Midterm

Question 1

Phases of Swallowing

Answer 1

Oral preparation
Oral phase (oral transit)
Pharyngeal
Esophageal

Question 2

Oral Prep Phase

Answer 2

1 swallowing
-place food in mouth, manipulate/chew food
Sensory recognition of food
Labial closure, seal and stripping
Buccal tension
Soft palate is pulled down and forward
Bolus manipulation
Chewing
Bolus formation

Question 3

Oral Phase

Answer 3

(1-1.5 seconds) step 2
Propel bolus posteriorly
Posterior movement of bolus
Tongue tip and lateral margins of tongue held against alveolar ridge 
Central groove at midline of tongue 
Lingual stripping

Question 4

Pharyngeal Phase

Answer 4

(1second) step 3
Transit bolus vertically through pharynx
Velopharyngeal closure
Hyolaryngeal elevation
Laryngeal closure
Base of tongue retraction
Cricopharyngeal opening

Question 5

Esophageal Phase

Answer 5

(8-20 seconds) step 4
Transit bolus vertically through esophagus
UES closes as soon as bolus passes into the esophagus
Bolus transits through esophagus via peristalsis

Question 6

Swallowing vs. feeding disorder

Answer 6

Swallowing disorder as problems with one of four stages of swallowing.
Feeding disorder-may have difficulty bringing bolus to oral cavity

Question 7

Definition of Dysphagia

Answer 7

Impairment in any of four phases of swallow may be symptom of underlying disease patient has.
Depending upon where damage was if had stroke.
Patient may lose weight, may have regurgitation.
May have reduced sensation.
Need saliva to help break down bolus in smaller pieces to help trigger swallow.

Question 8

Consequences of Dysphagia

Answer 8

Could be result of stroke, head and neck cancer, certain medications.
-Medical consequences- depends on disease. Could develop aspiration pnemonia, poor nutrition and hydration.
-Psychosocial consequences- patient part of senior group see show and lunch once a week. Now life has changed impacts functioning because of emotions now. -Celebrations and occasions are involved around eating impacts psychosocial
-Clinical management- clinical swallow exam. Get case history, chart review, make determination of patient after swallow exam to see if requires instrumental exam to further assess, then determine treatment options and strategies (diff. postures? Or diet changes?)
Clinical Examination
Instrumental Examination
Treatment Options

Question 9

Signs and Symptoms of Dysphagia

Answer 9

Difficulty recognizing food- cognitive function impacted
Difficulty controlling food/ liquid – do they regurgitate
Difficulty controlling saliva- constantly drooling? Open mouth no tight lip seal
Coughing
Recurrent pneumonia
Unexplained weight loss- important symptoms as well as tiredness
Gurgly voice – sound like gargling all the time. Wet vocal quality maybe food or liquid is going into airway. Not coughing to protect airway.
Any perceptual changes that they notice in their bodily functions. Leads patient to seek medical help, sometimes patients ignore symptoms until it gets too bad they seek help. Common complaint-food getting stuck.
-signs are objective measures of behavior that people elicit during examination.
Ex: lab findings to find out patient has pneumonia, or white blood cell count is really high. Sometimes symptoms overlap.

Question 10

Diagnosis and Treatment of Dysphagia

Answer 10

Define feeding and swallowing problem 
Identify etiology
Determine appropriate diagnostic tests
Plan approach
Implement treatment
Monitory progress
Evaluate progress 
Slp responsible for assessment and intervention of swallowing disorders. 
-chart review, patient interview to possibly identify etiology. Determine tests..

Question 11

Who Manages Dysphagia

Answer 11

Speech-language pathologist- primary person
Otolaryngologist- important for upper digestive tract
Gastroenterologist- lower digestive issues. If give Modified barium swallow. Give patients different food consistencies. Notice reflux but don’t diagnose-ask radiologist. Refer to gastro.
Radiologist
Neurologist- neurological based disorder, stroke, tbi
Dentist- if require any prosthetic device for oral cavity
Nurse- important because they are with the patients all the time. Help feed patients
Dietition- responsible for establishing type of diet
Occupational Therapist- may need different feeding utensils
Pulmonologist-physician/respiratory therapist- if patient is on trach or ventilator dependent. Not regular members of the team. But could have a role depending on primary diagnosis

