Adult Swallowing Flashcards
Signs and Symptoms of Dysphagia
Dysphagia is a difficulty or disorder with swallowing
It can be a combination of:
* Oral stage
* Pharyngeal stage
* Oesophageal stage
Characteristics of oral phase dysphagia
Can include elements related to changes in sensory/motor structure and function
Eg:
- Anterior spillage/drooling
- Reduced mastication
- Reduced anterior/posterior propulsion/transfer
- Oral residue
- Poor oral control (ie when moving bolus around mouth)
- Pain during oral preparation
Characteristics of pharyngeal phase dysphagia
Can include elements related to changes in sensory/motor structure and function
Eg:
- Delayed swallow onset (delayed reflex)
- Reduced or incomplete hyolaryngeal excursion
- Incomplete laryngeal vestibule closure
- Decreased pharyngeal contraction
- Pharyngeal residue
- Food sticking in pharynx
- Throat clearing and/or coughing during/after oral intake
- Laryngeal penetration
- Aspiration
- Decreased oxygen saturation (SpO2)
- Increased respiratory rate (RR) - tachypnoea
- Globus (feeling of something in your throat)
- Odynophagia = pain on swallowing
Causes of dysphagia
Dysphagia is the result of underlying medical disease/process. These can be categorised as:
* Neurological disorders
* Head and neck disorders
* OesophageaL disorders
* Respiratory disorders
* Iatrogrenic disorders
How do changes in swallow events result in dysphagia? Oral and Pharyngeal
Oral Phase: This phase involves manipulating food or liquid in the mouth and forming it into a bolus (a cohesive mass) ready for swallowing. Issues like poor tongue control, weak chewing muscles, or impaired coordination can lead to difficulty forming a bolus, making it hard to initiate the swallowing process.
**Pharyngeal Phase: **During this phase, the bolus is propelled through the pharynx and into the esophagus. Problems here can include difficulties in initiating the swallowing reflex, improper closure of the airway to prevent food or liquid from entering the lungs (aspiration), or weak pharyngeal muscles that affect the movement of the bolus.
Key safety and efficiency factors to determine an appropriate diet
- Avoid Aspiration Pneumonia
- Aspiration can lead to aspiration pneumonia
- Aspiration pneumonia = aspiration of swallowed materials from the pharynx that results in a lung infection (Groher & Crary)
- Prevalent in Nursing home residents
- Dysphagia is a risk factor however multifactorial - Langmore et al. 1998
- Dependence on feeding * (19.98 OR)
- Number of decayed teeth
- Tube feeding
- More than one medical diagnosis
- Number of medications
- Smoking
- Avoid choking
Recommendations for immediate eating environment to ensure safety
- Safety and efficiency. Ie is allowing sufficient time to eat, not feeling rushed. If eating is too slow, some strategies might be needed.
- Modified diet
- Consideration of seating/positioning
- Specialised equipment. Eg modified chair, modified utensils
- Level of communication suitable. Ie mealtimes should be sociable but carers need to have an awareness around how talking impacts the safety and efficiency of the person eating
- Consideration of level of support needed. Eg Does the person needs someone to assist them with feeding
- Carers eating alongside the person to provide good modelling and a more natural feeling setting (eg homelike)
Options for Compensation
Postural adjustments
* Lying down/side lying: Take bolus, lay on side, swallow (stronger side down)
* Chin tuck/Neck flexion: Swallow food or fluid with chin tucked down towards chest.
* Neck extension/chin up: Take bolus of food/fluid, hold breath, chin up, swallow.
* Head turn/rotation: Swallow food or fluid bolus with head turned to the affected side, e.g. if residue L>R, head turn to the left is indicated.
Manoeuvres
* Breath-hold: Take food/fluids, hold breath and swallow
* Supraglottic: Take food / fluid bolus, hold breath and swallow, then cough immediately post swallow.
* Super supraglottic: Same as for supraglottic swallow, but bear down with cough and attempt an effortful swallow
* Effortful swallow: Strong / hard swallow
* Mendelsohn: Keep larynx elevated voluntarily for as long as possible during the swallow.
* Multiple swallows: Several swallows per mouthful of food or fluid.
