Normal swallowing. Reflex? How many muscles required? How many times a day? Volitional?
- Sometimes Referred to as a Reflex, But is really much more complicated
- Requires the coordination of 50 different muscles/pairs of muscles
- The average person swallows hundreds of times/day
- Can be volitional or unconscious
WHat are the phases of a swallow?
Oral prep phase. All foods? Volitional? How to prevent loss? Skills required?
•Not required for all foods
•Is under volitional control
•All “exits” from the oral cavity are sealed to prevent loss
•Skills Required :
•Mastication- Food is chewed into smaller pieces and mixed with saliva
•Bolus Formation- Chewed up food is collected in the middle of the tongue
•Oral Clearance- Requires tongue strength and coordination to remove extra food from teeth, etc
Oral phase. What is it? Driving force? Skills?
•Controlled Transfer of food from oral cavity to pharynx
•Tongue movement in this phase is driving force behind the rest of the swallow
•Respiration inhibited/airway closed
•Anterior to posterior (A/P) Transfer
•Lingual Pulsion (force behind swallow)
•Oral Clearance- requires tongue strength to clear food from the tongue and palate
Pharyngeal phase. Skills?
Esophageal phase. What needs to happen?
•Peristalsis required to Move bolus through esophagus
•Without peristalsis food Will not reach Stomach
How do SLPs evaluate swallowing?
•Clinical or ‘Bedside’ swallow evaluation
•Modified Barium Swallow Study (MBS)
•Fiber endoscopic evaluation of swallowing (FEES)
Describe a clinical evaluation (bedside eval). Where seen? What is included? What is given? What observations are made?
•Patient seen at bedside or in the office
•Includes a thorough chart review/history and Oral Motor examination
•Foods and drinks of varying textures and bolus sizes are given to the patient
•Visual, auditory and tactile Observations are made about each phase and texture
•Recommendations are based on observations and clinical history
Describe modified barium swallow (MBS). Where conducted? What does pt swallow? What can you evaluate? What is directly observed?
-Conducted in Radiology with a Radiologist.
- Pt takes various textures mixed with barium
-Can evaluate all phases of the swallow
-Aspiration is directly observed
Fiber endoscopic Evaluation of Swallowing (FEES). What can be seen? Who is it good for?
•Flexible camera passed through the nose to visualize the pharynx
•Able to see the results of the swallow but not the swallow itself.
•Good for medically unstable patients who can’t be safely moved.
•Can be used repeatedly and for therapy
What are ppl with dysphagia at risk for?
•Individuals with dysphagia may be at risk for
•Skin Breakdown/Bed sores
•There is poor awareness of Dysphagia and possible risks associated with it
What does dysphagia disrupt? What kind of diet may a patient be on?
•Dysphagia disrupts daily routines and social routines
•Patients may be on a modified diet or be “NPO” (nothing by mouth)
•Patients who are NPO for a prolonged period of time will require alternate means of nutrition. In most cases this is a feeding tube.
What are the causes of dysphagia? Neurological disorders? Coritcal? Co-occurs with? What else can it be caused by?
•Almost Any of our Neurological disorders, especially Stroke, TBI, Dementia, Parkinson’s, ALS
•Can be cortical or subcortical, especially if the brainstem is involved
•Many patients may have dysphagia and Aphasia or Cognitive deficits
•Can also be caused by ‘mechanical factors’ such as head and neck cancers, Surgery, Prolonged intubation…
Penetration. Risk factor? Sensory response?
•Penetration: Occurs any time material enters the laryngeal vestibule
•Material stays above the level of the vocal folds.
•Considered a risk factor for aspiration
•May be redirected “down the right way” or may eventual be aspirated
•May or may not have sensory response (coughing, throat clearing, etc).
•Aspiration: Occurs any time material passes the vocal folds and enters the trachea
•In some may contribute to aspiration pneumonia
•Penetration and Aspiration are symptoms of anatomical or physiological problem.
•Always answer the question: Why did they aspirate?
Oral stage dysphagia
- Chewing slow mastication
- anterior loss
Oral Prep phase Disorders: Difficulty chewing. Root cause? Result?
- Muscle weakness, motor planning, decreased sensation, structural problems
- Increased choking risk, decreased intake
Oral prep phase disorders. Pocketing. Root cause? Result?
- Decreased sensation, decreased lingual strength/ROM, weak buccal muscle
- Aspiration/choking after the meal, decreased intake, dental problems
Oral prep phase disorders. Anterior loss. Root cause?Result?
- Weak labial seal, tongue thrust, decreased labial sensation
- Decreased intake, decreased lingual pulsion
Oral phase disorders. Root cause: Lingual weakness, incoordination. Symptom?
•Decreased bolus formation, oral residue
Oral phase disorders. Root cause: labial weakness. symptom?
Oral phase disorders. root cause: Base of tongue weakness. Symptom? Result?
•Pharyngeal residue in the valecula
Pharyngeal stage dysphagia
- Throat clearing
- Extra swallows
- aspiration - coughing
- silent aspiration?
Pharyngeal phase disorders. Root cause: Weak base of tongue/ pharyngeal constrictor. Symptoms? Result?
•Pharyngeal residue with risk of aspiration
•Extra swallows, coughing/throat clearing, complain of globus
Pharyngeal phase disorders. root cause: Decreased laryngeal elevation. symptom? result?
•Penetration/aspiration due to decrease epiglottic inversion
•Coughing, wet vocal quality
Pharyngeal phase disorders. root cause: Delayed swallow initiation. symptom? result?
•Penetration/aspiration due to food in pharynx prior to swallow
•Bolus transferred without laryngeal elevation
Esophageal phase disorders