Dysphagia Unit 2 Flashcards
(90 cards)
1
Q
overview of etiologies: anatomical
A
- structural problems
- either sufficient tissue or too much tissue
- birth defects
- removal of tissue due to tumors
- scar tissue
- calcium deposits
2
Q
overview of etiologies: physiological
A
- problems with how the structures function
- usually neurological problems
3
Q
overview of etiologies: iatrogenic
A
- problems secondary to medical intervention
- side effects of medication/treatment
- tracheostomy
- laryngectomy
4
Q
considerations with swallowing problems related to neurologic disorders
A
- large number of “silent aspirators” i.e. those who have no signs that aspiration is occurring
- fatigue factors
5
Q
silent aspirators
A
- no cough, throat clearing, gurgly vocal quality
- may be unaware of their swallowing difficulties
- no dry swallows even when food is visibly still in pharynx
- may be as high as 50% of neurologically impaired dysphagic patients
6
Q
fatigue factors
A
- prone to fatigue throughout the mean and/or throughout the day
- fatigue may negatively affect the patient’s swallow fuction
7
Q
when does aspiration occur?
A
can occur before, during, or after the swallow
8
Q
aspiration before the swallow
A
delayed swallow response
9
Q
aspiration during the swallow
A
poor pharyngeal constriction
10
Q
aspiration after the swallow
A
residue in the valleculae, pyriform sinuses, sulci (cheeks), or on the pharynx
11
Q
questions posed by the clinician for those who may improve
A
- what treatment should initiated to make the swallow more normal?
- will the patient be able to eat a normal diet? if so, when?
- is the patient’s recovery typical for this type of lesion?
- what other factors may interact with the neurologic damage to worsen the dysphagia?
12
Q
CVA: general considerations
A
- non-complicated (no other co-morbidities) stroke patients recovered steadily and quickly
- although recovery occurred, temporal measures were not normal
- recovery was most rapid in the first 3 weeks
13
Q
CVA: non-complicated (no other co-morbidities) stroke patients recovered steadily and quickly
A
95% returned to full oral intake by 9 weeks post assault regardless of site of lesion
14
Q
CVA: although recovery occurred, temporary measures were not normal
A
function swallows with no aspiration were achieved but pharyngeal transit times were longer with more oral and/or pharyngeal residue evident
15
Q
CVA: recovery was most rapid in the first 3 weeks
A
- suggest need to assess week 1 and then reassess week 3 or 4
- may have progressed from non-oral to oral intake in this short time
16
Q
CVA: lesions of the lower brainstem (medulla)
A
significant oropharyngeal impairments (location of major swallowing center is in the medulla)
17
Q
CVA lesions of the lower brainstem: 1st week post stroke
A
absent pharyngeal swallow
18
Q
CVA lesions of the lower brainstem: 2nd week post stroke
A
- delay 10-15 seconds
- often have submandibular tongue base and hyoid movement but no true swallow
- when swallow does initiate, reduced laryngeal elevation and anterior movement with reduced cricopharyngeal opening
- may have unilateral pharyngeal weakness
- some may have unilateral vocal folds paresis/paralysis
19
Q
CVA lesions of the lower brainstem: 3rd week post stroke
A
sufficient recovery for functional swallow and full oral intake (modified diet?)
