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Dysphagia > FINAL EXAM > Flashcards

FINAL EXAM Flashcards

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1
Q

The degree of cortical impairment depends on __

A

Location of damage
Extent of damage
Type of damage (trauma vs blunt force)
Unilateral vs. bilateral

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2
Q

what swallowing deficits would a lower brainstem stroke exhibit?

A

difficulty triggering the pharyngeal swallow
absent pharyngeal swallow
delayed pharyngeal swallow
reduced laryngeal elevation
reduced UES opening
medulla is affected

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3
Q

What is oral agnosia?

A

inability to visually recognize food or liquid

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4
Q

What oral agnosia may be exhibited in Dementia and Alzheimer’s patients?

A

The patient may not eat the food because they don’t realize it is food
May not know what to do with it or refuse to eat the food
Patient may need a feeding tube to maintain nutrition

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5
Q

why can patients with TBI be difficult to treat for dysphagia?

A

behavioral issues such as impulsive, poor attention and awareness
cognitive issues such as in and out of alertness, making it hard to counsel them and feed them
cannot eat or swallow if not alert

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6
Q

What swallowing deficits are associated with Parkinson’s?

A

oropharyngeal - poor bolus control
random tongue movement
tongue pumping/lingual rolling
delayed swallow initiation
pharyngeal residue
drooling (increases risk of silent aspiration)
incoordination of swallow and respiration
swallow as progressive as disease

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7
Q

Generalized treatments for Parkinson’s

A

Early Parkinsons’: exercises
Moderate Parkinson’s: sensory changes/input
Severe Parkinson’s: counseling on enteral nutrition/maximizing nutrition
quality of life as it’s a progressive, non-curable disease

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8
Q

Neurological disorders causing dysphagia: Dementia

A

causes dysphagia due to structural changes and chemical changes affecting neurological control

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9
Q

Neurological disorders causing dysphagia: TBI

A

external physical trauma to head
causes dysphagia due to changes in posture and muscular tone in muscles needed for swallowing
cognitive and behavior changes

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10
Q

Neurological disorders causing dysphagia: Parkinson’s disease

A

neurodegenerative disorder that occurs due to a disordered basal ganglia and causes slowed movements (bradykinesia) rigidity and tremors
rigidity and bradykinesia impacts swallow initiation time, UES relaxation, and pharyngeal residue

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11
Q

Neurological disorders causing dysphagia: Brain Tumor

A

causes dysphagia due to neurogenic changes, cranial nerve deficits, sensory/motor changes, cognitive changes

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12
Q

Neurological disorders causing dysphagia: ALS

A

progressive neuromuscular degenerative disease

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13
Q

Side effects of radiation; how does it effect swallowing

A

the scatter effect
mucositis - inflammation of mucous membranes
xerostomia - dry mouth in relation to decreased production of saliva
odynophagia - painful swallowing
edema - swelling
dental changes
fibrosis - scarring of tissue; changes into excessive fibrous connective tissue
may cause patient a lot of pain or discomfort when swallowing which leads to feeding tubes

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14
Q

why is dry mouth/xerostomia a problem in head and neck cancer patients?

A

causes patient to swallow less and less, which can lead to lack of nutrition, energy, weight loss, and insertion of feeding tube
this in turn can cause atrophy of pharyngeal muscles
this can also cause psychological and emotional problems as well such as depression

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15
Q

when should swallow treatment begin for a head and neck cancer patient?

A

the sooner therapy is initiated after cancer treatment, the better the outcome.
there is no consensus regarding the optimal time after treatment to begin dysphagia therapy

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16
Q

head and neck cancer before, during and after treatment

A

pre-treatment - establish baseline, protocols, START exercises and counseling
during - monitor, exercises, counseling
post - monitor for change, continue exercises, counseling

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17
Q

Why is it important to keep a head and neck cancer patient swallowing EVEN if they are aspirating?

A

Helps limit this buildup of residue and allows them to continue to exercise the structures to avoid worsening swallow inefficiency and atrophy of pharyngeal muscles

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18
Q

What is trismus?

A

Problems opening mouth, lockjaw
Reduced ability to open the mouth secondary to tonic/tight contraction of the muscle

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19
Q

What is a total laryngectomy-how does this affect swallowing?

A

physical separation of the GI tract from the respiratory tract; removal of the larynx, OR separation of the airway from the esophagus
This affects swallowing because there is no elevation because there is no larynx or hyoid bone

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20
Q

What specific swallow changes would you see in an oral cancer patient?

A

Limit mastication, bolus formation and containment, bolus control, and bolus transport from the front to the back of the mouth.

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21
Q

What specific swallow changes would you see in a laryngeal cancer patient?

