?
The thyroid is cut vertically: true VF, false VF, and arytenoid on the same side are removed
Thyroid is sutured back together
99
What is a problem associated with a hemilaryngectomy?
A lack of VF closure, risk of aspiration during the swallow, abnormal voice
100
What kind of compensatory strategy/therapy will often help patients after a hemilaryngectomy?
Postural adjustments: tilt head to one side so gravity keeps the food in the noncompromised channel
101
What is removed in a supraglottic laryngectomy?
epiglottis, hyoid, pre-epiglottic space, false folds, upper half of the thyroid
102
Which part of the larynx is spared in a supraglottic laryngectomy?
True VF
103
How does a patient achieve closure of the true VF during swallow?
holds their breath before swallow
104
What would be a major anatomical/physiological problem after a supraglottic laryngectomy?
Poor laryngeal elevation because attachments from the tongue to the hyoid are removed
105
If there is poor laryngeal elevation post supraglottic laryngectomy, what problems may occur?
UES may not open --> residue in pyriform sinuses
106
Are patients at risk for aspiration post supraglottic laryngectomy?
YES- the epiglottis is removed and cannot divert food into the lateral channels
107
What is a partial laryngopharyngectomy?
The same as supraglottic laryngectomy except portions of the pharynx are also removed
108
What are 6 general guidelines for swallowing therapy with treated LARYNGEAL cancer patients
1. counsel the pt. preoperatively to inform them about changes to voice and swallowing.
2. Therapy is behavioral; therefore, the patient needs to participate and be cooperative
3. Exercise programs begins after the sutures have healed; the programs are necessary until there is no sign of aspiration
4. patients should be seen daily as in-patients and weekly as out-patients
5. ROM exercises for the tongue base and larynx should begin before radiotherapy starts and continue 5-10 times daily for 10 minutes each time and for a period of months afterward
6. consistent support of all disciplines involved with the patient is important
109
What is a tracheotomy?
The surgical procedure of creating a stoma to breathe through
110
What is a tracheostomy?
a hole left behind in the trachea by the surgical procedure
111
Where is the tracheostomy tube inserted?
Below the larynx into the trachea
112
What are two indications for a tracheotomy?
1. airway obstruction
| 2. Prolonged ventilatory support due to underlying pulmonary or CNS disease
113
What are 3 categories of airway obstructions?
1. acute
2. Chronic
3. Both (acute and chronic)
114
What are 2 acute etiologies that necessitate a tracheotomy?
1. Infectious process or allergic reaction
| 2. upper respiratory infection
115
What chronic conditions lead to a tracheotomy?
1. presence of a mass
2. sleep apnea
3. hypertrophy of tonsils
116
What is a combination condition that lead to a tracheotomy?
vocal cord paralysis secondary to bilateral recurrent laryngeal nerve injury
117
VF paralysis refers to what the VF...
CANNOT do
E.g., bilateral AB-duction- the VF will not open
118
What are three conditions that result in prolonged ventilatory support?
1. COPD
2. Guillion Barre' syndrome
3. ALS
119
What are advantages of tracheostomy?
1. eliminates prolonged orotracheal intubation
2. facilitates pulmonary toliet when pt. is unable to clear secretions
3. Decreases possibility of subglottic stenosis that results from prolonged orotracheal intubation
4. More permanent solution
120
What is a disadvantage of a tracheostomy?
The trachea tends to stenos or narrow around the tube
121
What are possible effects of tracheostomy tubes on swallowing?
1. May inhibit laryngeal elevation --> reduced UES opening
2. may desensitize the larynx due to the presence of the trach tube which could result in an inhibition of the cough reflex
3. External compression of the esophagus by the trach tube cuff enables secretions to pool above the cuff level in the esophagus and then spill into the airway
4. may result in discoordination and "disuse atrophy" of the swallowing musculature
5. Creates a functional separation of degultition and respiration which may result in discoordination of glottic closure during swallowing
