Dysphagia

Another cause of dysphagia - congenital

(1) Down Syndrome (2) Cerebral Palsy (3) Cleft Palate (includes related syndromes like Pierre Robin, Charge Syndrome....)

Purpose of an MBS (or any instrument evaluation)

(1) View the anatomy and physiology of the swallow mechanism -----What is there and how does it function ----a dynamic test to observe the swallow (2) Can confirm or rule out aspiration ----Is there aspiration in the pharyngeal cavity ----Is there penetration ----Is there penetration but the patient coughs the material out ----what is the cause of the aspiration (3) Can develop a treatment plan and diet management ----Can use strategy like turn head toward the weaker side ----No attempt to cough = NPO ----Can't chew anything hard = soft puree diet

CN XII - HYPOGLOSSAL

(M) Contractions of the muscles of tongue' Impt: Bolus prep, sucking, swallowing •The hypoglossal innervates all extrinsic and intrinsic tongue muscles (It is strictly a motor nerve.)

CN X - VAGUS

(M) contains both sensory and motor fibers, important for taste to oropharynx, and sensation and motor function to larynx and laryngopharynx, important for airway protection. Epiglottis, hyoid laryngeal elevation & airway protection. •The vagus is responsible for raising the velum as it innervates the glossopalatine and the levator veli palatine muscles. •The vagus along with CN. IX innervates the pharyngeal constrictor muscles. •The vagus along with CN. XI innervates the intrinsic musculature of the larynx. It is responsible for vocal fold adduction during the swallow. •The vagus also innervates the cricopharyngeus muscle. •The vagus controls the muscles involved in the esophageal stage of the swallow as well as those that control respiration. (This is the only cranial nerve that influences structures inferior to the neck.) It, along with the vagus (CN. X), provides some innervation to the upper pharyngeal constrictor muscles (S) •The vagus carries sensory information from the velum and posterior and inferior portions of the pharynx. •The vagus also mediates sensation in the larynx.

CN XI - Spinal Accessory

(M) •CN. XI innervates the palatopharyngeus muscle which depresses the velum and constricts the pharynx. •It also innervates the muscularis uvula which tenses the velum. It, along with CN.X, innervates the levator veli palatini. (CN. XI is strictly a motor nerve.)

CN I - OLFACTORY

(S) collects smell info

Achalasia

*a serious condition that affects the esophagus *tertiary waves in the esophagus don't flow very well; there is an absence of contractions, or peristalsis. *failure of the LES to relax (open) during swallowing, often results in a "bird's peak" appearance as the LES comes to a point at the entrance to the stomach. *leads to a backup of food within the esophagus slowed peristalsis can be normal but is considered abnormal if it interferes with swallowing (ex: with aging swallow)

Neurological dysphagia (AKA neurogenic)

*having to do with the CNS (brain, spinal cord and CNs) *neurological = most common cause of dysphagia (1) MOST COMMON = CVA Also: (2) progressive/degenerative neurological diseases like Parkinson's, MS, ALS, dementia (3) cerebral palsy (CP) (4) tumor - also seen in mechanical (5) cranial nerve damage (6) head trauma

pressure reserve

*pressure reserve declines with age (esp in men) *this is the difference between isometric pressure and swallowing pressure Swallowing is generally "slowed" with age and Leads to a decreased "pressure reserve" leaving older people more at risk for dysphagia resulting from insults directly or indirectly to the swallowing system The implications are: (a) older people may be working harder to produce adequate swallowing pressures, and (b) age-related illness may put geriatric patients at higher risk for dysphagia, thus further complicating recovery.

Normal pathway for food through the pharynx

*the oral and pharyngeal phases of the swallow are inter-related - one doesn't stop before the next begins. Bolus enters the VALLECULAE Divides into two portions Moves into each PYRIFORM SINUS; it therefore goes around the airway, not down the midline. As LARYNX elevates, pyriform sinuses are raised to top of esophagus and bolus is dumped into the esophagus If food pools in the pyriform sinuses, it can dump into the trachea later when unexpected with the potential of being aspirated

Zenkers Diverticulum

- a pouching at the upper end of the esophagus -As we age, the long tubes of the body get pouches in them (part of the aging process) similar to diverticulitis - pouching of the large intestine that becomes infected.

TREATMENT

-Based on appropriate evaluation data -Based on evidence for particular techniques used -Long term and short term goals should be established -Prognosis determined

Neurological assessment of CN VII - FACIAL

-Facial movement -Forehead movement -Lip seal Important because it controls drooling, can they take food off the spoon, can they manage their own secretions

questions to ask continued

-Have you changed your diet in any way -Do you avoid hard things to chew -Do you avoid drinking from a cup or glass -Do you cough after you swallow -Do you have to swallow many times to get the food or liquid down -Do you have to take a drink right after swallowing food -Have you lost weight, Since when, how much, have you tried to lose weight -Does it hurt in your chest after you swallow -Does food come back up after you swallow. -Do you have problems swallowing pills -Do you become short of breath when you eat -Are you afraid of eating swallowing

health risks / medical complications associated with dysphagia

-Malnutrition (undernutrition) -Dehydration -Aspiration / Aspiration pneumonia -Weight loss - can be life threatening if rapid w/ overall decline in health Overall: Food and liquid intake decreases; Unplanned, rapid weight loss occurs; Overall decline in health and endurance results; May become life threatening. Impaired nutrition and decreased hydration significantly increase risk of skin integrity and delayed healing which can lead to life-threatening sepsis.

Results of dysphagia treatment

-Safe Swallow -Diet Modification (texture, temp, quantity) -Adaptive Eating Utensils -Postural Adjustment and Control -Reduction in Use of Feeding Tubes -Improved Quality of Life •Ultimate goal for all patients who ingest food orally is to develop a safe swallow. • patients with safe swallow will no longer need feeding tubes •Improving swallowing ability may be the last roadblock for a patient trying to regain feeding independence. Dysphagia treatments could ensure a higher quality of life, improved functional skill, and improved independence for many of these patients.

Behavioral changes to reduce GERD

-Staying upright after meals -Eating smaller, more frequent meals -Specific foods (e.g. spicy, pepper, caffeine, mints) to avoid -sleep with head of bed elevated

test labial function in a bedside evaluation

-Test range of motion by asking them to move tongue up and down, in and out, side to side, rapidly repeat /t/ /d/ /k/ check ROM of lips say eeeee and ooh, smile -Check for mobility, strength, (lips around a straw) -Check if tongue has hemiparesis (is it moving to one side? Any evidence of CN damage?) -Can the tongue clean food from between teeth and gums

pneumonia risk factors

-dependent for feeding -multiple medical diagnoses -current smoker -tube fed -dependent for oral care -number of decayed teeth -number of meds

treatment team

-interdisciplinary -SLP, OT, PT, Nursing staff, physician, support staff, family & friends -Each member of the team assists in screening, evaluating, developing a plan of treatment, and treating appropriate patients who have dysphagia. Each member provides services after obtaining Physician's Orders -The team will determine if the patient has potential for safe and comfortable oral intake of food and liquids. -If potential for oral intake of nutrition is poor; the team will develop a plan for the safest and most comfortable system for the delivery of nutrition and hydration. -Nutrition, safety and quality of life will be primary considerations for the management of the dysphagia patient.

