DYSPHAGIA - Unit 1 Flashcards
(95 cards)
1
Q
Signs and Symptoms of Dysphagia? (7)
A
- Inability to recognize food
- Changes in diet
- Inability to control food or saliva in mouth
- Increased secretions or excess saliva
- Pocketing
- Coughing before, during, or after swallowing
- Coughing at the end of or after a meal
2
Q
Timing of coughing during a meal? (3)
A
- Before swallow - lose control of bolus or *premature swallow
- After swallow - swallowing on residue
- During swallow - Poor airway closure
3
Q
Complications of Dysphagia? (3)
A
- Pneumonia
- Malnutrition
- Dehydration
4
Q
Aspiration (unsafe swallow) def:
A
- Food or liquid goes down below the level of the true vocal folds (unsafe)
5
Q
Penetration (unsafe swallow) def:
A
Food or liquid has entered the airway, into the vestibule, all but not past the true false
6
Q
Members of a Multidisciplinary Treatment Approach (6)
A
- Swallowing therapist or SLP - cannot assess or treat until treatment order by Dr. is made. Makes dietary recommendations. Keep in mind dietary issues.
- Physicians
- Nurses
- Occupational therapist - adaptive equipment, “plate to mouth,”can do dysphagia treatment, experts in hand-eye coordination
- Pharmacist - some meds can affect swallowing
- Radiologist - x-ray studies
7
Q
Patient Safety - 5 (*Know for test)
A
- Nutrition must never be compromised during the course of management of the patients swallowing problem. Do not force the patient to eat or early if they are getting sicker.
- No clear guidelines exist as to the amount of aspiration that can be tolerated by the patient before such complications as aspiration pneumonia arise. (some patients can chronically aspirate without getting pneumonia)
- Aspiration is kept at a minimum by controlling the amounts presented at the bedside and during radiological exams.
- Any patient who’s aspiration is larger than approximately 10% per bolus of a particular food consistency should be restricted from eating that consistency of food by mouth
- A radiographic exam will identify any silent aspirators.
- Silent aspirators are those patients whose sensitivity is reduced and who will ask great food or liquid without coughing or any other audible or visible signs.
- Approximately 50% of patients who aspirate do not cough every time.
- Even the most experienced clinicians failed to ID approximately 40% of patients who aspirate during the bedside evaluation.
- Therefore, a radiographic evaluation of any pt who is suspected of aspiration is absolutely necessary to:
a) identify the presence of aspiration;
b) define the etiology of aspiration;
c) examine immediate effects of selected treatment procedures and design appropriate therapy for the pt; and
d) determine the best method of nutritional intake (oral, non oral, etc.).
8
Q
Swallowing Areas (4)
A
- oral cavity
- pharynx
- larynx
- esophagus
9
Q
Oral Structures
A
lips, teeth, hard palate, soft palate, uvula, mandible, floor of mouth, tongue, faucial arches, palatine tonsils
10
Q
Sulci
A
Natural pockets or cavities (ie., cheeks, between lips & gums). In pts, they often collect food or liquid.
11
Q
Labiosulcus
A
Between gums and lips
11
Q
Foundation of the tongue?
A
Hyoid bone
12
Q
Lateral/Buccal Sulcus
A
Between cheeks and gums
13
Q
Cheeks are innervated by…
A
VII Cranial Nerve, Facial Nerve
14
Q
Floor of Mouth is made up of what muscles?
A
- mylohyoid
2, geniohyoid - anterior belly of digastric
All are supra hyoid = attach to mandible and hyoid bone
16
Q
Composed almost entirely of muscle fibers (oral cavity)?
A
Tongue
17
Q
Oral Portions of Tongue (6)
A
- tip
- blade
- front
- center
- back
- dorsum (upper surface) ends at circumvallate (upsidown V) papillae
18
Q
Pharyngeal Portion of Tongue
A
tongue base (circum. pap. to hyoid bone)
- active during pharyngeal phase of swallow
- involuntary neural control = brainstem
19
Q
Motor Innervation of Tongue
A
Hypoglossal (moves a lot) – 12th nerve
20
Q
Roof of Mouth consists of…(3)
A
- maxillary (hard palate)
- velum (soft palate)
- uvula
21
Q
Salivary Glands
A
3 on each side,plus many small glands throughout the mucous membranes
22
Q
Purposes of Saliva (4)
A
- maintains oral moisture
- reduces tooth decay
- assists in digestion
- neutralizes stomach acid
23
Q
Pharyngeal Structures:
Lateral and Posterior Pharyngeal Walls
A
3 pharyngeal constrictors:
superior, medial, inferior
24
Q
Pharyngeal Structures:
Anterior Wall of Pharynx (6)
A
- sphenoid bone
- soft palate
- base of tongue
- hyoid bone
- mandible
- thyroid and cricoid cartilages (the constrictors attach to these at various points)
25
Pharyngeal Structures:
| Glossopharyngeaus Muscle
1. The inferior fibers of the superior constrictor that attach to the base of the tongue.
2. It is responsible for tongue base retraction and simultaneous bulging of the posterior pharyngeal wall at the tongue base level.
