Dysphagia Flashcards
Discuss the steps in dysphagia Assessment
- Screening may be involved first to determine if Ax is necessary. Can be done by other healthcare professionals (CDA, nurse, nursing assistant, etc.). If concern is raised during screening, then move on to Assessment.
- Assessment should involve both sensory and motor functions.
Ax option #1: Bedside swallow with cranial nerve examination (should involve CNs V, VII, IX, X XI and XII). Patient questionnaires should be also done.
Ax option #2: Instrumental assessment provides more objective information regarding how sensory function may be impacting swallowing.
- Modified Barium Swallow Study (MBSS)/ Videofluoroscopic Swallow Study (VFSS)
- Fiberoptic Endoscopic Evaluation of Swallowing (FEES):
What is the largest need for instrumental examination for dysphagia?
To view function that cannot be viewed (or perceived well) clinically, and we need to assess function to determine if there are deficits. Most clinicians find anatomical changes by surprise. That is, they are not suspected at the bedside in most cases.
A major clinical indication for either VFSS and FEES, therefore, is silent aspiration. Another is to determine changes in timing, coordination, and weakness in the pharynx that leads to penetration, aspiration, and residue
3 major clinical indications to recommend VFSS/MBSS
- Specific concerns for esophageal problems
- Specific concerns for oral problems
- Assess for specific oral, pharyngeal, and esophageal anatomical changes contributing to dysphagia (e.g., Zenker’s diverticulum, fistula).
5 major clinical indications to recommend FEES
1.Assess secretion management, integrity of the larynx, and surrounding structures
2.Need to assess fatigue or textures not viewable on VFSS
3.Assess for specific laryngeal and pharyngeal anatomical and sensory deficits contributing to dysphagia (e.g., paralysis, presence/absence of sensation)
4.Concurrent voice changes/dysphonia.
5.Pre- and/or post-op head and neck surgeries
Advantages of VFSS and FEES
VFSS
Pros:
- Radiation exposure is considered minimal
- VFSS can be used to assess kinematics of swallowing
- Residue can be measured using special software
FEES
Pros:
- Can do bedside assessments as it is portable
- If equipment (ex. halo brace) is used by patient, FEES is beneficial as it would not obstruct view of study.
- Laryngeal function can be observed
- Has higher sensitivity to penetration and aspiration
Describe the supraglottic and super supraglottic swallow. What are these techniques used for? What’s the difference between the two?
The goal of the techniques is to:
1.Combine components of a breath hold for vocal fold adduction
2. A cough to eject any material that enters the airway 3. A repeat swallow to clear any remaining residue.
Both techniques have been shown to be beneficial for a variety of populations as both a therapeutic technique to facilitate better airway protection motor patterns as well as to serve as a compensatory strategy for an impaired swallow.
Supraglottic:
1. Take a deep breath and hold it. 2. Take a bite or a sip into your mouth. 3. Swallow while stillholding your breath. 4. Cough immediately after the swallow. 5. Swallow again. 6. Exhale and relax.
Super supraglottic:
1. Take a deep breath and hold it. 2. Take a bite or a sip into your mouth. 3. Bear down with your arms on the surface beneath you or pull up against the bottom of the seat to create tension in your body. 4. Swallow while still holding your breath and bearing down. 5. Cough immediately after the swallow. 6. Swallow again. 7. Exhale and relax
Holding your breath results in vocal fold adduction to prevent material from passing below the vocal folds. For patients with poor airway closure, the Super Supraglottic swallow may help to better achieve that by the addition of the arytenoid head approximation to the epiglottis and adduction of the false/ventricular folds Volitional coughing or clearing your throat helps clear any residue in the larynx or entrance to the airway. Then, the second swallow helps to clear any remaining residue. Both techniques have been shown to increase tongue vs. hard palate pressures
What should be present to recommend a supraglottic swallow?
- Decreased laryngeal vestibule closure leading to penetration or aspiration (impairment)
- Residue in the pyriform sinuses that spills into the larynx post-swallow (post-cricoid spillage) (impairment)
- Poor superior movement of the arytenoid heads towards the epiglottis during laryngeal vestibule closure (impairment)
- Effective volitional cough with ejecting penetrated or aspirated materials (strength)
Describe the effortful swallow.