Barrett's Esophagus

1 in 10 individuals with persistent untreated GERD develop Barrett's Esophagus -It's considered pre-cancerous, though relatively few patients with Barrett's develop cancer The persistent irritation by stomach secretions cause abnormal growth in the lower portion of the esophagus 3 times as prevalent in males - on the rise with white males

Screening components continued...

1) Behavioral Observation - (cognition, postural control, speech/oral motor coordination and respiratory status); 2) Water Screen (using teaspoon and cup sips); - fail (i.e., cough): referral to SLP for assessment - pass: diet prescription 3) Observation of diet tolerance (if prescribed) Debated techniques: Observing "wet voice" as an indicator Cervical Auscultation (specific acoustic features as indicators) Pulse Oximetry (desaturation as an indicator) Laryngeal Cough Reflex (absence of cough to irritant chemical as indicator)

Aging swallow (60 - 80 years) continued

1) Swallowing is slowed - Oral transit times slightly but significantly longer in older adults (.5-.6 sec). 2) Pharyngeal delay times slightly but significantly longer in older adults (.5-.6 sec) 3) Pharyngeal wall contraction is slower Elderly are more often "dippers" hold the bolus on the floor of the mouth, and pick it up with the tongue tip as the oral stage of swallowing is initiated

Clinical eval questions to ask

1-How long have you had the problem? 2-Did it start gradually or sudden onset -Sudden onset = CVA -Gradual/progressive = Parkinson's, dementia, MS, ALS, 3-What do you think caused the problem? 4- Do you have pain when you swallow? -Caused by bolus getting lodged -Odynophagia (painful swallow) -Surgical pts (removing malignancy in head or neck) may have more pain 5-Do you feel like you are choking? 6- Does food remain in your cheeks or lips? -Pocketing or squirreling (can see this at the bedside, need to teach pt to sweep it out) 7- Is it hard to chew? 8-Have you changed what you eat? -Older Pts tend to self switch to soft foods or pureed foods because of difficulty chewing/swallowing 9-Have you changed what you drink? -Drinking ice cold water can make you cough (it neutralizes in your mouth & becomes the same temp as your saliva which can be hard to manage)

Components of the screening process by an SLP

1. Interview with patient, staff, family: find out: Sudden changes in patients food preference Documented difficulty chewing Recent diet changes Duration of patient's mealtime Necessity for assistance at mealtime Choking, coughing, discomfort, drooling Ask patient/family if there has been unusual posture at mealtime, time between end of meal and sleep or nap, refusal to eat, evidence of pocketing 2. Brief chart review look in the chart for documentation of red flags (history of malnutrition, pneumonia, previous swallowing problems) Use this to confirm the information you obtained for the patient, staff, and family 3. Face to Face Screening with Patient observe patient during mealtime to see how he manages food and liquids Look for any of the RED FLAGS Observe rate and amounts of food presentation Observe patient's cognitive and awareness

Procedure for an MBS

1. get Dr orders for the study 2. schedule the appt with radiology 3. arrange for transport 4. arrange for other professionals if needed (nursing, respiratory etc). 5. SLP orders the evaluation tray 6. Radiology provides Barium and other supplies SLP positions (standing or sitting erect) SLP presents liquids (thin liquid, nectar liquid, honey liquid) in several formats (5cc bolus to straw sipping) as well as solids (puree, mechanical soft, regular solids, mixed consistencies) SLP introduces compensatory swallow strategies Radiologist reads and interprets MBS for: anatomical abnormality, swallow function, penetration/aspiration and clearance of the esophageal sweep If aspiration is noted, have radiologist request and administer a chest x-ray to monitor any damage to the lungs

non compliance policies

2 Policies you may encounter: 1) the medical team obtains an informed consent from the patient or power of attorney (POA)/healthcare surrogate to acknowledge that they have been educated on the current medical situation with all options, possible outcomes, or risks explained and understood. Copies are usually issued, and kept in the patient's medical chart. 2) a team meeting with the medical team is called, educating all parties involved in their choices, and risks associated with non-compliance of the recommended diet. This is documented in the medical chart. Each facility may have it's own policy on dealing with this and administration should be consulted on your facility's policies.

dippers

20% of all normal swallowers hold the bolus on the floor of the mouth, scoop it up on top of the tongue and then move it back. These are known as dippers. tongue tip behind lower teeth at initiation of swallow SEE THIS DURING THE ORAL STAGE Elderly are more often dippers

the esophageal phase of the swallow lasts

5-10 seconds

ASHA National Outcomes Measurement system (NOMS) for SLP and A

7 point functional communication measures Swallowing scale Level 1 Individual is not able to swallow anything safely by mouth. All nutrition and hydration is received by non-oral means Level 3 Alternative method of feeding required as individual takes less than 50% of nutrition and hydration by mouth, and/or swallowing is safe with consistent use of moderate cues to use compensatory techniques and/or requires maximum diet restrictions Level 5 Swallowing is safe with minimal diet restrictions and/or occasionally requires minimal cuing to use compensatory strategies. May occasionally self-cue. All nutrition and hydration needs met by mouth at mealtime. Level 7 •Individual's ability to eat independently is not limited by swallow function. Swallowing is safe and efficient for all consistencies. Compensatory strategies are effectively used when needed

Fistulas

A fistula is an abnormal connection between 2 hollow spaces - like the esophagus and the trachea. Can result from surgical procedures like laryngectomy. Tracheal-Esophageal fistula - aspirate because food goes into the bronchi and then directly into her lungs (Ex: pt who underwent radiation therapy and a hole was burnt, had to stop radiation until the fistula heals on its own) Fistula is an example of Iatrogenic dysphagia.

Anatomical differences - adult

ADULT ➢ intraoral space is larger, tongue doesn't fill up the space ➢ Base of the tongue and larynx descend during first 4 years of life ➢ No sucking pads (disappear at 6 months) ➢ Larynx is lower in the neck, it has dropped down to become vertical in the adult ➢ Hyoid is has turned from cartilage to bone ➢ Infants do NOT breathe at the same time they are swallowing. Just as in adults, they stop breathing during each swallow ➢ Tongue, soft palate, pharynx, larynx - lower in neck.

sippers

AKA Tipper tongue tip against alveolar ridge at initiation of swallow It is more typical to form the bolus on the top of the tongue. This is called 'sipper' SEE THIS DURING THE ORAL STAGE

nasopharynx (section of pharynx)

AKA epipharynx (from nasal choanae to elevated soft palate -- includes entrance to eustachian tube) -Does not have much of a role in swallowing -Closed off by soft palate in swallowing -If VPI - may see nasal reflux esp with liquids -Adenoids - on back of nasopharynx

LES - lower esophageal sphincter

AKA gastroesophageal sphincter connects the esophagus with the stomach and intestinal tract Barrier against reflux (upward flow of gastric contents) - closed at rest to allow passage of esophageal contents into stomach. Also relaxes during belching & vomiting

hypopharynx (section of pharynx)

AKA laryngopharynx structures between tip of epiglottis down to UES (cricopharyngeal sphincter) Mandible, hyoid bone, thyroid cartilage = mobile skeleton of hypopharynx Includes pyriform sinuses (bilateral pockets within pharynx formed by closure of UES

oropharynx (section of pharynx)

AKA mesopharynx pharyngeal space between elevated soft palate and epiglottis faucial arches separate mouth and oropharynx also includes the valleculae (bilateral pockets at base of tongue and epiglottis)

Hospital acquired pneumonia (HAP)

AKA nosocomial pneumonia refers to any pneumonia contracted by a patient in a hospital at least 48-72 hours after being admitted. It is thus distinguished from community acquired pneumonia. It is usually caused by a bacterial infection, rather than a virus.