Question 12

Settings for Dysphagia Patients

Answer 12

Acute Care Setting- hospital
Sub-acute Care Setting- more medical monitoring. Could be rehab within hospital or skilled nursing facility. Intensive speech but medically clear
Skilled Nursing Facility- more long-term care. Patient may have alzheimer’s . Care for patient and keep patient safe
Home Health Care- slp receives eval and conducts eval and treatment. May do more cognitive rehabilitation

Question 13

Aging is determined by

Answer 13

Passage of years
Genetic make-up
Environmental factors

Question 14

Swallowing Changes in normal aging

Answer 14

Changes in oral cavity
Loss of dentition and loss of bone mass
Reduced taste sensation
Changes in the pharynx/ larynx
Reduced maximal hyolaryngeal movement (reserve)
Ossification of thyroid and cricoid cartilages
Lowering of larynx to C7 (>70 y.o.)

Question 15

Presbyphagia

Answer 15

Normal age related changes in swallow function in healthy individuals
Increased duration of oral transit
Slight increase in frequency and extent of oral residue reduced sensation
Uncoupling of oral and pharyngeal stages
Delay in triggering of pharyngeal swallow
Delayed hypolaryngeal elevation
Increase in frequency and amount of pharyngeal residue

Question 16

Common complaints with COPD

Answer 16

Xerostomia- dry mouth
Heartburn
Chest pain
Mouth breathing
 lightheadedness
Restless leg syndrome
Sleep apnea

Question 17

Scleroderma

Answer 17

causes skin to thicken and harden. Lose energy and strength. Throw up food, lose weight. Difficult breathing, lose sense of balance. Respiration and swallowing needs to be coordinated.

Question 18

What is affected if there is cortical damage?

Answer 18

Anterior L or R hemisphere:
Oral phase impairment
Apraxia: no tongue response or searching tongue movement
Delayed oral transit
Pharyngeal phase impairment
? Delayed pharyngeal swallow
Note: Bilateral damage ↑ prevalence and severity

Question 19

What is affected if there is brainstem damage?

Answer 19

Lower brainstem (medulla)
Oral phase may or may not be intact (depending on CNXII involvement)
Pharyngeal phase impairment
Swallow reflex may be absent initially
Delayed pharyngeal swallow
Unilateral pharyngeal weakness
Reduced hyolaryngeal elevation → reduced UES opening

Question 20

Complicating Factors

Answer 20

Medical history (previous strokes)
Concomitant diseases (comorbidities)- combo of COPD or respiratory diseases, heart disease, TBI in addition? Impacts prognosis
Post-stroke complications-
Cognitive impairments- able to follow directions, alert, oriented, aware and able to perceive their problems?
Age

Question 21

What is affected with TBI

Answer 21

More diffuse damage
Coup, contrecoup
Shear
Swelling
Oral preparation, transit and/or pharyngeal phases may be imparied
Complications:
Physical damage to larynx, other structures
Cognitive deficits-follow directions, express verbally, answer questions, be oriented to person, place, time
Impulsiveness-severe risk for aspiration depending on what region is affected
? Compliance
depends on area affected

Question 22

Alzheimer’s complications

Answer 22

Characteristics
Agnosia for food – lack of awareness. Don’t open mouth in response to food
slow acceptance
slow or absent initiation of oral phase (abnormal bolus hold)
Apraxia for feeding- difficulty motor initiation and initiating oral stage. Knowing to form bolus.
Apraxia for swallowing
difficulty initiating oral stage (abnormal bolus hold)
-progressive in nature. Lose memory skills, not aware of surroundings.
Delayed pharyngeal swallow
Reduced strength of pharyngeal wall contraction- moving bolus down the pharynx into the esophagus
Reduced hyolaryngeal elevation

Question 23

Parkinson’s complications

Answer 23

Oral phase
Slow initiation of movement
Reduced jaw opening
Reduced lingual range of motion and strength
Slow oral transit due to ‘tongue pumping’ (i.e. repetitive anterior to posterior lingual movement with reduced lowering of the back of tongue)
Reduced base of tongue retraction
Reduced pharyngeal wall contraction
Reduced hyolaryngeal elevation (reduced airway protection and UES opening)

