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Dysphagia > MIDTERM > Flashcards

MIDTERM Flashcards

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1
Q

Oral prep explanations

A

Saliva is created. Bolus is prepared. Need a labial seal, increased buccal/facial tone, and lateral motion of jaw and tongue.

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2
Q

Cranial nerves involved in oral prep

A

CN V (trigeminal) VII (facial) XII (hypoglossal)

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3
Q

Oral phase explanation

A

Anterior to posterior bolus transit

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4
Q

Cranial nerves in oral phase

A

V (trigeminal) VII (facial) X (vagus) XII (hypoglossal)

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5
Q

Pharyngeal phase explanation

A

Velopharyngeal closure.
Forward hyoid movement.
Tongue base retraction to contact posterior pharyngeal wall.
Laryngeal elevation.
Closure of larynx (apneic period)
Pharyngeal constriction.
UES relaxes and opens

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6
Q

how does UES open

A

brainstem sends signal to relax
hyolaryngeal excursion provides traction

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7
Q

Order of laryngeal closure

A

Arytenoids tilt forward.
Epiglottic inversion.
True vocal folds adduct.

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8
Q

Pharyngeal phase cranial nerves

A

IX (glossopharyngeal) X (vagus) XI (accessory)

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9
Q

Esophageal phase explanation

A

Paristalsis (wavelike muscular contractions) moves bolus through esophagus

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10
Q

Esophageal phase cranial nerves

A

X (vagus)

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11
Q

Where is the main neural control of swallowing located?

A

Brainstem; specifically the medulla & pons

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12
Q

Cranial nerves of medulla

A

IX (glossopharyngeal) X (vagus) XI (accessory) XII (hypoglossal)

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13
Q

Cranial nerves of pons

A

V (trigeminal) VII (facial)

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14
Q

Medical consequences of pharyngeal dysphagia

A

Aspirational pneumonia
Dehydration/malnutrition
Mortality risk
Confusion
Organ failure
Decreased energy
Further decomp of swallow function

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15
Q

Psychosocial consequences of pharyngeal dysphagia

A

Costly
Social isolation
Fear
Stress to achieve expected consistency
Family burden
Displeasure

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16
Q

Rehab options following acute care

A

Inpatient rehab
SNF
Outpatient
Home health
Long term acute care

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17
Q

Normal changes of swallowing oral prep stage

A

Decreased lingual movement and strength

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18
Q

Normal changes of swallowing oral stage

A

Increased mastication time

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19
Q

Normal changes of swallowing pharyngeal stage

A

Decreased laryngeal excursion
Longer airway closure time
More residue
Slowed pharyngeal transit
Penetration is common
Aspiration occurs more often

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20
Q

Normal changes of swallowing in esophageal stage

A

Slower time for UES to relax
Esophageal transit may be delayed

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21
Q

What is the difference between penetration and aspiration?

A

Penetration - food/liquid at the vocal folds or above
Aspiration - food/liquid that falls below the true vocal folds

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22
Q

Changes of healthy aging

A

Decreased taste, smell, vision
Dentition changes
Voice, respiratory, musculoskeletal, and GI system changes
Sarcopenia (gradual loss of muscle mass, strength, function)

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23
Q

What clinical and instrumental methods do we use to evaluate swallowing?

A

Clinical swallow eval (bedside)
MBS (modified barium swallow)
FEES (fiberoptic endoscopic evaluation of swallowing)

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24
Q

Purpose of clinical swallow eval

A

Develop hypothesis of swallowing dysfunction
Determine if instrumental swallowing evaluation is warranted
Determine if patient can follow swallowing strategies