Modified barium swallow study (MBS)

AKA videofluoroscopy AKA videofluorographic swallow study (or VFSS) "gold standard" for evaluating all 4 phases of the swallow / esp. the oral and pharyngeal stage of swallowing utilizes fluoroscopy and a small amount of barium contrast to view ingestion of liquid and food through the oropharynx and esophagus in a full videofluroscopy the esophagus is evaluated also is a radiographic test, done by SLP and radiologist

pharyngeal cavity

ANATOMY: uvula moves back to the pharyngeal wall Epiglottis - moves up and back to protect the airway, if food goes down the airway (trachea) you aspirate Valleculae (space between epiglottis and base of tongue) food can pool here = dangerous Pyriform sinus - Chricopharyngeal sphincter Vocal cords - don't want food to go to the vocal folds

treatment team adult

Adult dysphagia teams include: primary physician, physician specialties, nursing staff, nutritionist, OT, PT, respiratory therapist SLP should have primary role May do joint eval with OT

after the swallow

All structures return to rest FEES=Sees epiglottis return, VP port re-open MBS= Sees all except TVCs reopening

laryngoscopy

An examination that lets your doctor look at the back of your throat, your voice box (larynx) , and vocal cords with a scope (laryngoscope). There are two types of laryngoscopy, and each uses different equipment. (Indirect and direct) Can an SLP perform laryngoscopy? Yes, unless state licensure prohibits

onset of the swallow

Arytnoids move medially/forward (FEES=good MBS=fair ) Tongue base retraction (FEES= partial view MBS= good ) VP closure (FEES= good MBS= fair/partial ) Epiglottal retroflexion (FEES= partial view MBS=good ) Hyo-laryngeal elevation (FEES= no MBS= good ) Lateral pharyngeal wall medialization (FEES= partial view MBS= fair ) UES opens (FEES= no MBS= good ) TVC begin closure (FEES= no MBS= no ) Bolus may appear in HP (FEES= good MBS= good )

Anatomical differences - newborn

CHILD / NEWBORN ➢ Intraoral space is small ➢ Lower jaw is small and slightly retracted ➢ Infant's tongue fills their mouth and sits more anterior than adult's, their mandible is smaller = tongue seems larger and has restricted movement ➢ Have sucking pads until 6 months old ➢ Larynx is higher in the neck, seems horizontal in the infant (reduces the need for laryngeal closure to protect the airway) ➢ Tongue, soft palate, pharynx, larynx - higher in neck. Provides added airway protection during the swallow. ➢ Eustachian tube is horizontal ➢ Hyoid is cartilage not bone (yet) ➢ Infants do NOT breathe at the same time they are swallowing. Just as in adults, they stop breathing during each swallow ➢ Prefer nasal breathing ➢ Nasal reflux is prevented by the upward and backward movement of the velum and bulging forward of the pharyngeal wall which create a separation of the oral and nasal cavities

swallowing disorders following CVA

CVA - 65% incidence of dysphagia Reduced triggering of the pharyngeal swallow(increased stage transition duration) Delayed trigger is the most frequent disorder; 82% in a study of 38 subjects with reduced lingual control at 50%. Reduced lingual control Reduced laryngeal adduction Reduced pharyngeal peristalsis Reduced UES opening Right hemisphere damage (RHD): --Greater frequency of penetration and aspiration --Pharyngeal swallow delay Left hemisphere damage (LHD): --Increased oral transit --Lack of oral motor coordination --Oral and verbal apraxia

Psychological dysphagia

Caused by mental disorders; Psychogenic swallowing problems exist when there is no underlying physiologic reason for the disorder (1) MOST COMMON: anorexia Also: (2) psychosis (3) neurosis (4) anxiety disorders (5) or previous choking so afraid to eat

Signs of aspiration

Changes in respiration rate Changes in lung sounds Facial grimacing Gagging Unexplained weight loss Dehydration Pneumonia or history of pneumonia Reddening of the face Difficulty breathing Audible breathing Coughing Gurgly voice quality High or low back pain Spiked fever Chronic, copious (abundant) clear secretions

treatment team child

Children with feeding/swallowing problems may have multiple medical problems Mouth, throat, upper airway, larynx, trachea, esophagus, stomach, lower gastro-intestinal tract involved in swallowing Pediatric teams include: SLP, pediatrician, OT, teachers, aides, parents, child, developmental interventionists, nurse, dietitian, dentist, social worker, psychologist, PT, audiologist, other specialists: gastroenterologist, neurologists, neonatologist, otolaryngologist, pulmonologist, radiologist

trachea / windpipe

Composed of C shaped cartilaginous rings leads to the lungs; intended to let air in and out of the lungs. It is NOT a patent tube as the cartilages hold its shape.

coughing

Cough does not necessarily indicate aspiration Cough does not necessarily indicate ejection of material from the larynx Absence of cough does not necessarily rule out silent aspiration or other swallowing problems (e.g. residue)

pharyngeal dysphagia signs

Coughing, throat clearing multiple swallows Choking, gagging Eyes watering (when they struggle) Delayed swallow (taking more than 5 seconds to swallow) remember that the pharyngeal phase of the swallow is 1 second Difficulty moving the bolus Nose running Gurgly voice Shortness of breath•multiple swallows •wet vocal quality/breath sounds •breathy vocal quality •reduced laryngeal elevation •not managing secretions

kyphosis

Disorder of the spinal cord, forward rounding (hump) of the back due to osteoporosis (can impact a swallow study - hard to sit upright) also causes problems with eating. This is considered a mechanical / structural problem.

Velum / soft palate

Elevation and retraction of the velum to the posterior pharyngeal wall prevents the bolus from entering the nasal cavity. the velum is a moveable fold that forms an incomplete septum between the mouth and pharynx consists of a fold of mucous membrane enclosing muscular fibers, an aponeurosis, vessels, nerves, adenoid tissue, and mucous glands.