Question 24

Amyotrophic Lateral Sclerosis

Answer 24

UMN and LMN damage
Oral phase:
Reduced lip closure
Reduced tongue mobility
Reduced bolus control
Reduced bolus propulsion (reduced tongue pressure)
Pharyngeal phase
Reduced base of tongue retraction
Reduced pharyngeal wall contraction
Reduced hyolaryngeal elevation (reduced airway protection and UES opening)
Earlier onset of dysphagia if UMN damage predominates

Question 25

Huntington's complications

Answer 25

``` Dysphagia Tachyphagia (‘bolt food’) Oral phase: Impaired bolus formation Impaired bolus propulsion Due to chorea Pharyngeal phase: Reduced base of tongue retraction Delayed pharyngeal swallow Reduced airway protection due to neck extension ```

Question 26

MS complications

Answer 26

Dysphagia Symptoms depend on site of lesion: spasticity vs. ataxia Reduced coordination of the oropharyngeal muscles and respiratory muscles Leading cause of morbidity and morality (dehydration, malnutrition, aspiration pneumonia) Complications: Cognitive impairments Medications Note: exacerbations and remittance!

Question 27

Endotracheal intubation:

Answer 27

``` arytenoid dislocation desensitization of pharynx and larynx development of granulation, stenosis-narrowing of the pathway because of the tube keeping the airway open Tube can be placed orally or nasal More long term-endotracheal intubation. ```

Question 28

Tracheotomy

Answer 28

``` reduced cough reflex reduced hyolaryngeal elevation development of granulation Inserted into the trachea, below the level of vocal folds. See handout ```

Question 29

Esophagus problems

Answer 29

we don’t diagnose we make recommendations for esophagus

Question 30

Eosinophilic Esophagitis

Answer 30

inflammartory condition where esophagus is stiffened. Going to be difficult swallowing solids because of inflammation. Can treat with meds. Structural problems may cause this

Question 31

GERD

Answer 31

- reflux up to the lower esophageal sphinctor-burning sensation

Question 32

LPRD

Answer 32

- reflux comes up to upper esophageal sphinctor- up into the esophagus into the pharynx

Question 33

NERD

Answer 33

- has GERD symptoms, burning sensation. Harder to make diagnosis because you don’t have the esophageal injury

Question 34

Types of Cancer

Answer 34

Oral Oropharyngeal Laryngeal

Question 35

Treatment for Cancer

Answer 35

Surgery Radiation Chemotherapy Combination of treatment

Question 36

Cancer and Dysphagia

Answer 36

Occurs when cell growth is out of control -sudden weight loss, severe fatigue even after you have slept, pain in unexplained areas, high fevers, lack of motivation to do anything, difficulty concentrating or wanting to participate in any type of activity. T= how big the tumor is N= if there is lymph node involvement and how extensive is the involvement M=metastisis distant or surrounding Difficult to predict type and severity of dysphagia based on diagnosis Treatment can lead to dysphagia

Question 37

Oral and oropharyngeal cancer Tumor Sites

Answer 37

``` Lips Lateral tongue margin Base of tongue Mandible Floor of mouth (anterior, lateral) Tonsils Hard palate Soft palate ```

Question 38

Cancer and Lip Resection

Answer 38

Reduced labial seal anterior bolus loss drooling

Question 39

Partial Glossectomy

Answer 39

``` Reduced bolus manipulation and formation Reduced bolus control Reduced propulsion Increased oral transit time Extent of tongue resected affects type and severity of symptoms ```

Question 40

Suturing of Tongue: Glossectomy

Answer 40

Reduced bolus formation and manipulation Reduced chewing Reduced bolus propulsion Reduced bolus control

Question 41

Mandibulectomy with anterior floor of mouth resection:

Answer 41

Disrupt attachments for muscles of the floor of the mouth Reduced oral preparation Reduced oral transit Reduced bolus formation

Question 42

Lateral floor of mouth resection

Answer 42

``` Penetration- occurs to level of vfs Reduced oral preparation Reduced oral transit Reduced bolus formation Delayed pharyngeal swallow Reduced base of tongue retraction Reduced pharyngeal wall contraction ```