26
Pharyngeal Structures:
| Pyraform Sinuses
1. Spaces formed between the thyroid cartilage and fibers of the inferior constrictor (where they attach), one on each side.
2. They end at the cricopharyngeus muscle, which is the most inferior structure of the pharynx
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Pharyngeal Structures:
| Vallecula
1. Wedge-shaped spaces formed between the base of the tongue and epiglottis.
2. One on each side.
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Inferior constrictor Faucal Arch
Faucal Arch; Paletopharingeous (posterior); Thickest of the three constrictors, arises from the sides of the cricoid and thyroid cartilage
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Inferior constrictor
Thickest of the three constrictors, arises from the sides of the cricoid and thyroid cartilage
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Esophagus
| upper esophageal sphincter (UES)
The valve going into the esophagus – at the base of the pharynx / superior end of the esophagus. It is made up of the cricoid lamina and cricopharyngeal muscle fibers.
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role of the UES
* Decrease risk of material “backflowing” from esophagus into pharynx.
* Tightest closure / pressure = just before swallow and during inhalation, so no air is pulled into the esophagus.
* Opens at critical time during swallow to allow bolus to pass into esophagus.
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Esophagus
| lower esophageal sphincter (LES)
located at the inferior end of the esophagus – it is the valve into the stomach.
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Larynx
| Location and action
at the base of the tongue, the pharynx opens into the larynx. The larynx acts as a valve to help keep food/liquid from entering the airway.
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Larynx
| superior boundary
epiglottis
• Top 1/3 rests against the base of the tongue
• Attached to hyoid bone (hyoepiglottic ligament\)
• Base = attaches to thyroid notch by a ligament
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Laryngeal Additus and Laryngeal Vestibule
| Def. and Boundareis
The opening into the larynx
| Boundaries: epiglottis, aryepiglottic folds, arytenoid cartilages, superior surface of the false vocal folds
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Ventricle
space between the false folds and the true folds
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Intrinsic Larynx
In general, the vocal folds close off (Adduction) for swallowing the same way they do for phonation. It is the same mechanism.
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Strap Muscles
Connect?
Importance?
Important because they connect floor of mouth, tongue base, hyoid bone, and larynx. When one moves they are all affected.
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Extrinsic Laryngeal Muscles:
| Levels of Protection (3)
a) epiglottis and aryepiglottic folds
b) false vocal folds with base of epiglottisc)
c) true vocal folds = the last level of airway protection before entering the trachea
40
Physiology:
| Deglutition = 4 phases:
1. Oral preparatory phase: food is manipulated in the mouth, masticated and reduced to a consistency ready for swallow.
2. Oral phase: the tongue propels food posteriorly until the pharyngeal swallow is triggered.
3. Pharyngeal phase: pharyngeal swallow is triggered and the bolus is moved through the pharynx.
4. Esophageal phase: esophageal peristalsis carries the bolus through the cervical and thoracic esophagus and into the stomach.
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Oral Preparatory Phase
1. Sensory recognition of food approaching and being placed in the mouth
2. Food enters mouth and labial seal is maintained to ensure no food/liquid falls out. This requires open nasal airway and nasal breathing.
3. Liquid bolus: held between the tongue and anterior hard palate
a) Hold positions: “tippers” = food held between midline of the tongue and hard palate with tip elevated against alveolar ridge. “dippers” = bolus held on floor of mouth in front of tongue(20%)
b) The soft palate is pulled down and forward (no chewing required), sealing off the oral cavity from the pharynx.
4. Solids: (when mastication is needed)
a) requires rotary lateral movement of the mandible and tongue
b) tongue positions material on the teeth
c) when upper and lower teeth meet, material is crushed and falls medially toward the tongue which pushes it back onto the teeth as the mandible opens
d) cycle repeats
e) tension in the buccal musculature closes off the lateral sulcus & prevents food from falling into the sulcus between the mandible and cheek
f) after chewing, tongue pulls food into a semicohesive bolus or ball before the oral stage is initiated
g) volume of bolus swallowed varies with viscosity of the food
(If there is a larger volume in the mouth, tongue subdivides it after chewing, forming a partial bolus for swallow while the rest goes to the side of the mouth for later swallows.)
