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Dysphagia > Final > Flashcards

Final Flashcards

1
Q

Types of objective swallowing evaluations

A

Modified Barium Swallow Study (MBSS); Videofluoroscopic Swallow Study (VFSS); Cookie Study (historical)

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2
Q

Limitations of clinical (bedside) swallow eval

A

correctly ids only 2/3rds of those who do and do not aspirate;

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3
Q

3 oz water test effectiveness

A

good screen but not comprehensive; sensitive 76% (extent to which people who have the disease test positive), specificity 59% (extent to which people who do not have the disease test negative)

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4
Q

3 ox water test effectiveness

A

good screen but not comprehensive; sensitive 76% (extent to which people who have the disease test positive), specificity 59% (extent to which people who do not have the disease test negative)

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5
Q

Clinical (bedside) eval: Wet vocal quality

A

variable definition between clinicians, NO STANDARD to compare to; no association w/ aspiration or penetration, potential use of id laryngeal dysfunction; “wet” label from SLP associated w/ LARGE amount of material on vocal folds

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6
Q

Clinical swallowing eval (bedside)

A

analyzes motor components of swallowing; only indirect sensory info re: the swallow; inadequate info on pharyngeal stage, inaccurate estimation of aspiration

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7
Q

Silent aspiration

A

2-25% stroke patients; central/local weakness & incoordination of pharyngeal muscles; reduces laryngopharyngeal sensation; impaired ability to produce reflexive cough

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8
Q

Unmanaged oropharyngeal dysphagia is increased risk for

A

airway obstruction; aspiration pneumonia; death; malnutrition; decreased quality of life

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9
Q

Materials needed for MBSS

A

Fluoroscopy suite or C-arm; barium sulfate; lead vest, gloves, thyroid shied, eye protection, dosimetry badge

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10
Q

MBSS provides what view of swallow?

A

lateral or anterior-posterior

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11
Q

Use MBSS in order to:

A

assess risk for aspiration; see phases of swallow, make dietary recommendations

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12
Q

Who does an MBSS?

A

a radiologist and an SLP; SLP determines progression of boluses and says “on/off” for flour

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13
Q

MBSS requires ____________ patient b/c __________

A

Medically stable patients for transportation to x-ray suite

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14
Q

Bolus consistencies

A

thin liquid, semi-thick liquid, thick liquid, puree, solids, multiple consistencies/textures

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15
Q

What you can see in MBSS

A

oral prep phase, swallow initiation, penetration, aspiration (before, during, & after swallow) and pharyngeal contraction; residue in valleculae, pyriform sinuses

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16
Q

What to look for in Oral Prep phase during MBSS

A

bolus formation; anterior oral spillage?; pocketing in sulci; bolus cohesiveness; mastication with solids?

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17
Q

What to look for in Oral Phase MBSS

A

Bolus location on tongue; method of poster movement (how tongue moves bolus); speed bolus movement; oral residue, location; posterior oral spillage?; location of pharyngeal trigger

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18
Q

What to look for in Initiation of Pharyngeal Phase MBSS

A

where is bolus when pharyngeal swallow initiated (when hyoid elevation begins?); is there delay in swallow initiation or is it posterior oral spillage?; is initiation timely (in seconds) regardless of bolus location?

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19
Q

What to look for during pharyngeal phase MBSS

A

hyo-laryngeal excursion (assess); pharyngeal wave (asses); is penetration present? does it remain, why occur; is aspiration present? silent or audible, when (before, during, after swallow) does it occur & why?; is there residue? where, why, does it clear w/ spontaneous subsequent swallows, does result in penetration/aspiration

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20
Q

Top-down assessment (MBSS)

A

palatal closure, superior constriction, BOT retraction sufficient for OPP; pharyngeal wave; laryngeal elevation; laryngeal excursion; UES relaxation and opening; UES closure

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21
Q

Pharyngeal to esophageal phase

A

UES- does it open adequately and for sufficient duration to allow bolus to pass from pharynx to esophagus? (if not, why- decreased hyolaryngeal excursion, UES spasm, etc); Does UES motility interfere w/ pharyngeal phase of swallowing?