A

Reduced laryngeal elevation
Reduced glottal and laryngeal closure
Reduced UES or PES opening
Reduced pharyngeal wall contraction

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22
Q

True/False. SLPs can diagnose esophageal dysphagia

A

FALSE. SLPs cannot diagnose – but they can perform esophageal SCREEN during MBS

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23
Q

Esophageal dysphagia can impact….

A

oropharyngeal function

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24
Q

The esophagus is……

A

Innervated by CN X (Vagus)
Proximal 1/3 - striated muscle; Distal 2/3 - smooth muscle
Hollowed muscular tube; Collapsed at rest; distends when food/liquid/air is swallowed

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25
what is peristalsis?
a series of muscular contractions
26
what are the three different types of peristalsis?
primary - rapid movement of cervical esophagus; slow movement of mid/distal esophagus; shortens secondary - distends tertiary wave - not peristaltic; disordered
27
symptoms of esophageal dysphagia
Food sticking in throat (globus sensation), coughing during/after meals – Common Chest pain, shortness of breath, respiratory symptoms, odynophagia – less common Patient sensation is often inaccurate Referred sensation – sensation of something stuck in throat, but actually stuck in esophagus due to esophageal innervation by vagus nerve
28
different kinds of structural disorders of the esophagus
esophageal stenosis/stricture schatzki's ring esophageal web malignancy/obstruction diverticulum
29
what is esophageal stenosis/stricture?
narrowing of esophagus caused by: - GERD, ingestion of corrosive substances (acids), radiation therapy, esophageal cancer, infection
30
schatzki's ring
circular band of mucosal tissue on distal/lower esophagus and usually symmetric see a slow progression of symptoms
31
esophageal web
thin membranes that grow on the upper 1/3; usually asymmetric
32
malignancy/obstruction
usually from esophageal tumors or Barrett's esophagus (premalignant condition due to severe/chronic GERD) progresses rapidly - usually advance by time detected
33
diverticulum
pouch/sac branches off esophagus due to bulging from esophageal pressure regurgitation zenker's diverticulum - common and develops at UES cricopharyngeal bar - failure of muscle to distend (stretch)
34
motility disorders of esophagus
1. GERD - LES muscle relaxation results in backflow of stomach acid into the esophagus 2. Laryngopharyngeal Reflux (LPR) - backflow of stomach acid into laryngopharynx 4. Achalasia - incomplete/absent relaxation of LES and bolus can't move into stomach; absent peristalsis 5. Eosinophilic Esophagitis - allergic inflammatory disease
35
treatments of esophageal disorders
myotomy dilation fundoplication botox
36
supplemental oxygen types for respiratory dysphagia
nasal cannula BiPap CPAP non-rebreather
37
what is the endotracheal tube?
oral intubation; long/plastic tube placed through mouth - vocal folds - trachea; cuff on the end can be inflated/deflated; connected to ventilator; patient sedated
38
What are the risks associated with the Endotracheal tube?
- granuloma - hematoma - ulcers - edema - vocal fold paralysis - deconditioning - delayed swallow response time
39
what is a tracheostomy tube?
a hole created in neck to the trachea allows patient to wean sedation, initiate mobility, possibility for speaking/swallowing, deflated to allow air to flow to oral cavity
40
risks of tracheostomy tube
1. decreased taste/smell 2. increased risk of aspiration 3. deconditioning from medical condition requiring trach placement
41
what is a cuffed trach and associated risks?
- inflated to maintain air from vent to lungs, prevent aspiration - increased risk of silent aspiration if cuff inflated
42
speaking valve
- Allows air in through trach during inhale and closes during exhale; moves air around trach tube through vocal folds and into oral cavity - Improves upper airway secretions, ability to cough/clear secretions and improves speech
43
what is COPD?
group of progressive lung diseases (emphysema and chronic bronchitis) chronic obstructive pulmonary disease
44
COPD risks
Increased risk of aspiration due to decreased hyolaryngeal excursion, delayed oral/pharyngeal initiation, deconditioning, swallow on inhale cycle, and earlier and longer apneic periods
45
what is iatrogenic dysphagia?
difficulty swallowing that is caused by medical treatment or intervention (surgeries)
46
True or false: head and neck surgeries increase risk of dysphagia
false
47
what surgeries can cause dysphagia?
thyroidectomy carotid endarterectomy (CEA) cardiovascular surgery skull base surgery
48
Possible complications of surgeries
damage to vagus nerve unilateral vocal fold paralysis intubation deconditioning
49
what are possible complications of cervical spine surgery?
prevertebral edema, esophageal injury, vagus nerve injury