5. Larynx and pharynx are at rest during the oral phase. Airway is open and nasal breathing continues. So, if individual loses control and bolus trickles into pharynx, material may continue to drop down and enter the airway. Pharyngeal swallow may not be triggered until it enters the larynx.
42
Oral Phase: (1 – 1.5 seconds to complete)
1. Initiated when the tongue begins posterior movement of the bolus
2. “Stripping Action” = midline of tongue sequentially squeezing the bolus posteriorly against the hard palate. Also described as “anterior to posterior rolling action”.
3. Sides and tip of tongue remain firmly anchored against the alveolar ridge
4. Thicker foods require more pressure and slightly more time to propel them through the oral cavity and pharynx.
Review: Needed so far...
• Intact labial musculature for a seal
• Intact lingual movement to propel the bolus
• Intact buccal musculature to keep food out of lateral sulcus
• Normal palatal muscles
• Ability to breath through the nose
43
Pharyngeal Phase:
1. “Trigger” = when the leading edge of the bolus (“bolus head”) passes any point between the anterior faucial arches (younger people) and the point where the tongue base crosses the lower rim of the mandible (older people), the oral stage is terminated and the pharyngeal swallow is triggered. Sensory receptors in the oropharynx and tongue are stimulated, sending a message to the cortex and brainstem which initiates the pharyngeal swallow. There are both voluntary and involuntary components to the swallow.
2. Once the swallow is triggered, the following physiological activities occur:
a) elevation and retraction of the velum, and complete closure of the VP port so that the bolus won’t enter the nasopharynx
b) elevation and anterior movement of hyoid and larynx
c) opening of the cricopharyngeal sphincter to allow material to pass from pharynx to esophagus
d) closure of larynx at all 3 sphincters to prevent food from entering the airway:
- true folds
- false folds
- epiglottis
e) ramping of base of tongue to deliver bolus to pharynx, followed by tongue base retraction to contact anterior bulging pharyngeal wall
f) progressive top to bottom contraction of the pharyngeal constrictors to squeeze the bolus through the pharynx
44
Esophageal Phase:
1. “Transit time” = bolus enters UES until it passes into the stomach at the LES (8-20 sec)
2. Peristalic wave, begins at the top of esophagus and pushes the bolus ahead of it until LES opens and the bolus enters the stomach
3. Patients with esophageal disorders = refer to Gastroenterologist for GI series
45
Swallowing changes with time
A. Infants and Children:
1. 2-7 tongue pumps (milk from nipple), once enough to form a bolus, swallow is triggered
2. Adult patter swallow = respiratory coordination = 2-3 months
3. Chewing = 10-12 months
4. Normal, adult chewing pattern = 3-4 years
B. Elderly:
1. Slight “normal” delay in triggering the pharyngeal swallow
2. Decreased strength of pharyngeal contraction – some need a second swallow
3. Esophageal transit and clearance is slower and less efficient
4. Taste and smell decrease with age
46
Variations in Normal Swallow:
1. Volume effects
2. Increased viscosity
3. Cup drinking
4. Straw drinking
5. “Chug-a-lug
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Components needed for all swallows to clear food from oral cavity and larynx with no residue and good airway protection:
* Oral propulsion of bolus into pharynx
* Airway closure
* UES opening / laryngeal elevation
* Tongue base – pharyngeal wall squeezing/propulsion to carry the bolus through the pharynx and into the esophagus
48
Disorders of Deglutition
| Described how?
described according to their symptomology and according to specific abnomalities in anatomy and neuromuscular functioning.
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Symptoms of abnormal swallow determined how?
clinically and radiographically
50
Anatomic / Neuromuscular Dysfunctions
the actual disorder leading to the symptoms for which treatment is designed.
(ie., aspiration and residue are symptoms – not disorders themselves.)
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Assessment of swallow
| 4 Parts:
* Case History and Chart Review
* Pt. description
* Bedside Evaluation
* Videofluoroscopy
52
Videofluoroscopy: 3 reasons to do one
- Define anatomic / neuromuscular dysfunctions
- Determine recommendations for Oral Intake vs. NPO
- Plan direct or indirect treatment
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A.P. View provides
- information on the oral stage
- symmetry of the swallow
- residue in the valleculae or pyraform sinuses
- vocal fold symmetry/movement
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Lateral View provides
-examine and measure OTT and PTT
-movement patterns of the bolus
-approximate amount and cause of aspiration that occurs
(Does aspiration occur before, during or after the swallow?)
