Module 3

Question 1

Complications of Dysphagia

RESPIRATORY:

Answer 1

Asphyxiation
Lobar collapse
Infection

Question 2

SECRETION MANAGEMENT:

Answer 2

Drooling

Dehydration

Question 3

Psychosocial

Answer 3

Social Isolation

Depression

Question 4

Nutrition/ Hydration

Answer 4

Malnutrition

Malaise

Question 5

Etiology & Conditions

Neurogenic

Answer 5

Neurological, Vascular, Brain injury

Question 6

Structural

Answer 6

Cancer, Stricture, Web

Question 7

Metabolic

Answer 7

Encephalopathy, Infections
Iatrogenic
Caused by intervention or treatment
Surgery related, medication related, Radiation
Congenital
Clefts, Tracheal issues
Mechanical
Trauma, Intubation, Acute Inflammation, 
Cervical Osteophyte

Question 8

S/sx Oropharyngeal Dysphagia: ask during evaluation

Answer 8

Coughing / Choking
Throat Clearing 
Difficulty initiating swallow
Drooling
Unexplained weight loss
Increase in RR
Increased congestion
Lower lobe infiltrate
Change in diet

Question 9

Requirements for Oral Prep / Oral Stage

Answer 9

Lip Seal: prevents anterior leakage / spillage
Buccal tension: keeps food from lower buccal cavities
Lingual ROM: keeps food from slipping out of control – holds bolus against hard palate; prevents posterior spillage; aids in mastication
Hard Palate: provides roof to control and manipulate bolus
Soft Palate Seal: prevents nasal regurg and posterior spillage

Question 10

Oral Prep / Oral Stage Impairments

Can result due to changes in motor and / or sensory function

Answer 10

Typically result from impairment of the tongue’s or lips’ ability to control the bolus
May also have difficulties with:
Mastication
Initiating swallow
Labial and facial control

Question 11

Due to tongue motor / sensory issues:

Answer 11

Cannot form a bolus due to reduced range of tongue motion or coordination
Cannot hold a bolus due to reduced tongue shaping of bolus and coordination of bolus
Residue on tongue due to reduced tongue ROM or strength or poor sensation
Adherence of food to hard palate due to reduced tongue elevation or poor strength
Poor bolus movement anterior to posterior due to reduced lingual coordination

Question 12

Due to jaw issues:

Answer 12

Unable to align teeth due to reduced mandibular movement
Reduced mastication because of this
difficulty with solids 
Due to dentition issues:
Poor ability to masticate solids
Due to palatal issues:
Nasal regurgitation
Premature spillage: Spills down your throat

Question 13

Due to facial / labial issues:

Answer 13

Oral pocketing due to reduced labial tension or tone

Loss of bolus anteriorly due to reduced lip closure

Question 14

Global changes

Answer 14

Delayed oral onset due to reduced oral sensation
Premature spillage of bolus into pharynx- likely due to poor bolus control as well as poor seal between the tongue and the soft palate resulting in premature leakage into the pharynx

Question 15

Oral Prep / Oral Stage Terms:

Answer 15

Anterior spillage
Poor bolus control
Poor bolus cohesion
Poor bolus movement anterior to posterior
Decreased / Prolonged mastication
Buccal pocketing / Oral residue
Tongue pumping
Premature spillage

Question 16

ASK: Oropharyngeal Dysphagia

Answer 16

Coughing / Choking
Throat Clearing 
Difficulty initiating swallow
Drooling
Unexplained weight loss
Increase in RR
Increased congestion
Lower lobe infiltrate

Question 17

Pharyngeal paresis/paralysis

Answer 17

Look for movement of the PPW, lateral pharyngeal walls
Asymmetry of bolus movement
Strong side pushes the bolus across midline to the weaker side, so the bolus passes down the weak side
Usually due too neurogenic issues