20
Q
CVA: high brainstem lesion (pontine)
A
- mild delays in oral transit time (3-5 seconds)
- mild delays in initiating swallow response (3-5 seconds)
- mild to moderate impairments in timing neuromuscular control in the pharynx
- may demonstrate aspiration before due to delay in initiating pharyngeal swallow or after due to neuromotor control issues in pharynx
- recovery to full oral intake may take 3-6 weeks
- longer if medical complications present (ex: pneumonia, diabetes)
21
Q
CVA: cortical stroke (anterior left hemisphere)
A
- may result in apraxia of swallow
- delay in initiating oral swallow with no tongue movement in response to presentation of food or mild to severe searching motions of the tongue
- oral groping, incoordination, and inconsistent errors
- mild oral transit delays (3-5 seconds)
- mild delays in initiating the pharyngeal swallow (3-5 seconds)
22
Q
CVA: cortical stroke (right hemisphere)
A
- mild oral transit (2-3 seconds)
- pharyngeal delays (3-5 seconds)
- once swallow is initiated, slight delay in laryngeal
- adds to aspiration before or just as swallow is initiated
- slower recovery than left CVA due to inattention and difficulty sequencing-following multiple step commands even with tactile cues and physical prompting
23
Q
CVA: multiple strokes
A
- often have more significant and multiple problems
- effects of CVA may be cumulative in nature
- failure of swallow to return to “normal”
- oral transit delays of 5 seconds or more
- delays in initiating pharyngeal swallow (5 seconds or more)
- may have reduced laryngeal elevation
- unilateral pharyngeal weakness with residue on pharyngeal walls and/or in pyriform sinuses
- reduced closure of the laryngeal vestibule resulting in penetration
- decreased attending skills and difficulty following swallowing strategies
24
Q
CVA: other considerations
A
- tracheostomy
- medications may worsen swallow
25
CVA: tracheostomy
- inflated cuffs with trachs reduce laryngeal elevation due to "drag" resistance of cuff on tracheal wall
- if longer than 6 months reduces laryngela closure due to limitation of air flow on vocal folds reducing stimulation to sensory receptors there
26
CVA: medications may worsen swallow
- antidepressants slow coordination making swallow worse
- xerostomia (dry mouth) as side effects or some medications or combinations of medications
- visual neglect
27
TBI (closed head trauma): general considerations
- swallowing problems can become quite complex dependent on extent and site of head injury, other bodily injuries, and nature of emergency care
- generally swallowing problems become more severe the longer the patient is in a coma
- usually tracheostomy, sometimes due to emergency situation due too high resulting in damage to the larynx
- prolonged intubation can also cause laryngeal damage
28
TBI (closed head trauma): injuries from direct head injury
- contra-coup damage
- twisting and shearing of the brainstem
29
TBI (closed head trauma): also potential puncture wounds of the head and neck region
laryngeal fractures, penetrating chest wounds affecting the esophagus
30
TBI: swallowing related considerations
- reduced lip closure, tongue range of motion
- poor bolus control
- abnormal reflexes (ex: bite reflex)
- reduced laryngeal elevation
- reduced closure of the airway entrance
- unilateral or bilateral pharyngeal wall paresis or paralysis
- tracheoesophageal fistula
- reduced velopharyngeal closure
- reduced laryngeal closure and reduced cricopharyngeal opening
31
tracheoesophageal fistula
an abnormal connection between your trach and esophagus
32
reduced velopharyngeal closure
preventing residue from going into the nasopharynx
33
TBI: other considerations
- impulsivity
- cognitive difficulties
- reduced sensation
- issues with compliance with treatment
- seem to be able to tolerated aspiration at first but will eventually create problems for them
34
TBI: impulsivity
tendency to put too much in their mouths too quickly
35
TBI: cognitive difficulties
decreased understanding of swallowing maneuvers
36
TBI: reduced sensation
reduced awareness of swallowing difficulties
37
cervical spinal cord injury
- swallowing problems even with no head injury present (with no head injury swallowing problems are generally pharyngeal)
- delay in initiating pharyngeal swallow
- reduced laryngeal elevation
- reduced cricopharyngeal
- reduced tongue base retraction
- decreased unilateral or bilateral pharyngeal wall functioning
- problems with vocal fold closure secondary to traumatic emergency airway management or to prolonged tracheostomy
38
cervical vertebrae 1 or 2
no sensory awareness of swallowing difficulty
39
cervical vertebrae 3 or above
generally in cervical brace on mechanical ventilation with trach tube with an inflated cuff
40
cervical vertebrae 5 or above
very high incidence of pharyngeal swallowing problems
41
cervical vertebrae 4, 5, or 6
decreased laryngeal movement and resulting reduced cricopharyngeal
42
cervical bracing
- not sure of effects on swallowing
- in a study done with normal halo brace, swallowing "felt more difficult" when wearing the brace
- MBS results showed increased duration of airway closure during the swallow while in brace but no other abnormal measurements
43
cervical fusion
- done to stabilize vertebrae in case of injury or degenerative disc disease
- post operatively swelling in posterior pharyngeal wall
- reduced laryngeal elevation and anterior movement with reduced closure of airway entrance and reduced cricopharyngeal opening
- unilateral or bilateral pharyngeal wall movement
- may have oral stage problems and delay in initiating swallow response
- may have some reaction to hardware in the neck area from surgical procedure
- generally significant recovery 3 months postoperatively
44
Guillian-Barre syndrome
- viral disease causing rapid onset of paresis which may progress to complete paralysis requiring tracheostomy and mechanical ventilation
- general weakness: paralysis begins several days after swallowing difficulty noticed
- generalized weakness in oral and pharyngeal swallow with reduced range of motion of oral tongue, tongue base, and larynx
- progressive paralysis over a period of several days
45
progressive neurological disease: questions raised by the clinician for these individuals
1. are there typical changes in the swallow that can help identify the disease?