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22
Q

Predictive risk factors for (severe) dysphagia

A

dysphonia, dysarthria, abnormal volitional cough, abnormal gag reflex, abnormal cough reflect, cough after swallow, and voice change (these suggest need instrumental examination)

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23
Q

Incidence of dysphagia by eval method low to high

A

screening (37-45%); clinical testing (55%); instrumental testing (64-78%)

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24
Q

Compensatory techniques (to try during MBSS)

A

chin tuck; head turn; head tilt; bolus size; textures; consistency

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25
Q

Considerations when recommending compensatory techniques during MBSS

A

KNOW WHY you’re trying physiologically; does it improve their swallowing efficiency?; will it fatigue patient?; can patient implement independently?

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26
Q

NG tubes and objective swallow eval

A

no need to remove for eval; aspiration risk for puree food and liquid same across groups

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27
Q

NG Tube vs G tube placement recommendations

A

NG tube: Short term (acute onset dysphagia, good potential for recovery, medical status improving); G tube: Long term (progressive, end-stage disease, lack of cooperation w/ treatment (alertness/consciousness), large CVA, minimal medical status improvement, need nutritional support beyond current oral intake)

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28
Q

Alternative means of nutrition

A

nasogastric (NG) tube (small/large bore); Percutaneous Endoscopic Gastrostomy (PEG) tube; Total Parenteral Nutrition (TPN)

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29
Q

What is FEES

A

flexible endoscope passed transversally to obtain superior view of pharynx, larynx, and portion of trachea to objectively eval pharyngeal swallowing function

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30
Q

MBSS cons

A

Requires radiation exposure; time limited (4 min); costly

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31
Q

MBSS pros

A

access in all hospitals, but patients must be able to go to the flour unit; time-tested

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32
Q

SLP FEES Scope of Practice

A

YES to (independently) evaluate (pharyngeal) swallow functioning, NO to making medical diagnosis (MD); need state liscence

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33
Q

Nasoendosopy (FEES) licensing recommendations

A

*vary by facility; class (10-16 hours), 5 FEES procedures w/ another clinician, 25 performance and interpretation of fees, knowledge of contraindications/adverse reactions

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34
Q

Adverse reactions to FEES

A

laryngospasm; vasospasm; epistaxis (RARE, no serious consequences)

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35
Q

FEES equipment

A

flexible endoscope, monitor, camera, recording mechanism

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36
Q

Why do FEES?

A

to assess for diet recommendations; need swallow eval that same day; need to test for fatigue; need repeat swallow exam to consider diet

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37
Q

Patients who may be good for FEES

A

patient to big for flour suite; ICU patient (ventilator, traction, cardiac monitors, etc); excess radiation concerns; fluoro contrast issues; if patient can’t be transported; patient on contact/respiratory isolation; need objective info secretion management; need visual feedback as teaching strategy; patients who refuse barium; patients who can’t afford MBSS; to visualize integrity of vocal fold closure; tx exam w/ time to try strategies; need more info from fluoroscopy

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38
Q

Fluoroscopy Indications

A

endoscope not available/accepted by pt; need oral phase visual; visual coordination oral & pharyngeal stage; need to visualize hyolaryngeal excursion, epiglottic displacement, laryngeal elevation, pharyngeal wave, UES opening ; need to visualize aspiration during height of swallow; facial/nasal issues; need to screen esophageal phase; endoscopy doesn’t fully answer questions

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39
Q

FEES (endoscopy) Cons

A

limited to superior view; more difficult to learn (certify); uncomfortable for some patients; confused/agitated patients will not take scope; white out during swallow

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40
Q

FEES vs Fluro

A

similar outcomes from both; FEES equally sensitive; FEES > Fluoro (MBSS) for secretion management

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41
Q

FEES provides visual feedback for:

A

clearing penetration/aspiration, obtaining airway closure, minimizing premature oral spillage, purpose of compensatory strategy

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42
Q

Chronological FEES interpretation

A

Before swallow: initiation (spillage to valleculae, down lateral changes, over epiglottis, to pyriform sinuses, into laryngeal vestibule?), penetration?, aspiration?; After swallow: aspiration? penetration? residue (valleculae, pyriform sinuses, pharyngeal residue)? present, what happens to penetration/residue

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43
Q

FEES Protocol (Langmore)

A

Velopharyngeal closure, appearance of hypo pharynx and larynx at rest, handling of secretions respiration, airway protection, phonation, pharyngeal musculature (symmetry, shape) ; administration of food & liquid; hypopharyngeal/laryngeal sensory testing