Question 18

Hyoid Elevation and Laryngeal Movement

Answer 18

Abnormal elevation:
No elevation
Poor elevation
Elevation occurs, but unable to be sustained

Question 19

Epiglottic Inversion

Answer 19

Normal epiglottic tilt is a 2 step process

1. Passively moves horizontally by hyoid elevation and posterior movement of the tongue
2. Contraction of the thyroepiglottic muscle further inverts the epiglottis

Question 20

Delay

Answer 20

Sensation issue
Swallow triggers “lower down” than typically noted
Mild:  Vallecula
Moderate:  Vallecula / Pyriforms
Severe:  Pyriforms
Prolonged pooling in these areas = delay

Question 21

Premature spillage =

Answer 21

Incompetence of the palatoglossal seal and is characterized by movement of the bolus posteriorly, without cohesive organized intent, prior to the onset of a swallow reflex.
Premature spillage is attributed to weakness and / or poor coordination of the posterior tongue or the soft palate or both

Question 22

Delay =

Answer 22

Typically sensation related
“hold the food in your mouth until I say swallow”
Residue
Mild, moderate, or severe amounts (SLP subjective) of the bolus can retained in the vallecula or pyriforms after the swallow, or posterior pharyngeal wall
Can be due to: Weakness
Poor base of tongue retraction
Reduced pharyngeal constriction
Poor pharyngeal coordination
Poor UES opening
Penetration
Entry of the bolus into the laryngeal vestibule above or to the level of the vocal folds
DOES NOT pass through the vocal folds

Question 23

Levels of Penetration

Highest to lowest

Answer 23

Epiglottic
Tip of the epiglottis, inferior surface
Aryepiglottic folds, False vocal folds
True Vocal Folds

Question 24

Penetration Can Occur:

Answer 24

Before the Swallow:
----Due to premature spillage or delay
During the Swallow:
----Due to poor coordination, laryngeal closure issues
After the Swallow:
----Due to residue

Question 25

Aspiration

Answer 25

Entry of the bolus BELOW the level of the vocal folds- into the airway Occurs if there is failure of the laryngeal protective mechanisms Hyolaryngeal elevation, epiglottic inversion, laryngeal closure

Question 26

Aspiration Can Occur:

Answer 26

efore the Swallow -----Due to premature spillage or delay During the Swallow ----Due to laryngeal incompetency and closure issues i.e. TVC issues, poor epiglottic inversion After the Swallow -----Due to residue or reflux

Question 27

How is Aspiration Normally Prevented?

Answer 27

Prevention of premature spill Prompt and organized transfer of food through the oral cavity and pharynx owing to timely and forceful contraction of the posterior tongue and the sequential contraction of the pharyngeal muscles and prompt opening of the UES as part of the sequential swallow

Question 28

Coordination of swallowing with respiration | Protective reflexes against aspiration including:

Answer 28

Laryngeal elevation, lifting up and forward movement of the larynx so as to move out of the way and "hide" under the epiglottis and the tongue during a swallow Reflexive closure of the larynx true and false vocal cords along with the AE folds Epiglottic inversion helps direct bolus around the airway during swallowing

Question 29

If these fail and the bolus enters the trachea, a strong cough reflex is normally triggered.

Answer 29

Airway clearance can also be achieved later by the mucociliary elevator (cillia)! Laryngeal Adduction Reflex

Question 30

Audible Aspiration

Answer 30

Both penetration and aspiration are “audible” in the normal population Clinically indicated by a reflexive cough or throat clear

Question 31

Silent aspiration

Answer 31

Not all penetration and aspiration is audible, voice, neurogenic, ventilator, teach Typically, do not know they are aspirating because they do not cough or clear their throat Clinical prediction of silent penetration/aspiration is notoriously inaccurate! voice quality, breathing, caught

Question 32

Factors to Consider about aspiration 
 Quantity | Larger quantities of material is riskier than aspiration of smaller, more minute quantities