Alternatives to MBS / Videofluroscopy

FEES FEEST Scintigraphy Ultrasound Electromyography Accelerometry Non instrumental tests: Cervical auscultation Blue Dye test

National systems with dysphagia scales

FIM = Functional independence measure by uniform data set for medical rehabilitation (UDS) --This is really a scale on eating not swallowing --Scales don't have to be scored by SLP --This test missed or understated progress made by 51% of patients LORS III - Lors American Data System (LADS) MDS OASIS ASHA National Outcomes Measurement system (NOMS) for SLP and A

Facility Specific outcomes measurements

Facility can design rating scales to measure change in functional status General and skill-specific ratings can be used Can be paper and pencil or computer (BOSS, PECS from Marianjoy)

test for chewing in an evaluation

Graham crackers Lorna dune (soft cookie that melts in your mouth) Hand on larynx - feel for elevation

dysphagia

Greek meaning dys - loss of, phagia - ability to eat/swallow

Swallow stage 3 - PHARYNGEAL STAGE

INVOLUNTARY ***************************************************************** •Starts when the swallow reflex/pharyngeal response is initiated (bolus goes over the base of the tongue - at which point you can no longer manage the swallow) •Stimulation of the anterior faucial arches. •Sensory stimulation received by the reticular formation in the brain stem •Causes series of simultaneous, physiological reactions designed to protect the airway(larynx, trachea, bronchi, lungs) from foreign matter •Biological purpose of the larynx is to protect the airway from foreign matter. A successful swallow involves airway protection •Nasal passage sealed off by raising the soft palate; food/liquid cannot enter the nose As the tongue elevates, velopharyngeal closure begins. This activity triggers the forward motion of the hyolaryngeal mechanism to increase the opening of the upper esophageal sphincter; the larynx also elevates; all of which leads to relaxation of cricopharyngeas musculature. -True VF close as arytenoid cartilages come together -False VF close -Arytenoid cartilages tip forward to touch base of epiglottis -Hyoid and larynx pull up and forward -Epiglottis pushed down -Bolus propelled through pharynx, UES opens -this stage ends when the UES closes

Swallow stage 4 - ESOPHAGEAL STAGE

INVOLUNTARY lasts 8-20 seconds •Most variable stage in patients •Most affected by the normal aging process ***************************************************************** The primary function of the esophageal body is passage of injected material from the pharynx to the stomach. With the sequential contraction of the esophagus and relaxation of the lower esophageal sphincter, the bolus is propelled through the esophagus by contraction above and relaxation below the bolus. The bolus passes from the proximal to the distal esophagus and into the stomach •Peristaltic wave helps move bolus through the esophagus and into stomach

MBS with Passy-Muir valve patients

If the Passy-Muir valve is in use, the exam should look at swallow with and without the valve (deflate the cuff)

Pocketing / Squirreling

If the Pt can't form a cohesive bolus - food gets trapped in the lateral sulci & anterior sulci (the space between the lower & upper lips and teeth) and/or under the tongue. This process may be deliberate because of fear of swallowing or it may be because of weak oral motor movement SEE THIS DURING THE ORAL STAGE *Must teach the patient how to do a tongue sweep - sweep around teeth and cheeks to clean out food, can also put on a glove and SLP cleans out the mouth, *If food is not cleared out - patient can aspirate or choke on the food later, can get a bacterial build up in the oral cavity, can get aspiration pneumonia, this is why oral hygine is so important

Laryngopharyngeal reflux (LPR)

If the stomach contents pass through UES and into pharynx

Indirect laryngoscopy

Indirect laryngoscopy is done in a doctor's office using a small hand mirror held at the back of the throat. Your doctor shines a light in your mouth and wears a mirror on his or her head to reflect light to the back of your throat. Some doctors now use headgear with a bright light. Indirect laryngoscopy is not done as much now because flexible laryngoscopes let your doctor see better and are more comfortable for you.

Anatomy of pharyngeal stage larynx arytenoids true vocal folds false vocal folds epiglottis pharynx pyriform sinuses valleculae hyoid bone

LARYNX =larynx moves up as a unit (elevates) and anteriorly about 1 inch to provide more posterior space for the bolus to move into so that it enters the esophagus rather than the larynx The timing of the movements of closure are: •Arytenoids rock medially •Arytenoids move further closed •True vocal folds close •False vocal folds close •Arytenoids tip forward to contact base of epiglottis •Larynx lifts up and forward •Epiglottis tips all the way over the arytenoids to close off vocal folds Anatomical spaces in the PHARYNX: Pyriform sinuses - cavities/recesses or cul de sacs on either side of larynx where food can collect. These spaces are below the level of the entrance to the esophagus during "rest" •During swallow they are raised up (with the movement of the larynx)to level of entrance to the esophagus allowing bolus to be dumped into the esophagus Valleculae - space between base of tongue and epiglottis. The hypo-epiglottic ligament which attaches the epiglottis to the base of the tongue, divides this into 2 spaces (actually another sinus) -- food can pool here

Indications for FEES

Logistic reasons •Transport to Radiology risky; medically fragile patient •Fluoroscopy not available: transportation to a hospital problematic - costly, stressful •Positioning problematic - contractures, neck halo, obese •Concern about radiation Clinical reasons: •Want to visualize larynx ----Voice suggests laryngeal involvement ----Anatomical changes: laryngeal trauma? Post-intubation? ----Post-surgery -- neurologic damage? •Visualize VP competence ( Velopharyngeal ) •Severe dysphagia & need for conservative exam ----Brainstem CVA; NPO for prolonged period •Compromised pulmonary clearance & need for conservative exam •Question re: aspiration of secretions •Sensation in laryngopharynx needs direct assessment •When extended therapeutic exam useful •When biofeedback to be used

2 of the most frequently used instrument evaluations for swallowing

MBS FEES

INSTRUMENTAL EVALUATIONS

MBS FEES FEESST If a patient presents with any signs/symptoms of pharyngeal dysphagia, then an instrumental study must be performed in order to adequately plan treatment.

Anatomy of oral stage (oral cavity structures)

Maxilla (upper jaw) Mandible (lower jaw) Upper and lower lips Cheeks Tongue Teeth Floor of mouth Hard palate Soft palate (velum) Uvula anterior/posterior faucial pillars (in front of tonsils on either side of your maxilla) lips lateral sulci, anterior sulci (space between teeth & cheeks) CN V (Trigeminal) CN VII (Facial)

Esophagus

Muscular tube that stays closed until food travels through it made of smooth & striated muscle links pharynx and stomach 20-25 cm (or 18" long) A patent tube; The esophagus is tonic (closed)at rest, and the action of opening is possible when the resting potential in the UES changes and due to mechanical action of the anterior-superior motion of the hyolaryngeal complex Begins with UES & ends with LES ----UES - junction betwn hypopharynx & esophagus ----LES - junction between esophagus and stomach

nutritive sucking

NS: 1 suck per second (up to 3 min)

Common swallowing complaints

Obstruction: food gets "stuck", feel full (called globus sensation for person reports that food is sticking at the level of the cervical esophagus), have a "lump in the throat" Liquids vs solids complaints Feeling of fullness or globus: Solid food dysphagia is usually disorder of esophageal origin; Liquid dysphagia is usually oropharyngeal dysphagia Choking on liquids & solids = Solids & liquids = disorders of esophageal motility or pharyngeal cause, described as choking on liquids or solids No choking on liquids & solids = esophageal cause Gastroesophageal reflux (heartburn) Chest pain, acid taste, pain or fullness in the chest Change in eating habits Avoidance of liquids or solids, sticky or crumbly foods No longer want to eat in restaurants due to choking or regurgitating Marked weight loss, no longer enjoy eating Excessive chewing of solid food = can be due to esophageal disease Liquids coming back through the nose = pharyngeal focus Tiring with foods that require mastication = neurological impairment Excessive time to finish a meal

oral stage prior to swallow

Oral preparation: tongue mvmt, chew, form cohesive bolus (FEES=poor, MBS=good) Leak, spill, dump bolus into HP (FEES=good, MBS=good if fluoro on)

Evidence based treatment data

Outcomes data = describes results of care in typical situations, describes improvements in functional terms Efficacy data = documents effectiveness of a Tx in a controlled clinical trial

PEG-tube in end stage dementia

PEGs were commonly used when patient had reduced PO intake or difficulty swallowing purpose was to prolong the patient's life, improve their quality of life, maintain adequate hydration/nutrition, eliminate aspiration, and prevent pneumonia however - patients may continue to aspirate their saliva and reflux of the feeding tube formula and are at risk for developing more oral and pharyngeal bacteria, increased skin breakdown and reduced quality of life. Complications of the PEG-tube (i.e. leaks or infection) may occur and some patient's may remove the tube due to confusion or agitation. Often times, families elect a PEG-tube to ensure the patient receives nutrition however it has been found that the body is unable to fully absorb this nutrition in end stage dementia.