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44
Q

FEES contraindications

A

Patients who are agitated, tacitly defensive, hyperactive gag reflex, bleeding disorder/blood thinner, history of fainting, significant acute cardiac problems

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45
Q

FEES risks

A

discomfort, gagging, nose bleed, allergic reaction (anesthetic, food), laryngospasm, vasovagal response

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46
Q

Endotracheal intubation

A

establishes temporary airway for pulmonary ventilation for surgery & life-saving situations; acute, crisis

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47
Q

Problems with Intubation (endotracheal intubation)

A

displaced arytenoid cartilage; parlayzed TVC; recurrent laryngeal nerve injury; reduced oropharyngeal sensation; laryngeal musculature deconditioning; upper airway edema; atelectasis; barotrauma; tracheal stenosis; trachealmalacia

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48
Q

Problems remaining post-intubation (endotracheal intubation)

A

dysphagia (aspiration, malnutrition); voice deficits (aphonia); communication deficit (low volume)

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49
Q

If patient is intubated, could expect _______

A

aspiration (check for presence), reduced sensation, severe reduction in frequency of swallow (due to muscular deconditioning)

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50
Q

______ & ______ travel through pharynx; goal to keep in respective channels

A

pulmonary air (trachea/lungs) & food and liquid (esophagus)

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51
Q

Respiratory/swallow sequence

A

expiration; cords close; pharyngeal phase; cords open; expiration

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52
Q

Indications for tracheostomy

A

prolonged intubation during course of critical illness; subglottic stenosis from prior trauma; obstruction from obesity for sleep apnea; congenital abnormality of larynx or trachea; severe neck/mouth injuries; inhalation of corrosive material/smoke/steam; presence of foreign body occluding airway; paralysis of muscles that affect swallowing causing aspiration danger; long term unconsciousness or coma

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53
Q

Cuffed trache

A

closes system & stabilizes breathing volume; prevents GROSS aspiration; easily ventilated

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54
Q

Cuffless trache

A

higher comfort level; easily changed; less build-up around cuff; less esophageal impingement; less likely to develop granulation or malaria

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55
Q

Cuffless trache

A

higher comfort level; easily changed; less build-up around cuff; less esophageal impingement; less likely to develop granulation or malacia

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56
Q

Do trach tubes cause swallowing problems?

A

May only be cuffed w/ airflow cut-off; reconditioning of muscles, other illnesses/consciousness also factors

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57
Q

Swallowing problems as result of trach placement

A

Mechanical disturbance; sensory deficit (airflow deficit); uncoordinated laryngeal closure

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58
Q

Mechanical disturbance of trash placement

A

anchors larynx, prevents full elevation/excursion; traction of cuff rubbing against posterior tracheal wall (chondritis becoming malacia); possible esophageal narrowing at (overinflated) cuff

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59
Q

Aspiration is more likely with ________ cuff compared to ______

A

high pressure low volume cuff 87%; low pressure high volume cuff 15%

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60
Q

Passy-Muir Speaking Valve resortes subglottic air pressure, allowing

A

restoration normal apnea sequence, allows upper airway cough

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61
Q

Known aspirators who get passy muir speaking valve will

A

continue to aspirate

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62
Q

Attempt passy-muir valve application prior to all swallowing evals if possible in order to

A

re-establish upper airway airflow and clearance potential

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63
Q

Stimuli are needed to excite receptors w/in oral-pharyngeal mucous to repeat pharyngeal swallowing most effectively, as evidenced by ________ and suggesting what intervention?

A

local anesthetic impairs initiation of swallow; ice chip therapy

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64
Q

Lack of _______ may effect receptors oral and pharyngeal afferents

A

saliva –> mechanoreceptor stimulus and resulting afferent response; air could do same?, respiratory central pathway maintains patent airway as most important reflex in oral and pharyngeal areas

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65
Q

Patients with tracheostomies show coordination deficits in:

A

reduced swallow apnea sequences; decreased hyolaryngeal elevation AND rotation w/ decreased UES relaxation (for FEW patients)

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66
Q

Steps of swallow assessment w/ tracheostomy

A

position optimally; lower/deflate cuff; apply PMSV if possible; clear oral cavity; begin 5 cc water if patient not eating; go objective whenever possible (1st FEES for sensitive to secretion management)

