Management of Dysphagia

Question 1

Besides aspiration, what are two reasons for getting a chest infection?

Answer 1

Poor oral hygiene and being fed by someone else

Question 2

What is the likelihood of an error in medication if you have Dysphagia?

Answer 2

21%

Question 3

What do compensatory strategies for swallowing work on?

Answer 3

Symptoms

Question 4

What do swallowing exercises work on?

Answer 4

Physiology/underlying disorder

Question 5

Who is a ‘head back’ postural technique good for?

Answer 5

postural change (compensatory strategy) that’s good for someone who has a good pharyngeal swallow but very little oral movement. Ideal candidate would be someone who has had a glossectomy but NEVER trial without an instrumental assessment

Extra precaution - hold breathe

Question 6

What is the first decision to make after completing a detailed assessment?

Answer 6

Whether to treat or not

Question 7

Name 2 examples of patient perception protocols for swallowing

Answer 7

EAT-10

Sydney Swallow Questionnaire

Question 8

Name 5 factors to consider when deciding whether to treat for swallowing or not

Answer 8

Medical diagnosis (e.g. prognosis, cognitive abilities etc.)
Motivation
Home support
Respiratory function/Cardiac function (some interventions are not appropriate if a person has difficulties here)
Response to trial therapy

Question 9

What are the Dysphagia treatment goals?

Answer 9

Ensure swallow safety
Increase swallow efficiency
Enhance quality of life

Question 10

Why is adequate nutritional support vital for successful rehabilitation?

Answer 10

Allows maximal recovery and helps to avoid confusion, fatigue, pressure sores and can make wounds breakdown (if not getting)

Question 11

Name 4 means of non-oral support

Answer 11

Intravenous line (IV) 
Nasogastric Tube (NG) 
Gastrostomy tube (PEG or RIG) 
Jejunostomy tube (inserted further down in the bowel)

Question 12

When would a person be given an NG tube?

Answer 12

If they haven’t eaten or are unlikely to eat for 5 days or more OR have inadequate intake (e.g. less than half normal intake for 10 days)

Question 13

How long can a NG tube stay in place?

Answer 13

Up to 3 months

Question 14

When is a PEG recommended ?

Answer 14

When swallowing problems are likely to persist for 6 weeks or more

Question 15

What are the 3 options for management of swallowing disorders?

Answer 15

Surgical (e.g. vocal fold medicalisation, laryngectomy)
Pharmacological (e.g. anti-reflux, saliva management)
SLT rehabilitation (most common)

Question 16

What are the 3 types of SLT management for swallowing disorders?

Answer 16

1. Compensatory
2. Exercises
3. Combined Techniques

Question 17

Name 5 types of compensatory management approaches

Answer 17

1. Postural changes
2. Altering sensory input
3. Modifying volume of bolus presented
4. Modifying viscosity of bolus
5. Intravenous-oral prosthetics

Question 18

Who is compensatory management most beneficial for?

Answer 18

People with poor cognition. Compensatory management does not require good cognitive awareness and can be ‘delivered’ by a carer

Question 19

Head Turn - how? why?

Answer 19

How - turn head toward weak side, closing off the weak side of the pharynx and changing the pressure in the UOS

Why - unilateral pharyngeal weakness

Question 20

Head Tip - how? why?

Answer 20

Why - for both oral and pharyngeal weakness on one side (e.g. Brainstem stroke - likely to have weakness of palate on one side)
How - tip to the stronger side so food will go that way and down the stronger side of the pharynx

Question 21

Chin Down/Tuck - how? why?

Answer 21

Why - delay in swallowing trigger, reduced laryngeal elevation and difficulty swallowing liquids
How - much chin toward chest - hold for 5 seconds, repeat x10

Question 22

Head back/ Chin Up - how? why?

Answer 22

Why - good for someone with very little oral movements but a good pharyngeal swallow (e.g. HNC - glossectomy)
How - head and neck are extended backward and the chin is lifted before initiation of the swallow

Question 23

Give an example of how to alter sensory input?

Who might this be useful for?

Answer 23

Changing bolus characteristics (e.g. temperature, taste - lemon barley water)
Use downward pressure of spoon
Suck/swallow
For apraxic person - want them to be feeding themselves/hand-over-hand

Question 24

When does the pharyngeal swallow start?

Answer 24

At the point at which the bolus is just coming past the point where the base of tongue and the mandible intersect with each other (if bolus goes past this point without the pharyngeal swallow being initiated - delay)

Question 25

How do you know if someone has a pharyngeal delay?