PO NPO

PO = Latin "Per os" meaning by way of the opening. Used to describe medicine or food taken orally NPO = Latin "nil per os" meaning nothing by mouth (no food or drink)

SCREENING

PURPOSE: *tells us if the patient is at risk for dysphagia or aspiration *to see if they need further evaluation & possible treatment SCREENINGS ARE: -quick -non billable, no Dr order needed, can't touch patient -instead - read chart, talk to nurse & to pt, observe pt as they eat/drink, listen for signs of dysphagia, talk to them about what they feel, WHEN ARE SCREENINGS DONE: *On every pt in an acute care facility with CVA or head trauma - before they are given anything orally *On every pt admitted to a skilled nursing facility (SNF) WHO CAN SCREEN: Nurses (e.g. when patients are admitted) SLP for targeted populations (e.g. new stroke; patient transferred back to long term care after acute hospitalization, new admits or high risk population). WHAT SCREENING CAN'T DO: •Screening cannot identify the reasons for the problem •Nor can treatment adequately be planned based on a screening

EVALUATION

PURPOSE: Help determine the cause of the problem, where the problem is, what needs to be done and to make further recommendations EVALUATIONS ARE: Much more comprehensive include bedside evals include instrumental evals (MBS, FEES, FEEST) include non instrumental evals (Cervical auscultation Blue Dye test) EVALUATION COMPONENTS: -Look at diet history -Look at respiratory status -Talk to the family -Ask if any changes to diet or digestive system -Check for oral hygiene = Are they pocketing, is their hygiene protecting them from mouth bacteria, is there an infection - which can lead to pneumonia, is there food in the mouth that can be swallowed later and stuck in the valleculae or pyriform sinus and aspirated

pharynx

PURPOSE: Food & air flow through the pharynx to the larynx, trachea & esophagus. Crucial for swallowing and respiration. ANATOMY: 3 sections of pharynx: nasopharynx, oropharynx, hypopharynx

CLINICAL BEDSIDE EVALUATION

PURPOSE: can check cognitive levels, leads to plan of Tx, may recommend further eval, may recommend instrument evaluation, may make diet changes The clinical/bedside exam is the best assessment of the oral phase and should include: evaluation of oral structures (ck oral hygiene) oral motor function (strength, coordination, mobility) laryngeal function, cognitive /communication skills swallowing (presentation of food during trial feeding)

oral cavity

PURPOSE: important for swallowing, oral inspiration of air, sound production, boundaries for sucking, chewing, bolus formation ANATOMY: Maxilla (upper jaw) Mandible (lower jaw) tongue, lips, teeth Cheeks Floor of mouth Hard palate Soft palate (velum) lateral and anterior sulci (where you pocket food) Uvula anterior/posterior faucial pillars faucial arches AKA tonsillar arches (trigger swallow)

nasal cavity

PURPOSE: warms & cleans the air before it enters the lungs ANATOMY: separated from oral cavity by hard and soft palate

History of MBS

Patients used to be given an upper GI (upper gastrointestinal exam) drank crystals that formed gas in the abdomen, then drink barium, dr used fluoroscopy to see how the barium flowed to the intestines. There was no change in the consistency of foods/liquids. Logemann started the modified barium swallow, looking at oral and pharyngeal cavities (later they added esophageal).

Dysphagia may be evaluated and treated by several members of a health care team. Which statement below describes the reason for the use of different team members?

Patients with dysphagia may have deficits caused by a variety of etiologies and related deficits and thus need the expertise of a variety of professionals

MBS food consistencies

Present various consistencies mixed with barium: -Thin liquid barium (supposed to be like water but is really like nectar juice) -Nectar (thicker liquid) -Vanilla Pudding (or could use applesauce) - Choc. Pudding too dark to see -Cookie (Lorna Dune) which dissolves Presentation order -3 oz thin -5 oz thin -10 oz thin -Uncontrolled cup, straw -Pudding -Solid -Others as needed SLP presents liquids (thin liquid, nectar liquid, honey liquid) in several formats (5cc bolus to straw sipping) as well as solids (puree, mechanical soft, regular solids, mixed consistencies)

penetration --- ABOVE the vocal folds---

Process where food or liquids enter the larynx but remain ABOVE THE VOCAL FOLDS. These foreign substances may or may not be ejected from the upper laryngeal vestibule penetration occurs more frequently in the elderly (60-80 yr olds)

aspiration pneumonia red flags from med history

Recognize "red flags" from the medical diagnosis: Episodes of fever, temp spikes = infection Episodes of congestion (on and off) = can mean that they are silently aspirating, unable to manage their own secretions, aspiration pneumonia Prior CVA Unexplained weight loss (not eating well)

team roles

SLP = Evaluates and treats patients with swallowing problems Physician = Identifies children with swallowing problems; makes appropriate referrals; OT = Evaluates and treats sensory & motor impairments and assesses prosthetic needs related to self-feeding and swallowing. Dietitian - Evaluates nutritional needs; follows therapy recommendations regarding consistencies of liquids and solid foods, determines needs for special diets; and ensures adequate nutrition when using alternative means of nutrition. PT - Evaluates and treats body positioning, sensory and motor movements necessary for safe and efficient swallowing, recommends appropriate seating equipment needed during feeding. Gastroenterologist: Determines any difficulties with the GI tract; performs diagnostic tests related to the esophageal segment of swallowing; and places feeding tubes if the patient/student needs an alternative to oral feeding. Radiologist - Evaluates swallowing problems through radiologic studies, primarily with Speech-Language Pathologists during videofluorographic swallow studies (VFSS.)

at height of the swallow

TVCs make complete closure (FEES= no MBS=no ) Bolus moves through HP (FEES= no MBS= yes )

the 1st movement in the larynx during the swallow is

The arytenoids rock medially

components of the upper aerodigestive system

The combined organs and tissues of the respiratory tract the upper part of the digestive tract (including the lips, mouth, tongue, nose, throat, vocal cords, and part of the esophagus and windpipe).