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67
Q

Special considerations when assessing swallow w/ tracheostomy

A

many patients have sensory deficits (aspirate silently); may be difficult in distinguishing what airway sounds w/ swallow change, using CA

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68
Q

FEES pros and cons

A

pros: view TVC laryngeal vestibule directly; longer duration; done at bedside. cons: cannot see cervical esophagus; invasive

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69
Q

Fatigue & feeding routines

A

several small meals max nutrition and min fatigue; feed after resting periods (NEVER after PT); follow objective recommendation management strategies

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70
Q

Possible strategies for management w/ trache

A

effortful swallow (increase hylaryngeal excursion & UES diameter); mendelsohn maneuver; double swallow; super supraglottic w/ deflated cuff only; termal-tacticle sim if warranted; encourage secretion swallowing w/ less oral suctions (*note: Keep cuff deflated (try))

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71
Q

Tools for management

A

Biofeedback (SEMG, FEES); exercises for pharyngeal contraction and larynx elevation

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72
Q

Evaluation of swallow w/ trache

A

do while cuff deflated if tolerated; attempt to time swallow in exhalation if possible if aspiration problem detected objectively

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73
Q

Evaluation of Swallow w/ Vent dependent patients

A

Review settings (cuff deflation? high pressure support? breathing rate?); monitor PiP and O2 stats, trache tubing for potential larynx/trachea movement, HR (attn for decline, but don’t up FIO2 just for decrease and more work of breathing); low minute volume alarm

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74
Q

Advantages of in-line passy-muir placement

A

communication; upper airway clearance (supraglottic and immediate subglottic); work of breathing; breathing/speech coordination; re-establishment of upper airway sensory awareness

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75
Q

SLPs in the hospital: effects by noncompliance

A

more hospital admissions for chest infections/aspiration pneumonia and aspiration pneumonia as cause of death (50%) when patients noncompliant

76
Q

SLPs in hospital: effects by outcomes associated w/ swallow evals

A

reductions in pneumonia rate (8% to 1%, 87% decrease)

77
Q

Aspiration increases relative risk of pneumonia by ______ times

A

7 (6.95)

78
Q

Risk factors pneumonia

A

older, male, severity of stroke, dysphagia, chronic obstructive pulmonary disease, coronary artery disease, ischemic stroke, permission dependency;

79
Q

Pneumonia after stroke associated with

A

mortality, longer hospital stay dependency at discharge BUT patents w/ more inpatient stroke services had reduced mortality after pneumonia; dramatically increased cost of hospitalization stay

80
Q

Dysphagia frequency in acute phase of stroke

A

over half of patients have; half resolve w/in 2 weeks, half develop chronically

81
Q

SLPs in hospital: effects by outcomes associated w/ swallow evals

A

reductions in pneumonia rate (8% to 1%, 87% decrease); decreased length hospital stay; increase nutrition; improved quality of life;

82
Q

Dysphagia frequency in acute phase of stroke

A

over half of patients have; half resolve w/in 2 weeks, half develop chronically (most likely in multiple, brainstem, or subcortical strokes0

83
Q

Of patients with dysphagia post CVA, how many aspirate and experience malnutrition?

A

half; 27% of aspirators, pneumonia

84
Q

Silent aspiration in neurogenic populations due to

A

voluntary compensatory processes that shield; reduced laryngeal cough reflex; cognitive impairment

85
Q

Voluntary compensatory processes for dysphagia (in neurogenic pops)

A

avoiding difficult to swallow items; cutting food into smaller pieces; smaller boluses; thorough chewing; slower eating; washing down solids with liquids; double swallowing; throat clearing/coughing; tilting/turning head while eating

86
Q

Prandial signs of neurogenic oropharyngeal dysphagia

A

drooling, impaired chewing, difficulty initiating swallow, nasal regurgitation, coughing, choking, food sticking in throat

87
Q

Non-prandial signs of neurogenic oropharyngeal dysphagia

A

Difficulty managing secretions (throat clearing, wet voice, coughing, choking)

88
Q

Complications from neurogenic dysphagia

A

Dehydration, malnutrition, laryngospasm, bronchospasm, aspiration pneumonia, asphyxia

89
Q

Etiologies of neurogenic dysphagia

A

stroke, TBI, dementia, huntington’s, parkinson’s, Amyotrophic lateral sclerosis, multiple sclerosis, guillain barre syndrome, myasthenia gravis, myopathies, cerebral palsy, iatrogenic, psychogenic etc