-movement pattens of oropharyngeal structures in oral, pharyngeal and esophageal stages of deglutition
55
Oral Transit Time (OTT)
time taken from the initiation of tongue movement to begin the voluntary oral stage of the swallow until the bolus head reaches the point where the lower edge of the mandible crosses the tongue base (normal = 1 – 1.5 sec.)
56
Pharyngeal Delay Time (PDT)
begins when bolus head reaches point where lower edge of mandible crosses the tongue base and ends when swallow is triggered (as indicated by laryngeal elevation).
57
Pharyngeal Transit Time (PTT)
the time elapsed from triggering the pharyngeal swallow (as indicated by laryngeal elevation), until the bolus tail passes through the cricopharyngeal region of the pharyngoesophageal (PE) sement. (Normal = max of 1 sec, usually .35 to .48 sec).
58
Disorders of the Oral Preparation Stage:
| Labial Weakness
1. Reduced lip closure = food falls from the mouth
• usually results from weakness
• usually one side of the mouth or the other
• lower or upper motor neurons
• seen when trying to take food off the spoon
• drooling / food leakage
2. Reduced lip strength or tone =
• food falls into sulcus (between lips and teeth)
• person may not be aware of it because of sensory loss and/or may not be able to use their tongue to get it out
• drooling / leakage
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Reduced tongue coordination
```
1. Can’t form or hold a bolus =
• bolus spreads throughout oral cavity
• premature loss of bolus into vallecula
• poor tongue control or “tongue thrust”
• abnormal hold position
```
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Reduced buccal / cheek strength or tone
* food falls into lateral sulci (between molars & cheek)
| * “pocketing”
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Disorders of the Oral Phase (3)
* oral phase starts when bolus is in the middle of the tongue, then begins going up and back toward the pharynx
I. Delayed initiation of the oral phase of the swallow due to oral sensory issues = apraxia, lack of oral sensation, dementia, oral-tactile agnosia
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oral apraxia
effects initiation of swallow reflexes; sequence problems in moving bolus back with tongue (doesn’t occur often)
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lack of oral sensation
can’t feel bolus on tongue, so not sure whether or not it is ready to be pushed back
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oral tactile agnosia
loss of ability to attach meaning to sensation inside the mouth. May know they have something in their mouth, but don’t know what it is (even more rare than oral apraxia)
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Tongue Incoordination
1. Tongue thrust at initiation of oral swallow = involuntary tongue thrust
• seen in people who have cerebral palsy and severe head injury
2. Uncoordinated tongue “peristalsis” = sequential contraction of the tongue to move the bolus back into the pharynx. When uncoordinated, the bolus will not move back eaily into the pharynx.
3. “Lingual rock and roll” = actually a type of #4. Repetitive pumping of the tongue, often seen in Parkinsons Disease
4. Piecemeal deglutition = patient forms a bolus but only swallows part of it
• slows down the amount of time it takes to eat a meal
• mostly seen in Alzheimer’s pts
5. Residue in the mouth after an oral swallow = in sulci, floor of mouth (under tongue), on tongue, roof of mouth, etc.
6. Premature overspill of liquid or pudding texture foods into the pharynx = considered
• considered oral phase because person is unable to form or control the bolus, therefore there is spillage (the “loose control” of it)
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Lingual Weakness
Reduced tongue elevation = the tongue can’t reach the palate during the oral swallow, resulting in loss of bolus or food sticking to the palate (residue)
• usually bilateral damage to tongue (Hypoglossal Nerve XII)
• with unilateral damage, one side of tongue is paralyzed but tongue can usually still form a bolus
2. Residue in the mouth after an oral swallow = in sulci, floor of mouth (under tongue), on tongue, roof of mouth, etc.
67
Disorders in Triggering the Pharyngeal Swallow
Delayed initiation of pharyngeal swallow = can be caused by brainstem or subcortical CVA, dimentia, throat surgery, radiation treatment, etc.
* need sensory stimulation from tongue, back of pharynx, and pillars which send the message to the brainstem that food is coming
* significant amounts of radiation can make tissue stiff and numb
* dementia, because of the loss of neurons in the brain
68
Disorders of the Pharyngeal Phase
| Structural Issues, such as:
1. Cervical osteophytes = abnormal bony growth of cervical vertibrae – will push out on tissue of the pharynx. Can hinder the bolus from going down.