The videofluoroscopy study (MBS) shows:

The complete swallow sequence, including oral and pharyngeal phases

thick liquids are required because

The thicker bolus moves more slowly and maintains cohesiveness

lingual surface

The tongue, which is covered by a mucous membrane, extends from the hyoid bone at the back of the mouth upward and forward to the lips Its upper surface, borders, and the forward part of the lower surface are free; elsewhere it is attached to adjacent parts of the mouth. The extrinsic muscles attach the tongue to external points, The intrinsic muscle fibers, which run vertically, transversely, and longitudinally, allow it great range of movement. Papillae - covers the upper surface of the tongue giving it a rough texture

Structural abnormalities of the esophagus

These all narrow the esophagus: -Rings - narrowing of esophagus at LES or distal end of esophagus -Strictures - narrowing of esophagus in any location preventing passage of the bolus; -Hiatal hernia in which part of the stomach moves into the esophagus blocking bolus movement -Esophageal Webs - mesh like strands of tissue crisscross the esophagus (a tightening of tissue that closes off the esophagus)- Pt. coughs or complains that food won't go down. Cause is unknown, some infants born with them. Adults can develop webs; they are benign or malignant

CN IX - GLOSSOPHARYNGEAL

This is the major nerve for the swallowing center;Sensory input involved in the initiation in the swallow comes from the trigeminal, facial, and glossopharyngeal nerves. (M) muscles used in swallowing to the salivary glands; innervates the 3 salivary glands in the mouth, Innervates the gag reflex •It innervates the stylopharyngeus muscle which elevates the larynx and pulls it forward during the pharyngeal stage of the swallow. This action also aids in the relaxation and opening of the cricopharyngeus muscle. It, along with the vagus (CN. X), provides some innervation to the upper pharyngeal constrictor muscles (S) all sensation and taste receptors on posterior 1/3 of tongue (bitter); carries sensation from the velum and the superior portion of the pharynx. A lesion may have impaired the gag reflex unilaterally

Material data set (MDS)

This is the screening form used at the bedside in a SNF Every pt in a SNF has one in their file

sections of the tongue

Tongue Tip: Picks up the bolus to bring it onto the lingual surface to initate the swallow. As the oral stage is initiated the tongue tip and sides contact the alveolar ridge. Mid Tongue: Sequentially elevates from front to back propelling the bolus posteriorly. Back of Tongue: The back of the tongue begins at the circumvallate papillae extends to the front of the soft palate. As the bolus and tongue motion approach the anterior faucial arches and base of the tongue, the pharyngeal swallow should be triggered

swallow sequence

Tongue back Swallow reflex- velum elevates to close nasal airway Bolus passes thru pharynx, epiglottis moves backward to cover airway, larynx elevates, true VF and false VF contract Bolus - through UES into esophagus, UES closes to prevent reflux Bolus moves to stomach

Swallow stage 1 - ORAL PREPARATORY STAGE

VOLUNTARY AKA enjoyment phase this is the pleasurable stage of swallowing (taste and smell of food) no time limit since everyone takes a different amount of time to chew ***************************************************************** Bolus is formed = food is broken down by chewing, mashing with tongue, exposure to enzymes in saliva that break down fiber in the food so it is formed into a bolus (called the reduction phase) The tongue arranges the bolus and moves it posteriorly to a position where it can be chewed (in the region of the molar teeth) . Bolus is held between tongue and hard palate Velum is pulled against base of tongue to keep bolus from spilling into pharynx

Swallow stage 2 - ORAL STAGE

VOLUNTARY -- lasts 1 second, The oral phase is primarily a delivery system. AKA oral transit phase ***************************************************************** begins as soon as bolus is propelled posteriorly by tongue toward pharynx Tongue makes rolling, squeezing action against the palate forcing food backward (a type of peristalsis) bolus is manipulated from the from to the back of the mouth Ends when the bolus passes the anterior faucial pillars or arches - as the bolus passes this point, the swallow reflex is triggered -Swallow reflex more often described as pharyngeal response Contact of the back of the tongue with the soft palate retains the bolus in the oral cavity, preventing early spillage into the pharynx. The velum then elevates as the lips and buccal muscles contract to build pressure and reduce the volume of the oral cavity. The posterior tongue is depressed, and the anterior and middle portions of the tongue differentially elevate and begin the propulsion of the bolus to the oropharynx

MBS with non ambulatory or semi patients

Videofluoroscopy chairs and a C-arm can facilitate the exam and help position non-ambulatory or hemi patients

diagnosing the type of dysphagia

We can do a BEDSIDE EVAL and say: Pt shows symptoms of oral-pharyngeal dysphagia, oral dysphagia, oral-prep dysphagia (because you can see those symptoms at the bedside) Need an INSTRUMENTAL EVAL to dx: Pharyngeal dysphagia esophageal dysphagia (you won't see signs of this at the bedside but you may HEAR signs of these at the bedside) ○ Although you can't judge adequacy of the excursion of the larynx at bedside, you can make some judgment of the movement

Swallowing upside down

You CAN swallow while upside down even though it is more challenging, less comfortable and there is reduced laryngeal elevation at times Laryngeal excursion was completed, however 2/4 subjects displayed reduced laryngeal elevation. Signs and symptoms of possible aspiration exhibited by 3/4 subjects via coughing, watery eyes, and a sensation of a bolus remaining after the swallow.

GERD - gastroesophageal reflux disease

acid reflux, stomach contents move up the esophagus because the lower esophageal sphincter (LES) isn't functioning well. Bolus mixes with the acids of the stomach and then travels back up the esophagus, this can cause aspiration of gastrointestinal fluids & acids Aspiration of acidic contents has the most severe effect on lungs SYMPTOMS: The most common c/o of patients with GERD is "globus" - a feeling of tightness or lump in the chest/throat Some may experience the burning sensation called "heartburn" Dx and Tx: GERD is diagnosed when there is persistent Reflux. ph monitoring confirms the presence and severity of GERD If untreated, causes red erosion on esophagus making motility slower and sometimes resulting in strictures Usually treated with medication like H2 antagonists or Proton Pump Inhibitors (PPI)

Aging swallow

adults begin to notice changes in swallowing at age 60-65

Pros of MBS

allows you to see the WHOLE swallow documentation of the swallow status diet recommendation treatment recommendation referrals to specialists (ENT, GI, dietary, neurology) improvement to quality of care / quality of life suggestions for the treating physician: (CXRs (chest X-ray) or medication management for the esophageal phase component)

deglutition

also refers to swallowing

FEEST --FEES with sensory testing

alternative to MBS / Videofluroscopy You don't give the patient food Start like you would for a FEES but then you put in a puff of air (laryngeal reflex) If patient reacts by closing off the vocal cords - then you know that the patient won't aspirate Very few people are trained to do these

Electromyography

alternative to MBS / Videofluroscopy •Electromyography measures electrical impulses generated by muscles of neck, larynx, pharynx. Does not specify location of difficulty

FEES -Fiberoptic Endoscopic Evaluation of the Swallow -Flexible Endoscopic Evaluation of the Swallow

alternative to MBS / Videofluroscopy •Evaluates the non-oral components of the swallow •Flexible, thin endoscope inserted nasally (into the nose) into the back of the nasal cavity, through the back of the mouth (behind the soft palate) and into the pharynx •A light source, camera, video tape utilized •Positioned to view the pharynx, vocal cords, larynx (Also velopharynx, oropharynx) •Visualizes the swallow before and after it occurs; not during the swallow Developed by Dr. Susan Langmore

Ultrasound

alternative to MBS / Videofluroscopy •Ultrasound techniques can visualize the movement of the larynx (excursion) but not generally the action of the vocal folds

Accelerometry

alternative to MBS / Videofluroscopy •Use of surface microphone which picks up contraction of muscles. •Computerized Laryngeal Analyzer (CLA) newly developed.