90
Q

Left CVA dysphagia

A

apraxia, mild delay in oral transit, mild delay in initiation of pharyngeal swallow (2-3 seconds); often normal pharyngeal stage once initiated

91
Q

Right CVA dysphagia

A

mild delay in oral transit, mild delay in initiation of swallow (3-5 seconds), delayed laryngeal elevation; more likely produce more severe dysphagia; impulsivity, decreased attn, poor judgement hard for compensatory strategies

92
Q

Subcortical CVA dysphagia

A

mild delay in oral transit, mild delay in initiation of pharyngeal swallow, impaired timing

93
Q

Unilateral v Bilateral CVA dysphagia

A

higher incidence and severity in bilateral; higher incidence w/ multiple CVAs

94
Q

Brainstem CVA dysphagia

A

most severe, persistent dysphagia b/c location of medullary swallowing center; severe initiation delay, reduction in elevation and anterior larynx excursion; reduced UES opening; unilateral pharyngeal weakness of vocal cord paralysis

95
Q

TBI dysphagia

A

diffuse nature of oropharyngeal deficits (variety; CN injury possible 9acceleration/deceleration injury); cognitive deficits may influence safe oral intake (decreased attn, short-term memory, reasoning)

96
Q

Dementia Dysphagia

A

decreased awareness of food in oral cavity; higher level cognitive processes involved with eating; pneumonia rates increase w/ decreasing physical and cognitive function, increase w/ gastrostomy tube placement

97
Q

Parkinson’s dysphagia

A

common in later stages; tremor/gait impairment (motor problems in coordination); pneumonia prevalent primary cause of death; oral: excessive lingual rocking/pumping, pre-swallow loss of bolus w/ spillage into pharynx/larynx; swallow hesitancy; pharyngeal: pooling reside, delayed onset of pharyngeal response

98
Q

Huntington’s disease/chorea dysphagia

A

advanced stages; management difficult due to cognitive impairment, abnormal movements (poor respiratory control), postural problems; increase calorie needs due to movement disorder; tachyphagia, respiratory chorea a/ aerophagia and excessive belching

99
Q

ALS impairment/dysphagia

A

UMN: spasticity, indoordination, increased reflexes; LMN muscle wasting, fasciculations, decreased reflexes; bulbar- speech and swallowing impairment; spinal- upper and lower extremity impairment; respiratory (bulbar & spinal)- cause of death

100
Q

Multiple Sclerosis dysphagia

A

optic nerves (optic neuritis), cerebrum (cognitive/behavior changes); spinal cord (weakness, spasticity, numbness, bowel and sexual dysfunction); brainstem (vertigo, nystagmus, dysarthria, dysphagia), cerebellum and BG (ataxia, tremor); treat w/ pharmaceuticals ; dyspagia in later stages as reduced pharyngeal peristalsis, delayed swallowing reflex, loss of control of secretions, disturbances in salivary flow, reduced range/speed of movement, abnormal taste sensation

101
Q

Guillain-Barre Syndrome

A

respiratory and nutritional supportive care often required (vent and tube feeding);

102
Q

Myasthenia Gravis (MG) dysphagia

A

neuromuscular junction disorder reducing supply of muscle-activating neurotransmitter; global rapid muscular fatigue (impeding swallow)

103
Q

Myopathy dysphagia

A

pharyngeal and esophageal involvement

104
Q

Cerebral Palsy dysphagia

A

lack of muscle coordination & tone, spasticity; wide variety of functional involvement; dysphagia: persistence of primitive reflexed (bite, suck/swallow), impaired tongue movement, decreased stability of mandible

105
Q

Iatrogenic dysphagia

A

medications; Benzodiazepines (sedative) decreased arousal, suppression of brainstem swallowing control; Antiemetics (for nausea/vomiting) extrapyramidal reactions (tradeoff dyskinesia); intubation and trache (laryngeal dysfunction); surgically induced (CEA, esophagectomy, anterior cervical fusion, poster fossa tumor resection)

106
Q

Psychogenic dysphagia

A

psychological, emotional problems manifesting as dysphagia (remember: many cases are undiagnosed neurological impairment)

107
Q

Dysphagia management

A

determine need for tube feeding; treat underlying cause of dysphagia; compensatory strategies w/ good knowledge of underlying cause; avoid meds that worsen; surgical management