Question 43

Partial Laryngectomy

Answer 43

``` Removal of hyoid bone and top of larynx May include removal of the epiglottis, false vocal folds, arytenoids, aryepiglottic folds Results in Delayed pharyngeal swallow Reduced airway protection Reduced hyolaryngeal elevation Reduced UES opening- pharyngeal phase ```

Question 44

Total Laryngectomy results in

Answer 44

Reduced pharyngeal wall contraction At risk for tracheo-esophageal fistula development At risk for a pseudoepiglottis- false epiglottis forming

Question 45

Radiation At Risk For:

Answer 45

Tracheo-esophageal fistula – forming opening Xerostomia (first 3-6 months) very dry mouth Edema (first 3-6 months) Mucositis (first 3-6 months) Fibrosis (years following treatment): depends on how long radiation/chemo was, what other diseases patient has had reduced base of tongue retraction reduced laryngeal elevation reduced pharyngeal wall motion

Question 46

Malnutrition,Dehydration and Xerostomia

Answer 46

Consequences of multiple issues related to dysphagia but are also related to cancers. Think of medications patient is on look up side effects of medication, when pt takes the medication. Could affect their swallowing as far as dry mouth.

Question 47

Medical Record Contains Info:

Answer 47

Patient’s medical history Findings from physical exam by physician Reports of laboratory tests Findings of special examinations Findings from consultants PT, OT Notes of treatment Medications Surgical options-procedures they had, hospitalizations Progress notes by all disciplines- motivated? Cooperative? Cognitively aware? Follow directions? Express themselves well? Gives info on how pt performs in other types of therapy hoping it would be a carryover into your treatment. Lab results- weight, nourishment What is patient’s medical diagnosis, what is the dysphagia a result of. Previous hospitalizations. Function previous to incident. Medications they are currently taking. Perception of overall illness. Patient’s perception of their swallowing problem.

Question 48

What does a Screening do

Answer 48

predicts the likelihood that a person has dysphagia

Question 49

Disease Process in a Medical Record

Answer 49

The disease process or combination of contributing factors that are related to dysphagia Course of recovery varies Surgical procedures will vary We discussed many diseases

Question 50

Surgical procedures in a medical record

Answer 50

Procedures, date performed, and resolution | Piror to dysphagia how did it affect their swallowing disorder.

Question 51

Airway Status

Answer 51

Artificial airways

Question 52

Pulmonary Status

Answer 52

Pneumonia- are they at risk, have they previously had this Radiographs- chest xrays, visualizing the lungs to see if pneumonia is present at the time. Aspiration pneumonia- symptoms cough, fever,

Question 53

Nutrition

Answer 53

Oral intake 24-hour dietary recall-pt reporting amnt of food and intake to keep track of nutrition and dehydration Enteral Intake-nutrition directly into GI tract from a tube Parenteral Nutrition- nutrition directly into the bloodstream Weight change- how much weight loss in what pd of time, look at hydration. What they should be (BMI) vs. what they actually are and create ratio. Lab values/blood parameters- possible reasons why the pt is not getting enough nutrition.

Question 54

NG Tube

Answer 54

short term feeding tube placed directly into nose and goes down into stomach. Not for a patient that needs a long term feeding tube. Physician does it bedside it is very quick. Negatives: very uncomfortable, patient who is not cognitively aware may pull it out.

Question 55

Gastric G Tubes

Answer 55

more long term. Tube directly into the stomach. Surgical procedure requires surgeon. Negative- if pt has reflux

Question 56

PEGS

Answer 56

percutanious endoscopic gastronomy tube- more common, surgical, requires local anesthesia

Question 57

Hydration

Answer 57

Fluid in/urine out monitor Serum Sodium Osmolality

Question 58

Interview

Answer 58

Questionnaires Surrogate informants Educate nursing aides about dysphagia. Different checklists that are available.

Question 59

Parent Interview Record

Answer 59

``` Chief Complaint Patient’s Perception of the Problem Character of Complaint Course of Complaint Activities of Daily Living Previous Treatment ```

Question 60

What is the definition of swallowing screening

Answer 60

used to refer to a minimally invasive evaluation procedure that provides quick determination of - likelihood dysphagia exists; - whether pt requires referral for further swallowing assessment; - whether safe to feed pt orally (for purposes of nutrition, hydration, and administration of medication); - whether pt requires referral for nutritional or hydrational support.