50
what is cervical osteophytes and possible complications?
- Bony outgrowth of the cervical vertebrae; narrows pharyngeal space - Possible complications: Obstructive dysphagia, most symptomatic at C3 and C6
51
what is an esophagectomy and possible complications?
- removal of esophagus or portion of esophagus - Possible complications: vagus nerve injury, changes to esophageal motility, stricture, pharyngeal/esophageal dysphagia
52
what are possible complications of thermal burn trauma?
inflammation intubation/trach anoxic BI sedation
53
Postural maneuvers & compensation techniques for dysphagia: head tilt
directs bolus to good/strong side
54
Postural maneuvers & compensation techniques for dysphagia: head turn
closes weak side
55
Postural maneuvers & compensation techniques for dysphagia: chin up
improves anterior-posterior oral transit; use only with good pharyngeal phase/airway closure
56
Postural maneuvers & compensation techniques for dysphagia: chin tuck
improves oral containment, increases BOT/PPW contact, decreases laryngeal vestibule diameter
57
Postural maneuvers & compensation techniques for dysphagia: supraglottic swallow
improves laryngeal vestibule closure
58
Postural maneuvers & compensation techniques for dysphagia: super-supraglottic swallow
tighter laryngeal vestibule closure
59
Postural maneuvers & compensation techniques for dysphagia: effortful swallow
increases BOT/PPW pressure, pharyngeal pressure, improves UES opening and hyolaryngeal excursion
60
Postural maneuvers & compensation techniques for dysphagia: repeat swallows
can clear pharyngeal residue
61
Postural maneuvers & compensation techniques for dysphagia: mendelsohn maneuver
improves hyolaryngeal excursion/UES opening, improved coordination but difficulty to teach
62
associated risks with chin tucks
can increase risk of aspiration with delayed initiation, pyriform sinus residue
63
what are compensation techniques that are modifications?
Small bites/sips, slow rate, alternate liquids/solids, no straws, etc. Liquid modifications – thin, nectar/mildly thick, honey thick/moderately thick liquids Carbonated/sour/cold bolus – immediate effects of timing, but no long-term improvement Frazier free water protocol – thickened liquids (as indicated) at meals, free water between meals (Strong oral care required) Diet modifications – national dysphagia diets, IDDSI, clear or full liquids
64
benefits of liquid modifications?
slows bolus transit reduces aspiration; but no strong evidence it decreases pneumonia rates possible decreased fluid intake
65
exercises principles for swallowing rehabilitation include..
1. gradual progression of intensity 2. frequency (Number Of Training Sessions Per Unit Of Time) 3. load
66
head and neck muscular swallowing rehabilitation is specialized for
speech > force
67
effortful swallow
targets lingual/palatal pressure, lingual strength, oral manipulation, pharyngeal pressure, hyolaryngeal excursion/UES opening, BOT/PPW pressure
68
tongue-hold/masako
works on BOT/PPW contact and pharyngeal constriction
69
head-lift/shaker
targets laryngeal elevation, hyolaryngeal excursion/UES opening
70
CTAR (chin tuck against resistance)
targets laryngeal elevation, hyolaryngeal excursion/UES opening
71
mendelsohn maneuver
targets laryngeal elevation
72
EMST (expiratory muscle strength training)
targets buccinator strength, BOT/PPW contact, hyolaryngeal excursion, laryngeal vestibule closure, cough strength, breath support
73
MDTP (McNeil Dysphagia therapy program)
possibly targets pharyngeal response and hyolaryngeal excursion
74
jaw opening
targets laryngeal elevation, UES opening
75
Effortful pitch glide
targets laryngeal elevation, hyolaryngeal excursion, pharyngeal contraction/shortening
76
sEMG (device)
adjunctive therapy and biofeedback
77
NMES (neuromuscular electrical stimulation)
possibly targets pharyngeal response time, pharyngeal transit time, hyolaryngeal excursion
78
IOPI (device)
targets lingual/palatal pressures, bolus/pharyngeal transit, BOT/PPW contact
79
swallow strong/tongueometer
targets lingual/palatal pressures; biofeedback
80
true or false: there is no evidence to support thermal-tactile stim
true
81
biofeedback
sEMG - visual representation of muscular effort placed during swallow response; patient can visualize effort and increase/decrease with feedback provided
82
what are two swallowing prevention techniques?
Pharyngocise – various exercises included to be completed prior to or during XRT for head/neck cancer Therabite – device used to improve/maintain jaw opening Targets muscle preservation, trismus, saliva production, taste
83
Head/neck development in normal infant/child development
- oral cavity/jaw smaller - oral cavity filled by tongue - large/fat buccal pads - uvula/epiglottis in contact at rest - larynx/hyoid bone higher in neck - Eustachian tubes shorter and run horizontal