108
Q

Chin tuck back (retraction)

A

narrows valleculae; prevents valleculae residue post-swallow; rarely used, requires cognitively intact patient

109
Q

Head rotation (left/right)

A

medializes TVC, closes single side of pharynx; closure of airway/narrowing of pharynx/directs bolus down good side; rotate to side of weakness in order to seal off weakness

110
Q

Chin down

A

widens valleculae; prevents moment of bolus into the airway prior to airway protection

111
Q

head tilt (left/right)

A

directs bolus along strong side or oral/pharyngeal cavity; allows for cohesive bolus and increase in coordination; Towards side of strength

112
Q

thermal stimulation

A

do when pharyngeal delay present; sensory enhancement for decreasing delay but NO carryover

113
Q

head tilt back

A

closes valleculae; reduces residue in valleculae;

114
Q

supraglottic swallow

A

do when penetration/aspiration present before/during swallow; closes TVCs tightly/clears airway immediately

115
Q

effortful swallow

A

do when decreased base of tone retraction or pharyngeal retraction; decreases post-swallow residual, increases swallow efficiency

116
Q

super-supraglottic swallow

A

do when decreased base of tone retraction or pharyngeal retraction; suproaglottic & effortful decreases post-swallow residual, increases swallow efficiency

117
Q

mendelsohn maneuver

A

do when decreased UES compliance/timing (pyriform pooling); decreases pyriform residuals/UES opens for longer time

118
Q

double swallow

A

do when pharyngeal residuals present; clears residuals

119
Q

mouth hydration

A

do when dry mouth; provides lubrication

120
Q

Lingual exercise

A

do when poor lingual range of motion/strength; strengthen lips and increases range of motion

121
Q

Pharyngeal exercise

A

do when poor pharyngeal contraction; increases pharyngeal strength/range of motion

122
Q

UES exercise

A

do when decreased UES opening; improves UES opening

123
Q

Larynx exercise

A

do when decreased laryngeal elevation; increases laryngeal elevation

124
Q

Lip exercise

A

do when poor lip closure; better lip closure

125
Q

palatal exercise

A

do when nasal reflux; effects are very questionable (don’t do?)

126
Q

jaw exercise

A

do when truisms; greater mouth opening

127
Q

swallowing aid for poor lip closure, poor anterior tongue movement

A

extended spout cup

128
Q

swallowing aid for trismus

A

pediatric spoon

129
Q

swallowing aid for poor grip and need to tilt head back

A

drinking aid w/ soft spout from bottom of cup

130
Q

swallowing aid to limit dosage of thin liquid

A

limited sip cup

131
Q

swallowing aid to bypass oral prep & oral stages

A

glossectomy spoon

132
Q

swallowing aid to place back of tongue in high position

A

straw

133
Q

swallowing aid for anterior closure

A

pacifier

134
Q

swallowing aid to direct bolus pass oral prep/oral stages

A

60cc syringe

135
Q

swallowing aide to close velopharyngeal port

A

palatal obturator

136
Q

swallowing aid to separate oral and nasal cavities

A

hard palate obturator

137
Q

swallowing aid to encourage palate to close

A

palatal lift

138
Q

CN V (UMN v LMN)

A

UMN: no effect (bilateral innervation); LMN: ipsilateral paresis, decreased bite, jaw deviates towards side of lesion

139
Q

CN VII (UMN v LMN)

A

UMN: forehead movement preserved, contralateral lower weakness; LMN: Unilateral weakness/paresis including forehead on ipsilateral side

140
Q

CN IX (UMN v LMN)

A

we don’t rely on gag reflex for swallowing

141
Q

CN X (UMN v LMN)

A

UMN: voice harsh, strained & poor palatal movement; LMN: soft palate droops ipsilaterally, uvula deviates contralaterally, voice breathy, hoarse, possible nasal regurgitation or hyper nasality

142
Q

CN XI (UMN v LMN)

A

LMN: hemiparesis/paralysis ipsilaterally when turning head (sternocleidomastoid); hemiparesis/paralysis of shrugging shoulders (trapezius) contra laterally

143
Q

CN XII (UMN v LMN)

A

UMN: Tongue deviates to opposite (contralateral) side, no atrophy; LMN: flaccid paralysis, atrophy on ipsilateral side, tongue deviates ipsilaterally, tongue fasciculations