Answer 32

Depth How far does aspiration travel down trachea? Just below vocal folds? Into distal airways? Further down aspiration = more dangerous Physical Properties of the Aspirate Thin liquids easier to clear Solids can obstruct airway and be fatal Acidic material from reflux is dangerous (lungs highly sensitive to caustic acid=pnemonia) Aspiration of saliva from oral cavity can be dangerous if saliva contaminated with infectious organisms (poor oral care) Lungs can tolerate aspiration of water much better than anything else

Question 33

Pulmonary Clearance Mechanism

Answer 33

Strong and productive cough? Other pulmonary issues? Bed bound? Walkie-talkie? Smoker?

Question 34

Penetration / Aspiration Scale

Answer 34

Score                                Description of Events 

 1      Material does not enter airway 2      Material enters the airway, remains above the vocal folds, and is ejected from the airway. 3      Material enters the airway, remains above the vocal folds, and is not ejected from the airway. 4      Material enters the airway, contacts the vocal folds, and is ejected from the airway. 5      Material enters the airway, contacts the vocal folds, and is not ejected from the airway. 6      Material enters the ariway, passes below the vocal folds, and is ejected into the larynx or out of the airway. 7      Material enters the airway, passes below the vocal folds, and is not ejected from the trachea despite effort. 8      Material enters the airway, passes below the vocal folds, and no effort is made to eject.

Question 35

Esophageal Stage Impairments Can result in retention of the bolus in the pharynx or esophagus May be a result of:

Answer 35

``` Mechanical obstruction CP bar, stricture, osteophyte Weakness Motility Disorder Impairments of the UES or LES ```

Question 36

S/sx Esophageal Dysphagia

Answer 36

``` Globus sensation Change in dietary habits Reflux Coughing up particles of undigested food Pyriform sinus pooling Diverticulum Unexpected weight loss Recurrent pna Difficulties with pills increased mucus production trachesophageal ```

Question 37

CP Bar

Answer 37

The UES is an area that is longer than the cricopharyngeus and consists of a zone of high pressure consisting of some fibers of the inferior constrictor muscle, the cricopharyngeal muscle, and some circular fibers of the proximal cervical esophagus. fails to relax and open, the bolus may have difficulties passaging from the pharynx to the cervical esophagus Opening is the physical separation of the walls (of the sphincter), whereas relaxation is loss of tension or loosening

Question 38

CP Bar

Answer 38

UES is seen videofluoroscopially as “sticking out” posteriorly – known as a CP bar Thumb-like indentation Can be obstructive or nonobstructive

Question 39

Diverticulum

Answer 39

An “outpouching” of the tissue forming an opening for material to gather in the esophagus Usually forms in an area of weakness Zenker’s most common

Question 40

Zenker’s most common | Manifests itself as:

Answer 40

Dysphagia Globus sensation -----May fill up with food, causing the person to cough up partially ingested food into the mouth Halitosis ----Potential infection of the pharyngeal areas due to food stuck Involuntary gurgling noises when swallowing Rarely causes any pain

Question 41

Cervical Osteophyte

Answer 41

More than half of the people over the age of 60 have osteophytes, or bone spurs Osteophytes in the spine are a normal sign of aging and are not a cause for concern unless they result in pain or neurological symptoms

Question 42

Cervical osteophytes

Answer 42

are bone spurs that grow on any of the seven vertebrae in the cervical spine Cervical Osteophyte formation Typically occurs when ligaments and tendons around the bones and joints in the cervical spine are damaged or inflamed. The inflamed or damaged tissue abnormally influences surrounding bone growth (though hard, bones are constantly renewing, like fingernails and hair). As a result, new bone cells are deposited where they would not normally grow.

Question 43

Frequently Used Terms

Answer 43

``` Retrograde bolus movement Slowing of the bolus Posterior prominence (CP bar) Obstructive in nature Congruent with (osteophyte, narrowing of the esophagus, etc.) Backflow Reduced clearance Stasis Outpouching ```