* 3 second prep: Hold bolus for the count of 3 then swallow
Swallow Exercises
* Chin Tuck against resistance (CTAR)
* Masako AKA Tongue hold
* Shaker
* Thermotactile stimuli
Options for rehabilitation
Options for Rehabilitation - changing and improving the underlying physiology to enable permanent change to function (this may include recovery)
* IOPI – Iowa oral performance instrument (tongue/lip strength) -
* sEMG – surface electromyography Treating Dysphagia With sEMG Biofeedback | The ASHA Leader
* EMST – expiratory muscle training
* Rehab techniques often incorporate biofeedback
* Provides visual feedback
* Synchronous/asynchronous
Rehabilitation and biofeedback
* NMES –electrical stimulation to the peripheral muscles aiming to target neuroplasticity. Primary muscle groups targeted include supra and infrahyoids
* Pharyngeal electrical stimulation: Electrical pulses delivered via catheter, aiming to increase sensory feedback through the nervous system - PHADER trial
* Transcranial Direct Current Stimulation (tDCS) – external electrical stimulation to an areas of the cortex.
* Functional magnetic stimulation (rTMS) – magnetic stimulation to stimulate efferent (motor) and subsequent muscle contraction
What person-centred factors need to be considered?
- ICF (Body structures and functions, participation and activities)
- Consideration of client preferences
- Safety
- Efficiency
- IDDSI
Dysphagia and Neurological disorders
Impairment of the neurological system – acute and degenerative disorders
* Prevalence in stroke 51% (Mann et al)
* Can occur across all levels or within one centre
* Impacts across sensory, motor or both functions
* Key areas of injury (CNS/PNS):
- Cortical level (lobes)
- Subcortex
- Cerebellum
- Basal ganglia (eg is their a difficulty with motor patterns and refining them)
- Brainstem (contains cranial nerves so responsible for all our breathing and swallowing reflexes
- Peripheral cranial nerves
- Myoneural junction
- Muscular/sensory end organs
* Dysphagia can present as acute or degenerative in nature depends on medical
diagnosis
Dysphagia and Head and neck disorders
Cancer = abnormal cell growth, commonly a tumor however cancers can
have other forms (e.g. myeloma – blood cancer)
* Impairment due to cancer within the head and neck area
* Risk factors are not restricted but include tobacco, human papillomavirus (HPV). HNC 6th most commonly occurring cancer (Manikantan et al.)
* Degree of dysphagia dependent on tumour size, location, TMN classification and age
* Dysphagia can also occur (and increase) after treatment for cancer
* Treatment options include:
- Surgery (open and transoral robotic surgery – TORS)
- Radiotherapy
- Chemotherapy
* Signs and symptoms could include changes around efficiency of swallow. Eg residue or clearance during the pharyngeal phase
OR
Around safety. Eg lack of free movement of muscles being impeded due to mass
Dysphagia and Oesophageal disorders
structural (stenosis, malformation, diverticulum): usually a narrowing, band of tissue (ring), external compression (e.g. enlarged aorta), diverticulum (herniation).
- Zenker’s diverticulum = located on posterior pharyngeal wall in pharyngeal oes
ophageal segment
- Cricopharyngeal bar = herniation at C6-7
* Motility disorders : absent, reduced or in-coordinated peristaltic wave. Can include spasms
* Sphincter abnormalities: absent/incomplete opening (achalasia), reduced duration of opening or incomplete closure
* Reflux (Gastro-oesophageal reflux disease): overt retropropulsion of stomach contents into oesophageus. Impact include odynophagia and dysphagia.
Dysphagia and Respiratory disorders
Impact to breath/swallow synchrony (timing/duration)
* Airflow limitation (impacting on cough strength)
* Sequence of swallow events can be altered/adapted (swallow on inhalation vs
expiration, delayed reflex) – Ghannocuhi et al.
* Impacts to the oral and pharyngeal phase of swallow
* Associated muscle weakness (can impact on the degree of movement -
hyolaryngeal excursion)
* Changes to laryngeal sensitivity - reduced response to penetration/aspiration – Clayton et al.
* Increased use of energy and risk of malnutrition
* Increased GERD
* Acute exacerbations (acute flare-ups) can increase risk of aspiration
Dysphagia and Iatrogrenic disorders
Related to illness or medical treatment
* Artificial airways – endotracheal tubes/tracheostomy
High incidence and increased risk of silent aspiration (McIntyre et al;. 2020)
Surgery involving face/neck/chest/brainstem area: stretching or severing of the cranial nerves
e.g thyroid, carotids, aortic surgery, spinal surgery
* Oral surgery – including removal of teeth/jaw alignment
* Trauma (facial)
* Burns (thermal and chemical)