Scintigraphy

alternative to MBS / Videofluroscopy •accurate way to evaluate and manage dysphagia •Small doses of radioactive sulfur colloid mixed with various consistencies • considerable radiation exposure to patient •After each bolus, patient placed under a scintigraphy counter which quantifies the percentage of aspirated material •Can be performed in conjunction with MBS •Allows for more objective measurement of aspiration than MBS •Does not allow clinician to view phases of the swallow; only the after effects •It indicates the symptom of aspiration but does not provide info as to the cause or aspiration. •Easy to perform at bedside •Good for non-mobile or fragile patient (although this is worrisome - can do a FEES instead or wait and then do a MBS) •Low cost test •Time consuming if used to test various food consistencies. Should be followed for 24 hrs. Need to test one consistency at a time over that period, then next consistency *more objective than the MBS (MBS interpretation is subjective - ie - what % of time they are aspirating, etc.)

Cervical auscultation

alternative to MBS / Videofluroscopy not an instrument test - done at bedside •Use of stethoscope to listen to sounds in the cervical region as the swallow occurs •Must be trained to identify the sounds associated with laryngeal protection and swallow •Not standardized; can be administered at bedside, inexpensive.

Blue Dye Test (AKA Evans Blue Dye Test)

alternative to MBS / Videofluroscopy not an instrument test - done at bedside •Used with tracheostomized patients ONLY -1st the patient is suctioned by the nurse or respiratory therapist (very uncomfortable) -Blue food coloring used to dye the oral secretions or food/liquids that pt consumes ------Mix it with applesauce or vanilla pudding ------Can also use blue Gatorade or Powerade -Feed the pt then suction them again -The material that you suction should come out clear If it comes out blue - then it means that the pt is aspirating At measured intervals after the dye is introduced (1 to 5 min, 1 hour, 24 hours) by examining tracheal secretions to detect signs of aspiration of the dye. If dye found in tracheal secretions, there is a confirmation of aspiration. -Why repeat this again so long after the 1st suctioning? To see if there is a delayed swallow or pooling in valleculae or pyriform sinus and they swallow later

when velum is relaxed (normal position)

anterior surface is concave marked by a median raphe' posterior surface is convex lower portion is the palatine velum- this hangs like a curtain between the mouth and the pharynx palatine uvula - cone shaped process that hangs from the middle of the lower border arches / pillars of the fauces - arching lateral and down from the base of the uvula on either side are two curved folds of mucous membrane, containing muscular fibers

Which of the following disorders do NOT apply to the esophagus? --aspiration --achalasia --Barrett's --Webs/rings

aspiration

MBS allows you to

assess oropharyngeal function of the swallow determine the least restrictive diet assess occurrences and causes of penetration /aspiration and how to prevent/minimize them assess occurrences and causes of oropharyngeal residues and how to minimize the residues view bolus flow through the esophagus via an esophageal sweep (similar to a screening) view the physiology (function) of the oral cavity which a FEES cannot do

an optional component of FEES is

assessment of sensation (FEEST)

aspiration can occur

at any time before, during or after the swallow

when does aspiration occur

at any time during any phase of the swallow ➢ before - liquid spills if cant trigger a swallow reflex (spills down) ➢ during - while swallowing if not controlled ➢ after the swallow - from pooled material in the valleculae and p. sinuses *however, aspiration most commonly occurs DURING the swallow

for an MBS you need

barium, food or liquid, lead shield you do NOT need food dye

patient asleep or not attending to tasks

cannot do FEES or MBS if patient is in this condition

chin tuck position

compensatory strategy to prevent aspiration and reduce pharyngeal residues chin tuck doesn't always make swallowing safer The efficacy of this strategy should be confirmed under fluoroscopy because it places the patient at higher risk for oral phase deficits and possible aspiration.

Why conduct an MBS? Signs and symptoms of aspiration or dysphagia:

coughing, throat clearing, breathing difficulty, rhinorrhea (runny nose) and watery eyes with PO intake, increased secretions and drooling, vocal quality changes, wet/gurgly vocal quality, multiple swallows with a single bolus, pain while swallowing, globus sensation (feel like there is a lump in your throat) recent pneumonia and need to rule out silent aspiration

the clinical bedside dysphagia eval allows the clinician to do the following:

determine need for alternative means of nutrition / hydration recommend additional tests to Dx and treat dysphagia facilitate determining the etiology of dysphagia assess the oral phase including labial and lingual function may lead to a diet modification

Pre-feeding exam

equipment needed in the room includes: gloves tongue depressor light pudding, cookie, straws

non compliance with dietary recommendations

family may be noncompliant with diet recommendations due to knowledge of pt wishes, quality of life issues, recorded advanced directives, or lack of understanding of the consequences

what do patients aspirate

food liquid (including saliva) contents of stomach (GERD, vomit)

Backflow - intra-esophageal reflux or retrograde flow

food goes partially down esophagus then comes back up. It does not mix with the stomach acid so it isn't as dangerous as acid reflux

aspiration ---BELOW the vocal folds---

food, liquid or other foreign matter passes BELOW THE VOCAL FOLDS into the lungs. aspiration rates do NOT increase in the elderly

penetration is

foreign matter entering the laryngeal vestibule

Which of the following is considered the major nerve of the swallowing center?

glossopharyngeal

neurological assessment of CN V - Trigeminal

important for Oral Motor -Facial quadrants (sensory) feeling in 4 areas of the face, important after CVA where pt may feel it on one side but not the other due to hemiplegia, Parkinson's pts may have parts of face with sensation and other parts with no sensation -Jaw ROM motor (can open/close jaw, move it from side to side) helps with chewing -Symmetry of movement -Masseter palpation (touching the masseter muscle) •Masseter muscle moves the jaw up and down to help with chewing

CN V - TRIGEMINAL

important in oral stage of swallow; Sensory input involved in the initiation in the swallow comes from the trigeminal, facial, and glossopharyngeal nerves. bolus propulsion, upward movement of hyoid. (M) - innervates muscles for chewing, move lower jaw, & palatal elevators - impt for rooting, sucking, initiation of swallow; Innervates these muscles: temporalis, the masseter, the medial, and the lateral pterygoid, the tensor veli palatine muscle, which tenses the velum. It assists the glossopharyngeal nerve in raising the larynx and pulling it forward during the laryngeal substage of the pharyngeal swallow. (S) - info from cheeks, nose, lips, teeth and skin over lower jaw. Provides feedback from mouth during sucking, nose (during breathing), soft palate during swallowing. Carries sensory info from face, mouth & mandible, carries sensation feedback for all but taste from anterior 2/3 of tongue.