144
Q

CN V Trigeminal

A

motor via foramen ovale: Muscles of mastication (temporalis, masseter, lateral & medial pterygoid); tensor tympani, tensor veli palatini, mylohyoid, anterior belly of digastric; Sensory: anterior 2/3 tongue via Spinal Trigeminal Nucleus; Sensory for face via Ophthalmic (superior orbital fissure), Maxillary (foramen rotundum) & Mandibular (foramen ovale & including all motor)

145
Q

CN VII Facial

A

Motor via internal auditory meatus: facial expression, posterior belly of digastric, stylohyoid, stapedius; Sensory: area behind ear & anterior tympanic membrane via spinal trigeminal nucleus; parasympathetic: sublingual (mucoidal) and submandibular (both); Special sensory: taste anterier 2/3 tongue (Solitary tract nucleus)

146
Q

CN IX Glossopharyngeal

A

Sensory for gag reflex; sensory and special sensory for posterior 2/3 tongue (Spinal Trigeminal Nucleus, Solitary tract); Parasympathetic: Parotid (serous) otic ganglion; motor: stylopharyngus (dilates pharynx); carotid sinus- blood pressure

147
Q

CN X Vagus

A

Sensory: Internal Branch of Superior Laryngeal Nerve- supraglottic, triggers swallow; Motor for gag reflex, external branch superior laryngeal nerve- cricothyroid & cricopharynxgeus; recurrent laryngeal nerve- adduction and abduction of true vocal folds

148
Q

CN XI Accessory

A

motor: trapezius and sternocleidomastoid; jugular foramen

149
Q

CN XII Hypoglossal

A

Motor: extrinsic muscles of tongue (genioglossus, styloglossus, hyoglossus/geniohyoid) & intrinsic muscles of tongue (superior & inferior longitudinal, vertical, transverse)

150
Q

Ansa Cervicalis

A

C1-C3; motor: infrahyoids- depress hyoid (thyrohyoid, sternohyoid, sternothyroid, omohyoid; geniohyoid (FoM) and Thyrohyoid (moves thyroid up)

151
Q

Floor of mouth muscles

A

Mylohyoid, anterior belly digastric (CN V); Geniohyoid CN XII

152
Q

Pharyngeal plexus

A

motor function for pharynx and palate

153
Q

Vocal fold adduction

A

lateral cricoarytenoid, transverse & oblique arytenoids, thyroarytenoid, vocales (recurrent laryngeal nerve)

154
Q

vocal fold abduction

A

posterior cricoarytenoid (CN X, recurrent laryngeal nerve)

155
Q

Extrinsic muscles of tongue

A

palatoglossus (CN X), genioglossus, styloglossus, hyoglossus (CN XII)

156
Q

Pharyngeal plexus

A

motor function for pharynx and palate; motor portion CN IX, X, XI (Glossopharyngeal, Vagus, Accessory)

157
Q

CN X Vagus

A

Sensory: Internal Branch of Superior Laryngeal Nerve- supraglottic, triggers swallow; Motor for gag reflex, external branch superior laryngeal nerve- cricothyroid & cricopharynxgeus; recurrent laryngeal nerve- adduction and abduction of true vocal folds; special sensory- take epiglottis

158
Q

Muscles of UES

A

Cricopharyngeus, thyropharyngeus, upper esophageal muscle

159
Q

Physiology of UES opening

A

Cricopharyngeus and sphinteric muscles (thyropharyngeus, UE muscle) relax via CN IX; Floor of Mouth( mylohyoid, anterior belly diagastric, geniohyoid) muscles contract, move forward to open the UES

160
Q

Time for each phase of swallowing

A

Oral prep: varies; Oral: 1; Pharyngeal 1-1.25; Esophageal: 8-20

161
Q

Oral Prep phase problems

A

mild occlusion, difficulty chewing, xerostomia, trismus, lateral spillage, bolus splitting, unable to form cohesive bolus

162
Q

Oral phase problems

A

posterior spillage, discoordination, lateral spillage, BoT retraction deficits, posterior/anterior spillage, tongue thrust, posterior lingual elevation deficit, bolus retention on any mouth surface, nasal reflux

163
Q

Pharyngeal stage problems

A

superior deficit (nasal reflux); medial: bolus retiention PPW, tongue, valleculae; inferior: bolus retention & residue on pyriform sinus