Question 61

What questions can a screening procedure answer with respect to swallowing

Answer 61

used to determine whether any of following represent a risk of dysphagia and/or a reason to maintain an NPO - a known history of dysphagia; - a medical diagnosis that frequently involves swallowing impairment (e.g., stroke); - reduced level of consciousness; - overt signs of aspiration; - overt signs or complaints of difficulty swallowing.

Question 62

MBS purposes:

Answer 62

- define abnormalities in anatomy and physiology causing symptoms - i.d. and evaluate treatment strategies enabling pt to eat safely/efficiently - why pt is aspirating

Question 63

different strategies

Answer 63

``` exercises to strengthen muscles body positions diets different consistencies change in habits ```

Question 64

Ask for MBS from physician at skilled nursing facility. Completed bedside on patient that showed clinical signs of aspiration including coughing immediately after thin and thick liquids. A wet vocal quality. Patient did not show clinical signs of aspiration with pudding. Doctor refuses to send the patient for an MBS. How do you make your request to the doctor?

Answer 64

It’s a cost issue, the patient has to be transported out. Educate the physician and tell the doctor they could be silently aspirating. Could be life threatening. Educate the family as well. Tell the family you don’t agree with the doctor and what you recommend. When you write it write what you recommend and what you have expressed to the physician and the family. Doctor may still decide not to. Happens often. Write specifically what you have educated to the family. Don’t be so brief.

Question 65

I saw patient for CSE (bedside examination) and I recommended an MBS and patient remain NPO until study is complete. However, Dr. refuses MBS and says “slp to feed whatever diet seems safest.” 1. Do you begin trial feeds? 2. What do you tell the doctor?

Answer 65

No, it isn’t safe. Don’t start trial feeds because it is going against your license. If you did trial feeds during clinical exam tell the doctor what happened, patient coughed, patient became out of breath. Show documentation. Educate the doctor on findings, what you did, signs and the literature. What you tried and each issue with each consistency.

Question 66

My boss wants me to teach the OT how to treat dysphagia 1. What do you tell your rehab director? 2. How do you prepare for meeting with rehab director?

Answer 66

bring state licensure laws, your research, code of ethics, ashas national outcomes measurement systems- has aspects about measurements of efficacy of treatment of dysphagia. Look on asha for guidelines. Be aware of all guidelines. If you are in doubt you can call asha. You don’t cross train.

Question 67

Bedside Swallow Exam

Answer 67

``` Review of medical records Comprehensive interview with client Oral mechanism examination Trial feedings observation Feeding recommendations Referrals for either: Further instrumental assessment (need physician’s prescription to be covered by insurance) Specialized testing by other professionals ```

Question 68

Instrumental Dysphagia Exam

Answer 68

More objective, quantifiable measure of swallowing function Commonly used approaches: Fiberoptic Endoscopic Examination of Swallowing: visualization of swallowing through flexible tube with recordable camera Ultrasonography: uses sound waves to recreate a picture of structures (most beneficial in oral phase evaluation Videofluorscopy: same as a modified barium swallow (most commonly used; “gold standard”)

Question 69

How is Dysphagia treated?

Answer 69

SLP works to remediate oropharyngeal dysphagia Compensatory approaches Restorative approaches To maintain nutrition, dietary modifications and/or alternative nutrition via a feeding tube Nasogastric, gastrostomy, jejunostomy Include ongoing assessment of client’s response to intervention, and adjust goals and approaches to fit evolving needs

Question 70

What happens if the PES/UES malfunctions?

Answer 70

Can lead to residue in the piriform sinus and possible post swallow aspiration

Question 71

What causes aspiration?

Answer 71

material falls into the larynx below the VF due to abnormal swallowing or altered level of consciousness

Question 72

List the oral structures.

Answer 72

lips, teeth, cheeks, mandible, hard palate, tongue (tip, blade, back), anterior faucial arches

Question 73

List pharyngeal structures.

Answer 73

velum, tongue base, pharyngeal walls, epiglottis, UES | valleculae, piriform sinuses

Question 74

List laryngeal structures.

Answer 74

true VFs; false VFs; ariepiglottic folds