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25
Importance of case history during clinical swallow eval
How current and previous medical conditions can impact function Patient's subjective complaints Obtain info on gross motor/cognition/communication
26
Role of UES (upper esophageal sphincter)
Opens when larynx closes to protect airway and prevent aspiration Signal from brainstem allows it to relax/open and further pulled open via traction from hyolaryngeal excursion/elevation
27
Main muscle of UES
Cricopharyngeus
28
Why are the normal healthy elderly at risk for swallowing problems?
Overall reduction in reserve anatomical/physiological changes Poor reserve to tolerate age related changes in addition to illness Penetration and possibly trace aspiration may be normal
29
Oral mech cranial nerves lingual movement, strength, coordination
XII hypoglossal - motor movement - range lateralization elevation stick out your tongue, move side to side, now quickly, move up and down push tongue into cheek then other cheek push tongue on outside of cheek, push against patient tongue DDK phrase
30
Oral mech cranial nerves jaw
V trigeminal jaw opening to resistance, jaw lateralization
31
Oral mech cranial nerves lips
VII facial V trigeminal assess labial seal - close your mouth and fill cheeks with air
32
Oral mech cranial nerves oral cavity
velum/soft palate assessment - X vagus V trigeminal movement/elevation; open mouth and say ahh (note hypernasality, use tongue depressor)
33
Oral mech cranial nerves face
VII facial V trigeminal facial symmetry - smile, pucker
34
oral mech cranial nerves gag
IX glossopharyngeal X vagus use tongue depressor to lightly contact posterior tongue or anterior faucial pillars contraction? 1/3 of normal people do not have gag reflex
35
oral mech cranial nerves larynx
X vagus cough strength quality and productivity voice strength quality and productivity breath support?
36
oral mech cranial nerve taste
VII facial IX glossopharyngeal
37
Viscosities for clinical swallow eval
liquids, puree, solids mixed ex. water, applesauce/pudding, crackers use ice chip as appropriate
38
Volumes for clinical swallow eval
small sip, normal drink, large drink, consecutive drink gradually increase volume 1/2 teaspoon, full teaspoon, small bite, large bite *look at self-feeding & do multiple trials*
39
Clinical swallow eval limitations
Cannot assess pharyngeal or esophageal phase Cannot determine if aspiration or penetration is present
40
Signs of aspiration clinical swallow eval
Cough, choke, wet vocal quality, throat clearing
41
Hyolaryngeal palpation
Positioning of fingers on larynx for palpation Index finger on hyoid bone Middle finger on thyroid notch Ring finger on cricoid cartilage
42
MBS purpose
Suspicious of dysphagia and require confirmation, additional concerns Identify/determine type and severity of swallowing function or impairment Determine presence, cause and response to penetration/aspiration Assess use of compensatory strategies or diet modifications on bolus flow and airway protection MBS is NOT a “pass” or “fail” test*
43
MBS pros
Lateral & anterior posterior view Oral, pharyngeal and upper esophageal views of phases Determine type and severity Visualization penetration/aspiration
44
MBS cons
Radiation exposure No direct view of mucosa/vocal folds Equipment is not mobile Time limit Weight limit Not for medically complex patients Costly
45
MBSimp Oral Phase Components
1. Lip closure 2. Tongue control during bolus hold 3. Bolus preparation/mastication 4. Bolus transport/lingual motion 5. Oral residue 6. Initiation of pharyngeal swallow
46
MBSimp Pharyngeal Phase Components
7. Soft palate elevation 8. Laryngeal elevation 9. Anterior hyoid excursion 10. Epiglottic movement 11. Laryngeal vestibular closure 12. Pharyngeal stripping wave 13. Pharyngeal contraction 14. Pharyngoesophageal segment opening 15. Tongue base retraction 16. Pharyngeal residue
47
MBSimp Esophageal phase components
17. Esophageal clearance
48
MBS compensatory strategy evaluated
Spontaneous secondary swallow
49
Why MBS? (is indicated if...)