84
gut development for infant/child
anatomic completed by 20 weeks; physiologic function late in gestation
85
lung development for infant/child
latest to develop; 28 weeks - surfactant development
86
neurological development for infant/child
- 1st trimester - spinal cord beings to develop - 2nd trimester - brainstem matures, breathing/sucking/swallowing being to emerge - 3rd trimester - brainstem most highly developed, primitive cerebral cortex
87
fetal development
- 7 weeks lips form - 13 weeks swallowing - 18 weeks sucking - 32 weeks suck/swallow coordination - 37 weeks suck/swallow/breathe coordination
88
infant swallowing phases
oral prep oral transit initiation of pharyngeal swallow pharyngeal phase esophageal phase
89
what is the purpose of adaptive reflexes and what are they?
direct feeds to gut rooting, suckling, sucking
90
nutritive vs nonnutritive suck
Nonnutritive suck – suck/swallow ratio 6:1 to 8: 1, twice as fast as nutritive suck Nutritive suck – integrates suck/swallow/breathe; suck/swallow 1:1 ratio (Immature (3-5 sucks/burst), transitional (5-10 sucks/burst), mature (10-30 sucks/burst))
91
what is the purpose of protective reflexes and what are they?
airway protection tongue protrusion, phasic bite, gag, tongue lateralization, cough, laryngeal chemoreflex
92
infant/child disorders that cause dysphagia
1. Respiratory disorders (newborn apnea, pulmonary hypoplasia, RDS, BPD, laryngomalacia) 2. Cardiac disorders (tetralogy of fallot, transposition of great arteries, VSD, patent ductus arteriosus) 3. GI deficits (NEC, Hirschsprung’s disease, esophageal atresia, GERD, EoE) 4. Neurological disorders (hydrocephalus, TBI, CP, intraventricular hemorrhage, seizures) 5. Cleft Lip/Palate (lip only, lip and palate, hard and/or soft palate, velopharyngeal insufficiency) 6. Congenital (Pierre Robin sequence, Moebius syndrome, Down syndrome) 7. Material Conditions (FAS, NAS) 8. Prematurity (difficulty with state control, stress, postural control, oral motor control, gut maturity/health, physiological control, respiratory rate, heart rate, endurance, suck/swallow/breathe) 9. Tongue Tie (tight lingual frenulum, creates heart shaped tongue when protruded, can affect breast feeding (poor latch), treatment with frenulotomy) 10. Sensory processing (hypersensitivity, hyposensitivity, oral sensitivity) 11. Autism Spectrum (usually demonstrate oral motor delay, sensory sensitivity or desire for sameness) * Any of these deficits can result in nutrition/hydration/energy concerns
93
child treatment for dysphagia
1. Oral sensory – motor therapy; determine if skill deficits, learned behavior or both 2. Special Feeding equipment – teething toys, gum brushes, food nets, nosey cups 3. Oral motor toys – chewy tubes, bite blocks, tongue depressors 4. Specialty spoons – textured, maroon 5. Positioning – important, feed/back/ trunk/head support 6. Behavioral Feeding Therapy
94
what is the purpose of behavioral feeding therapy?
- Increase desirable behavior - accepting foods offered, eat acceptable amount, eat variety of foods, quality over quantity - Decrease undesirable behavior - refuse foods, verbal/physical protests, withdrawal or refusal
95
infant treatment for dysphagia
1. Side-lying – changes direction of gravity, milk diverted to cheek 2. Flow rate – slow flow to improve coordination of suck/swallow/breathe, improves ability to control flow 3. External Pacing – tip bottle downward to allow fluid into bottle, but leave nipple in baby’s mouth 4. Thickened liquids – slows flows, decreases regurgitation, use caution with commercial thickeners 5. Chin/Cheek support – improves seal on nipple; used as a cue not a crutch 6. Quality over Quantity – support positive experiences; negative experiences can create stress and eventually learn to avoid eating or develop bad patterns
96
what is cue based feeding?
involves following the infants cues to drive feeding
97
what does quality vs quantity mean in infant feeding?
priority is feeding performance over amount taken in
98
what are the signs of stress in infant feeding?
- change in state/alertness - change in tone/postural control - raised/furrowed brows - pull head back - turn head away - hand/arm extension - finger splay - gulping, gurgling, milk spilling out of mouth - coughing/choking, gagging - Change in cardio-respiratory behavior
99
what are the sings of disengagement in infant feeding?
- pushing nipple out - no active rooting/sucking, - unable to re-alert - use of weak suck
100
what is involved in a child/infant evaluation for dysphagia?
Swaddling – important to regulate state, improves coordination; midline flexion – arms/legs to chest Treatment strategies are used during evaluation to compensate for deficits if noted Caregiver focus If dysfunction or risk of aspiration present, pursue MBS or FEES

Dysphagia (5 decks)

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