2. are there predictable changes in swallowing in keeping with the lesion locations?
3. how long can the patient continue eating by mouth?
4. what techniques can prolong safe oral intake?
46
Alzheimer's vs. Dementia
- dementia is a general term for a decline in mental ability severe enough to interfere with daily life
- alzheimer's is the most common cause of dementia
- alzheimer's is a specific disease and dementia is not
47
Alzheimer's disease
- progressive dementia
- food agnosia
- feeding apraxia
- swallowing apraxia
- decreased lateral tongue motion for chewing
- delay in initiating pharyngeal swallow
- bilateral pharyngeal wall weakness
- reduced laryngeal elevation
- reduced tongue base retraction
48
dementia
- disconnect between oral and swallow and pharyngeal swallow
- may be several minutes before the pharyngeal swallow initiates
- pharyngeal swallow is intact once it is initiated
49
dementia: disconnect between oral and swallow and pharyngeal swallow
disconnect between neural pathways between the cortex (controls oral swallow) and medulla (brainstem that controls pharyngeal swallow)
50
ALS
progressive upper and lower motor neuron degeneration involving the corticobulbar tracts, corticospinal tracts, or both
51
ALS: corticospinal tract
carries motor signals from the primary motor cortex in the brain, down the spinal cord, to the muscles of the trunk and limbs (involved in the voluntary movement of the muscles of the body)
52
ALS (corticospinal tract): swallowing complications
- slow to develop swallowing problems
- reduced velar movement with food in nasal cavity
- reduced pharyngeal wall contraction
- 1st sign may be slow progressive weight loss and little/no awareness of a swallowing problem
53
ALS: corticobulbar tract
carries motor, information from the primary motor cortex to the muscles of the face, head, and neck by synapsing with motor cranial nerves in the brainstem (responsible for innervating the muscles of the face, head, and neck as well as the muscles involved in swallowing, phonation, and facial expression)
54
ALS (corticobulbar tract): swallowing complications
- decreased tongue mobility (less able to control material in oral cavity)
- unable to increase tongue pressure to handle thicker foods (reduced lip closure, drooling, food spillage from front of mouth)
- reduced velar function (food in nasal cavity)
- reduced tongue base retraction with reduced pharyngeal contraction resulting in residue in the pharynx (potential aspiration after the swallow)
- delay in initiating pharyngeal swallow (risk of aspiration before the swallow)
- reduced laryngeal elevation and reduced cricopharyngeal opening
- complete laryngeal closure is impaired with resulting laryngeal penetration
- respiratory compromise
55
Parkinson's disease
- typical repetitive anterior to posterior tongue rocking pattern in oral transit
- slight delay initiating swallowing response
- decreased tongue base retraction
- reduced pharyngeal wall contraction with residue in pharynx and pyriform sinuses after each swallow
- reduced laryngeal closure
- some cricopharyngeal dysfunction may also occur
- end stage of disease may include dementia and severe rigidity making postural changes difficult
56
Parkinson's disease: readuced laryngeal closure
incomplete vocal fold closure resulting in aspiration during the swallow
57
post polio
- symptoms appearing 30 years post assault even for those who may have had no swallowing problems with the initial assault
- unilateral and bilateral pharyngeal wall weakness
- reduced tongue base retraction
- reduced laryngeal elevation with decreased closure of the laryngeal vestibule resulting in aspiration after the swallow
- patients don't realize the increased swallowing difficulties and have to be convinced of changes by showing results of MBS study
58
multiple sclerosis
- multiple plaques in the neurological system from the cortex to the brainstem and cerebellum to the corticospinal tracts
- most common problems: delay in triggering pharyngeal swallow, reduced tongue base retraction, reduced pharyngeal contraction with residue in the valleculae
- depends on which cranial nerves are involved
59
multiple sclerosis: hypoglossal (XII)
- reduced lingual control of bolus
- reduced control of chewing and oral transport of bolus
60
multiple sclerosis: vagus (X)
- reduced tongue base movement
- reduced pharyngeal wall movement
- reduced laryngeal function