164
Q

Esophageal stage problems

A

cricopharyngeal bar, weakness FoM (narrow opening), stricture, aperistalysis

165
Q

Cricopharyngeal Bar

A

When cricopharyngus doesn’t relax; treat with botox

166
Q

Why do we need to recognize symptoms associated w/ esophageal disorders

A

to refer appropriately, rule out other etiologies, recognize the normal anatomy & physiology in order to provide best care and recognition/treatment for impairment

167
Q

Bolus presentation for FEES

A

Thin liquid, thick liquid, honey thick liquid, puree, solid (avoid getting residue on scope if possible)

168
Q

Bolus presentation for MBSS

A

Thick liquids, puree, solid in small to increasing amounts; thin liquids first ruins initial baseline

169
Q

Bolus presentation for Bedside Eval

A

Ice chips, water, nectar thick, honey thick, pudding thick, puree, soft solid, solid

170
Q

SEMG

A

Surface ElectroMyography; biofeedback examining muscle contraction during swallow (graph of peaks); limited assessment since only surface musculature but helpful for swallowing treatment for cognitively intact patients (ex: head & neck cancer)

171
Q

SEMG

A

Surface ElectroMyography; biofeedback examining muscle contraction during swallow (graph of peaks); limited assessment since only surface musculature but helpful for swallowing treatment for cognitively intact patients (ex: head & neck cancer); limited effectiveness, definitely efficacious

172
Q

VitalStim

A

electric stimulation to elicit muscle contraction to depress hyoid, which actually needs to elevate for swallow (training muscles to overcome/strengthen vs damaging your swallow); mixed evidence, no definitive support

173
Q

Blue Dye Test

A

Tells us if there’s gross aspiration BUT doesn’t rule out aspiration; reapply dye every 4 hours, check for aspiration every 7

174
Q

Myotomy

A

Surgery that cuts the lower esophageal sphincter so that food can enter stomach; would use if stricture of esophagus

175
Q

Zenker’s Diverticulum

A

Esophageal pouch in upper esophagus that makes it difficult to swallow, causes food regurgitation; treat w/ botox, surgery, or cricopharyngeal dilation; refer to ENT

176
Q

Cricopharyngeal Dilation

A

Stretching out cricopharyngeal muscle (UES) with bougie catheter

177
Q

How is botox used in swallowing disorders?

A

may be used to temporarily relax muscle/prevent contraction of muscle; placed in neck and lasts for 3-6 months; could treat cricopharyngeal bar, stricture (depending on cause), Zenker’s diverticulum

178
Q

Intervention with exercises in neurological disorders?

A

NO; degenerative diseases will continue to get worse, causing fatigue

179
Q

To provide best treatment, _______

A

gain full understanding of patient via assessment

180
Q

G-tube as prevention for aspiration, aspiration pneumonia?

A

NO; reflux can still be aspirated, does greater damage than food

181
Q

Langmore Predictors article re: g-tube

A

aspirations of tube feeding cause aspiration pneumonia; bacteriology of aspiration pneumonia of saliva from mouth say saliva bacteria is cause of aspiration pneumonia, poor hygiene may be likely from nurses when getting g-tube

182
Q

Clinical utility of MBSS

A

NOT just detecting aspiration; useful for routine management (to identify strategies, maneuvers, bolus sizes, diet consistency in therapy); highest clinical yield when diagnosticians can examine structural movement related to bolus movement simultaneously

183
Q

Role of subglottic pressure in tracheostomy

A

allows upper airway clearance by cough

184
Q

Can aspiration pneumonia be seen & diagnosed using chest x-ray alone?

A

no, rule-out diagnosis (rule out other causes of aspiration first) *note aspiration also rule-out diagnosis

185
Q

Importance of knowing anatomy when working in head and neck surgery

A

huge population of our caseload; need to know where nerves are, understand the normal to compare to abnormal

186
Q

What does Leder indicate about trache as cause of aspiration?

A

no causal relationship; consider other diseases, aspiration before trache continues

187
Q

Aspiration before, during, and after UES opening

A

before: result of delay in laryngeal elevation, closure of supraglottic structures; during: result of incomplete upper airway closure; after: due to inhalation of pharyngeal residue/poor pharyngeal clearing

Dysphagia (2 decks)

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