Answer 25

At bedside give them a bolus and ask them to swallow while you palpate the larynx. You know they have tried to move the bolus when you feel the floor of mouth muscles moving. If the pharyngeal swallow doesn’t happen for a while after this - delay. Only way to be sure = VF

Question 26

What is ‘dump and swallow’ and who is it for?

Answer 26

If you know the pharyngeal swallow is safe but you know a person has reduced oral control. Get them to take a large volumes, head back and swallow. Using a large volume as you want them to get as much down as is possible.

Question 27

When would you suggest a decrease in bolus volume?

Answer 27

If there is a delay in the pharyngeal swallow - a smaller bolus will be contained within the vallecula until the pharyngeal swallow is initiated. (But you would try increasing bolus first - that is a more natural way to eat/drink)

Question 28

Give 3 examples of intra-oral prosthetics:

Answer 28

``` Palatal lowering appliance (bring hard palate down so the tongue can reach it) Palatal obturator (fill a hole where palate is split - HNC) Palatal lift (plate with extension at the back to keep soft palate in semi-elevated position) ```

Question 29

Name 3 types of Oro-motor exercises:

Answer 29

1. Tongue strengthening (e.g. depressor) 2. Range of movement (same as assessment) 3. Bolus control (e.g.polo on string) Note: these can be very good but might not translate easily to swallowing (need lots of coordination for that)

Question 30

Masoko Maneuver/Tongue Hold Maneuver | Aim? How?

Answer 30

Aim: increase BOT and PPW contact - this pressure generator is really important How: Tongue is held between the teeth to anchor it in an anterior position - the further out the tongue the harder it is. This encourages the PPW to increase movement and forces the BOT to work harder NB: never with food/drink

Question 31

Vocal Fold Adduction Exercises | For who? How?

Answer 31

For someone with vocal fold palsy | How - bearing down (e.g. pushing/pulling up on a chair) and brining the vocal folds together

Question 32

Falsetto - why?

Answer 32

Encourages laryngeal elevation - e.g. arpeggios/glides

Question 33

Shaker Exercise Aim? How?

Answer 33

Aim - increase hyoid elevation. As the hyoid is attached by the hyolaryngeal muscles, this will also increase laryngeal elevation How - lie on your back, elevate your head to look at your toes, hold for 5. Repeat 3-5 times Note: might need to make adaptions for people with find it difficult to get on/off bed

Question 34

Neuromuscular Electrical Stimulation How does it work? What is the issue with it?

Answer 34

How: by applying surface electrodes to muscles of swallowing to stimulate them and get them to contract (used by physios for foot drop) Issue: so many pharyngeal muscles - don’t necessarily know what you re stimulating (some for elevating, some for lowering) Note: NICe guidelines being developed

Question 35

Name the 5 types of combined management techniques for swallowing

Answer 35

1. Thermo-tactile 2. Supra-glottic swallow (SGS) 3. Super supra- glottic swallow 4. Mendelssohn Manoeuver 5. Effortful swallow

Question 36

Thermo-Tactile Stimulation Aim: How:

Answer 36

Aim: stimulating nerve ending in the mouth with tactile and temperature How: dip laryngeal mirror in ice-water for 10 seconds. Stroke lightly vertically up/down on each anterior faucial arch for 3-4 times toward the bottom Note: conflicting evidence

Question 37

Supraglottic Swallow: Aim? How?

Answer 37

Aim: Designed to close the vocal folds to protect the airway How: patient is instructed to hold his/her breathe just before swallowing to close the vocal folds. The swallow is followed immediately by a volitional cough

Question 38

Super-Supraglottic swallow: Aim? How?

Answer 38

Aim: designed to voluntarily move the arytenoids anteriorly, closing the entrance to the laryngeal vestibule before and during the swallow. Initially designed for people with supra glottic laryngectomy. How: Similar to to SGS. But with increased effort - hold breath and bear down. Continue to hold breath and swallow. Immediately after swallow, forceful exhalation

Question 39

Mendelssohn Maneuver: Aim? How?

Answer 39

Aim: prolong elevation of the larynx and therefore prolong UOS opening How: Swallow normally. When you feel the voice box go up, grab it with the throat muscles and don’t let it go down. Hold for the count of 3, let go. Repeat x5

Question 40

Effortful Swallow: Aim? How?

Answer 40

Aim - increases posterior tongue base movement to facilitate bolus clearance How - patient is instructed to swallow and push hard with the tongue against the hard palate ((Huckabee & Steele, 2006)

Question 41

What is the suggested order of compensatory/exercises/both for long term dysphagia management (acknowledging this will vary depending on the individual)?

Answer 41

1. Postural Changes 2. Alter sensory input 3. Swallow manoeuvres 4. Exercises 5. Volume changes 6. Food consistency modification (last for long term problem)