Steps:
- Close your mouth and lips (optional: and press your tongue against the roof of your mouth). Swallow as hard as you can, like you are trying to swallow a large pill to help you squeeze your tongue and throat muscles tighter.
- Squeeze really tightly. Repeat 5-10 times.
Patients may have xerostomia (dry mouth) during this. If safe, they can take breaks with water.
Research has indicated that completion of effortful swallows can improve: tongue to palate contact, increased base of tongue (BOT) retraction and contact with the posterior pharyngeal wall (PPW), hyolaryngeal elevation and excursion vocal fold closure, pharyngeal constriction, and opening of the upper esophageal sphincter (UES)
This leads to increased pressures to propel the bolus down through the pharynx and into the esophagus more efficiently
What should be present to recommend an effortful swallow?
- Post-swallow residue along the tongue, hard palate, or base of tongue
- Decreased contact of the base of tongue and posterior pharyngeal wall
- Decreased pharyngeal stripping wave/constriction (AP and/or lateral)
- Decreased hyolaryngeal elevation - Decreased hyolarygeal excursion and decreased UES opening - Decreased epiglottic inversion
- Residue in the vallecula, along the posterior pharyngeal wall and/or in the pyriform sinuses
- Decreased laryngeal vestibule closure
Residue along the base of tongue Residue in the vallecula, along the posterior pharyngeal wall and/or in the pyriform sinuses Decreased laryngeal vestibule closure Decreased pharyngeal constriction
Describe the steps of the mendelsohn maneuveur and what its purpose is.
Steps:
- Find your Adam’s apple with your finger.
- Swallow and feel it lift up as you swallow.
- Swallow again, but try to hold the swallow and hold your breath while keeping your Adam’s apple up during the swallow. Hold this for 2 seconds.
- Release and breathe.
- Repeat this 5-10 times for 3-5 total sets. Allow 1 minute between sets for rest.
Completing the Mendelsohn exercise can improve hyolaryngeal elevation, airway closure, and UES opening
What should you see in an exam to recommend the Mendelsohn maneuver?
- Decreased hyolaryngeal elevation
- Incomplete/decreased epiglottic inversion
- Decreased laryngeal vestibule closure
- Poor UES opening and pyriform sinus residue post-swallow
On FEES:
- Incomplete/decreased epiglottic inversion
- Residue in the pyriform sinuses post-swallow
Describe the chin tuck against resistance (CTAR) and what its purpose is.
Tucking chin while swallowing. Some use a ball under the chin as means of resistance.
This exercise can strengthen the muscle group called the suprahyoids/submentals and improves hyolaryngeal elevation and excursion
When targeting hyolaryngeal elevation, what are you looking to improve?
It can lead to overall improved airway protection, because the entrance to the laryngeal vestibule/upper airway is further out of the way of the bolus flow as it elevates during the swallow.
It can also lead to increased opening of the upper esophageal sphincter (UES) in extent and duration of the opening which can lead to overall reduction of residue in the pyriform sinuses.
What would you see in an exam to recommend the chin tuck against resistance (CTAR)?
On an MBSS/VFSS, if you identify:
- Decreased anterior movement of the hyoid bone
- Post-swallow residue in the pyriform sinuses
- Esophageal retention (food getting stuck) in the upper esophageal segment or just below it.
On FEES, if you identify: - Residue in the pyriform sinuses
At bedside, patients may complain of food getting stuck or feeling residue at the bottom of their throat.
Describe the tongue press exercise and what its purpose is.
The tongue press exercise incorporates strengthening components of isometric squeeze without removing the tongue from its natural environment during swallowing (the oral cavity) and without need for external planes on which to apply resistance, such as a tongue depressor.
Steps:
- Relax your mouth and jaw so that your teeth touch each other lightly.
- Anterior tongue-press : Find the bump or ridge just behind your teeth, in front of the roof of your mouth.
- Press against the ridge with your tongue firmly and hold it for 10 seconds. You will feel the muscles under your jaw tighten. Repeat this exercise 5-10 times.
- Posterior tongue-press: Find the edge of the hard palate, near where it meets the soft palate.
- Press against the palate with the back part or your tongue firmly and hold it for 10 seconds.
- You will feel the muscles under your jaw tighten. Repeat this exercise 5-10 times.