61
multiple sclerosis: glossopharyngeal (IX)
reduced triggering of pharyngeal swallow
62
muscular dystrophy
- muscular definition
- overall problem for muscular dystrophies of all types is reduced pharyngeal wall contraction
63
muscular dystrophy: myotonic dystrophy
- prolonged contraction and difficulty relaxing involved muscles
- sternocleidomastoid
- muscles of mastication
- cricopharyngeal sphincter
64
muscular dystrophy: oculopharyngeal dystrophy
- selectively involves ocular and pharyngeal muscles
- reduced pharyngeal contraction
- dysfunction of the muscular portion of the cricopharyngeal juncture (doesn't relax)
65
chronic obstructive pulmonary disease (COPD)
- demonstrate airflow limitations (failure to exhale sufficient amounts of carbon monoxide)
- no aspiration found in COPD patients studied but differences with some confirmation of same in studies of individual patients
- suggested that during exacerbation of respiratory issues patients swallowing on inhalation as opposed to exhalation (increased risk for aspiration)
- COPD patients may experience more GERD and increased risk of aspiration due to reflex
- unable to determine if some of the above is cause of or result of exacerbation
66
oral swallowing concerns
- apraxia of swallow
- trismus
- reduced length strength/range of motion
- reduced labial tension/tone
- reduced buccal tension/tone
- reduced tongue range of motion/strength
- reduced tongue coordination
- reduced tongue-palate contact/reduced tongue elevation or strength
- residue in the oral cavity related to scar tissue
- poor dental status
67
trismus
- reduced mouth opening
- often a side effect of radiation treatment to the mouth/pharynx
68
reduced lip strength/range of motion
food spillage out of the front of mouth/drooling
69
reduced labial tension/tone
residue in anterior sulci
70
reduced buccal tension/tone
residue in lateral sulci
71
reduced tongue range of motion/strength
residue on the tongue
72
reduced tongue coordination
- poor bolus formation/transport/loss of liquid or pudding consistency into the pharynx
- premature slippage over the back of the tongue
73
reduced tongue-palate contact/reduced tongue elevation or strength
residue on the hard palate
74
pharyngeal swallowing concerns
- reduced velopharyngeal strength
- unilateral or bilateral pharyngeal wall weakness
- reduced tongue based retraction
- reduced laryngeal elevation/reduced cricopharyngeal opening
- laryngeal penetration
- reduced vocal fold closure
- cricopharyngeal dysfunction
75
reduced velopharyngeal strength
nasal emesis
76
unilateral or bilateral pharyngeal wall weakness
residue on pharyngeal walls
77
reduced tongue based retraction
residue in the valleculae
78
reduced laryngeal elevation/reduced cricopharyngeal opening
residue in the laryngeal vestibule and/or pyriform sinuses with potential aspiration after the swallow
79
laryngeal penetration
bolus in the laryngeal vestibule either coughed out or aspirated after the swallow
80
reduced vocal fold closure
aspiration during the swallow
81
cricopharyngeal dysfunction
- residue in the pyriform
- slow or partial entry of bolus into esophagus
82
esophageal swallowing concerns
- cricopharyngeal dysfunction
- esophageal stenosis (narrowing) or constrictors
- tracheoesophageal fistula
- Zenker's diverticulum
- reduced esophageal motility
- acalasia
- gastroesophageal reflex disease (GERD)
- laryngoesophageal reflux
83
cricopharyngeal dysfunction
reflex of material back into esophagus
84
esophageal stenosis (narrowing) or constrictors
- failure of bolus to pass through esophagus and/or possible reflux into pharynx
- aspiration after the swallow
85
tracheoesophageal fistula
- a hole develops between the tracheal-esophageal wall
- aspiration after the swallow
86
Zenker's diverticulum
- side pocket that forms when the esophageal or pharyngeal wall herniates
- food collects in the pocket
- aspiration after the swallow
87
reduced esophageal motility
slow transport of bolus through the esophagus
88
acalasia
- lower esophageal sphincter fails to relax
- often disrupts peristaltic movement as material backs up in the esophagus
89
gastroesophageal reflux disease (GERD)
- generally described as heartburn
- may also include chest pain, recurrent sinusitis, chronic cough, hoarseness, asthma, laryngitis, globus sensation, and/or middle ear infections
90
laryngoesophageal reflex
when stomach acids reach the level of the larynx