Clinical exam fails to answer clinical question Swallowing complaints or deficits are vague and require confirmation or more analysis Nutritional or respiratory issues indicate suspicion for swallowing dysfunction Safety or efficiency of swallowing is a concern Direction for swallowing rehab/goals Assists to identify underlying medical problem contributing to dysphagia symptoms
50
Why NOT MBS?
Patient is too medically compromised Patient is too uncooperative MBS would not alter the clinical course/plan
51
Information obtained from MBS
Visualization of the oral and nasal cavities, nasopharynx, oropharynx, hypopharynx, larynx, upper trachea and upper esophagus Self-feeding skills All aspects of MBSimp
52
Normal physiology oral prep components
No labial escape Cohesive bolus between tongue to palatal seal Timely and efficient chewing and mashing with complete recollection of bolus
53
Normal physiology oral components
Brisk tongue motion Complete oral clearance Bolus head at posterior angle of ramus at initiation of swallow
54
Normal physiology pharyngeal components
No bolus between soft palate and posterior pharyngeal wall Complete superior movement of thyroid and approximation of arytenoids to epiglottic petiole Complete anterior movement of hyoid Complete epiglottic inversion No air/contrast in laryngeal vestibule Complete stripping wave Complete pharyngeal contraction Complete distension of PES no obstruction Complete pharyngeal clearance
55
Normal physiology esophageal components
Complete clearance No retrograde flow
56
Purpose of FEES
Visual of pharynx and larynx Provides info relative to swallowing physiology and safety
57
Info obtained from FEES
Anatomical variations Vocal fold movement VP closure Secretion management Presence of aspiration/penetration Airway closure Swallow initiation Pharyngeal residue Epiglottic inversion Effectiveness of compensatory strategies
58
White out analysis in FEES
closure of airspace around endoscope height of swallow if not indicated means poor pharyngeal clearance
59
Pros of FEES
Can assess secretion management Visualize surface anatomy No radiation Test compensatory strategies Portable for medically fragile patients
60
Cons of FEES
No oral or esophageal phases White out period during pharyngeal phase More invasive Cannot see laryngeal elevation and BOT retraction
61
FEES is indicated when....
MBS not available Difficult positioning Concern for radiation exposure Want to assess secretion Medically fragile patient
62
FEES is not indicated.....
Patient has severe agitation Recent/significant nasal trauma Bilateral nasal obstruction Can't tolerate procedure Need to see esophageal clearance, BOT retraction, laryngeal elevation etc.
63
Eval components of FEES
Anatomy Timing Residue Secretions Aspiration/penetration
64
Residue + FEES
Look at location, amount, consistency, sensation, and clearance (cued vs reflex) More residue = decreased pharyngeal pressure Location of residue = where pressure is decreased
65
Secretions + FEES
Unique to FEES Amount (none to pooling) Texture Location Important to look at because secretions may fall in airway due to swallowing dysfunction **bacteria risk**
66
Compensatory strategies evaluated in FEES
single drink, small bite, head tilt, chin tuck, alternate liquids/solids, breath hold, effortful swallow, repeat swallow Unique to FEES!
67
Viscosities FEES
thin liquids nectar puree solid repeat as appropriate
68
Viscosities of MBS
5ml thin 5ml thin cup sip thin sequential thin 5ml nectar cup sip nectar sequential nectar 5ml honey 5ml pudding solid
69
Differences in MBS and clinical swallow eval
radiation exposure MBS barium presence MBS oral cavity view only CSE mobile equipment CSE time limit MBS oral phase only CSE pharyngeal residue MBS visualization of swallow MBS amount of aspiration MBS aspiration cleared MBS hardware view MBS weight limit possible MBS MD present MBS medically complex patients CSE
70
Differences between MBS and FEES
radiation exposure MBS tolerance of scope FEES visualization of surface anatomy FEES visualization of vocal folds FEES secretion FEES compensatory strategies FEES positioning FEES esophageal visualization MBS UES function MBS visualization during height of swallow MBS total laryngectomy ?? (MBS)

Dysphagia (5 decks)

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