2. Pseudoepiglottis = after total laryngectomy
69
Pharyngeal Weakness
Unilateral or bilateral residue on pharyngeal wall and/or in pyraform sinuses = muscle contractions that propels food down are weak and don’t contract tightly enough to force the food down – leads to residue in the pharynx.
• “residue” = left after the swallow
70
Reduced Tongue Base Retraction
1. Food residue in the valleculae
• usually caused by reduced tongue base contraction to meet the posterior pharyngeal wall
• poor laryngeal elevation may also contribute to this
• in a normal swallow, the base of the tongue goes back pushing out any food in the vallecula and helping to close off the airway
71
Reduced laryngeal elevation/excursion
1. Residue in pyraform sinuses or near opening of the airway
• can leave residual food near the opening of the airway
2. Penetration
• if larynx doesn’t pull up tightly with base of tongue, there is a gap where food can get into the larynx
• especially troublesome while drinking liquids – prone to aspiration
3. Poor cricopharyngeal opening
• if larynx doesn’t elevate totally, it doesn’t pull open the cricopharyngeal sphincter
• may also be caused by spasticity of UES/CP muscle
• bolus doesn’t pass through so it builds up in pyraform sinuses or at base of pharynx and may spill over into the larynx
72
Poor Airway Closure
Reduced closure of the airway opening due to incomplete or weak adduction of false folds and arytenoids as larynx is elevated to the base of the epiglottis
• if false folds don’t adduct tightly, food or liquid can get through the epiglottis and get to the trachea. (penetration &/or aspiration during swallow)
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Reduced Velopharyngeal Closure
1. Nasal penetration during the swallow
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Disorders of the Esophageal Phase
| Reflux: 2 Types
```
GERD = Gastroesophogeal reflux disorder
LPR = Laryngopharyngeal reful
```
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GERD
Lower Esophogeal Sphincter
Symptomatic
Irritated, heartburn, tightness, pressure
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LPR
Lower and Upper Esophogeal Sphincter
Microspills through esophagus, settles in the pharynx or larnyx and causes irritation
"Asymptomatic or Silent" reflux
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Esophageal Disorders:
| Tracheo-esophogeal Fistual
Hole from trachea to esophagus
| Surgical treatment
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Zenker's Diverticulum
Pocket in lining of esophagus
| Traps things at the base of pharynx near the Laryngeal and Cricopharyngeal regions
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Swallowing Disorders after Stroke
| Brainstem Stroke - #1
*Long-term
Very significant impact
Absent Pharyngeal swallow (no reflex)
Normal Oral Phase
1-2 wks = may get reflex back, but very delayed
Unilateral = adductor paralysis of vocal folds = breathy = poor airway opening
poor laryngeal elevation = poor cricopharyngeal opening
*Residue on the weak side
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Subcortical Stroke #2
Oral prep phase is weak
Poor oral transit
Greater delays in reflex than cortical
Generalized weakness in all parts of pharyngeal swallow
3-6 wks will develop a functional swallow
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Cortical Stroke
| Right CVA #3
More significant than LCVA
Oral transit issues
Delay in trigger
Slow or weak laryngeal elevation
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Cortical Stroke
| Left CVA #4
3 wks = functional swallow (significant improvement)
Greater risk of Brocca's apraxia
Initiation of oral prep is delayed
Mild delay in trigger
Once triggered = pharyngeal swallow normal
*Good prognosis for both cortical strokes
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Swallowing Problems are Exacerbated by:
```
Other strokes
TIA
Heart/Lung issues
Antidepressants
Diabetes
High blood pressure
```
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Cheek Innervation: Motor
Facial 7
85
Tongue Innervation: Motor
Hypoglossal 12
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Tongue Innervation: Sensory
Trigeminal 5
| Glossopharyngeal 9
87
Roof of Mouth (velum) Innervation: Motor
Vagus 10
88
Roof of Mouth (velum) Innervation: Sensory
Glossopharyngeal 9
89
Lip Innervation: Motor
Facial 7
90
Lip Innervation: Sensory
Trigeminal 5
91
Mandible: Sensory
Trigeminal 5
92
Pharynx Innervation: Motor
Vagus 10
93
Pharynx Innervation: Sensory
Glossopharyngeal 9
94
Larynx: intrinsic
Vagus 10
95
Larynx: extrinsic
Hypoglossus 12