CN VII - FACIAL

important in oral stage of swallow; Sensory input involved in the initiation in the swallow comes from the trigeminal, facial, and glossopharyngeal nerves. Similar to CN V (M) muscles of facial expression, salivary glands (facial expression contributes to infant-parent bonding). Innervates lip muscles: orbicularis oris & zygomaticus which contract during oral prep & oral transit to prevent food from dribbling out of mouth. Innervates buccinator muscles in cheeks which tense to prevent pocketing of food between teeth and cheeks. (S) info about taste from receptors on anterior 2/3 of tongue (sweet/salty/sour);

Mechanical dysphagia (AKA anatomical / physical)

inability to chew and or swallow because of damage/changes to anatomical structures which prevent the mechanical processing of food: structural problems = can result from surgery mechanical = things don't move well after surgery or radiation physical = trauma to throat (1) MOST COMMON = Cancer (tumor occupies space within the anatomy) Also: (2) Poison (drink lye) (3) Surgery (remove malignancies on jaw or tongue) (4) Smoke inhalation (5) chemical damage (i.e.: radiation exposure) (6) fistula in trachea or esophagus, allergy

Aging swallow (80+ years)

increased risk of dysphagia as the result of illness and subsequent general weakness •Reduced pressure reserve - especially in men •1) Hyoid & laryngeal maximum vertical movement significantly reduced in the elderly •2) Hyoid and laryngeal movements up to the time of cricopharyngeal opening virtuallyidentical in young adults and elderly patients •Reduced flexibility •1) Cricopharyngeal opening durations across volumes reduced in the elderly •2) Cricopharyngeal opening diameter across volumes reduced in the elderly •a) Timing similar to 60-80-year-olds •b) Safety and efficiency of swallow unchanged

stroboscopy

is a special method used to visualize vocal fold vibration. It uses a synchronized, flashing light passed through a flexible or rigid telescope. The flashes of light from the stroboscope are synchronized to the vocal fold vibration at a slightly slower speed, allowing the examiner to observe vocal fold vibration during sound production in what appears to be slow motion. Most SLP's can perform

AAO

is patient awake, alert, oriented can't perform a clinical evaluation is they are not

Barrett's esophagus

is precancerous is more common in men than women is increasing among white American males is caused by persistent irritation of lower esophagus due to untreated GERD

dysphagia screening

is used to identify the need for evaluation and possible treatment

dysphagia is not a disorder by itself

it is a symptom of a disorder. You must have something that causes the dysphagia like CVA, cardiac surgery, CP, Down Syndrome, Cleft Palate, Parkinson's, dementia, MS etc.

UES - upper esophageal sphincter

junction between hypopharynx and esophagus made of cricopharyngeus muscle fibers and inferior pharyngeal constrictor The UES remains closed or tightened until the swallow reflex/pharyngeal response is initiated. As the bolus travels through the pharynx and the larynx raises and moves anteriorly, the UES opens to receive the bolus, closes around it and the bolus is moved by peristalsis until it reaches a sphincter at its lower end called the LES (Lower Esophageal Sphincter)

To test the function of CN XII (Hypoglossal), have the patient:

lateralize the tongue to either side

SLP radiation precautions for MBS

lead apron, thyroid shield, protective gloves, protective glasses, a dosimeter badge (put on the outside of apron) to measure the cumulative amount of radiation rec'd each month

swallowing evaluations

lead to the plan of Tx or plan of care - which may include further evaluations

Direct fiber-optic (flexible or rigid) laryngoscopy

lets the dr see deeper into your throat to: Find the cause of voice problems, such as a breathy voice, hoarse voice, weak voice, or no voice. Find the cause of throat and ear pain. Find the cause for trouble swallowing, a feeling of a lump in the throat, or mucus with blood in it. Check injuries to the throat, narrowing of the throat (strictures), or blockages in the airway Rigid laryngoscopy can be used to remove foreign objects, collect tissue samples, remove polyps from vocal cords or to find cancer of the larynx

One of the most serious consequences of dysphagia is aspiration. Aspiration occurs when:

liquids or solids pass below vocal folds

Another cause of dysphagia - Iatrogenic

meaning caused by an illness (1) Chemotherapy (2) Medications (2) Radiation (causes scar tissue, tracheoesophogeal fistulas) (3) Surgery

if a pt aspirates during a swallow study is the test immediately stopped?

no

3 oz water test

not an instrument test - done at bedside These are done by the nurse or doctor - Used as a screening tool in hospital for (CVA, head trauma or progressive neurological disease) Results have a lot of false positivies Have pt sit upright in bed Give 3 oz cup of water - tell them to drink without stopping Coughing, gagging = aspiration The developers of the test felt that no MBS was needed if the pt passed this test

Cons of MBS

not in color is filmed laterally unless you turn the patient

in what phase of the swallow is the bolus manipulated from the front to the back of the mouth

oral

mechanical dysphagia results from

oral cancer

what phase is the enjoyment phase

oral prep

the clinical bedside evaluation provides info about what phases of the swallow

oral prep oral phases

Patient radiation precautions for MBS

patient will be exposed to a small amount of radiation but benefits outweigh the risks MBS radiation is approximately equal to: --a complete set of CXR's (chest x-rays) --or a day in the sun MBS should NOT be performed for persons with a barium allergy, who are pregnant, or have a severe bowel obstruction/perforation. In addition, alternative liquids/foods may be required due to food allergies.

abnormal oral phase symptoms include

piecemeal bolus transfer pocketing in lateral sulci premature spillage to the valleculae

the most significant difference between screening and clinical bedside swallow eval is

screening identifies patients at risk for dysphagia eval seeks to determine the causes of the problem

The Normal Swallow: What Can be Seen Endoscopically (FEES) vs Fluoroscopically (MBS

see below:

Swallow stage 5 - ANTICIPATORY STAGE

some include this 5th stage at the beginning when looking at food you see it, smell it, start to salivate in anticipation and this motivates you to eat AKA pre-oral prep stage

dry swallow

swallow your saliva

bolus

the collected and shaped body of food/liquid. If a solid - it has been chewed and chemically processed by enzymes prior to being swallowed

Aging swallow continued (from lab)

the larynx may begin to lower slightly in the neck, approaching the 7th cervical vertebra. Arthritic changes in the cervical vertebra may impinge on the pharyngeal wall, decreasing its flexibility. The oral stage of swallowing is slightly longer in older adults as is the "normal" delay in triggering the pharyngeal swallow (Less than 1 sec.). A small amount of residue may be seen in the valleculae and pyriform sinuses in normal elderly subjects. Esophageal function deteriorates more significantly with age so that esophageal transit and clearance are slower and less efficient after age 70

if patient aspirates on all consistencies and isn't safe for PO intake

the medical team (including MD, SLP , nursing) must consider the risks and benefits of continued oral nutrition and hydration. PO intake may be decided if remaining PO is medically recommended by the pt's MD, or this choice is made by the pt./POA with a clear understanding of the risks of aspiration and pneumonia. This should be clearly documented. Strict pulmonary monitoring should accompany decisions to continue PO intake. The PCP may determine that alternative means should be the main source of hydration and nutrition. Consultation between the team may lead to a Palliative Care consult.

silent aspiration

the most dangerous because there are no obvious signs Material enters the airway, passes below the vocal folds and no effort is made to eject material (like coughing) Some warning signs include: Significant delay in swallow Premature release of bolus into pharynx They take a drink of water and it pours down over the base of the tongue, in the pharyngeal area, without triggering a swallow Difficulty in terminating respiration Less than 1 inch excursion of the larynx History of pneumonia History of congestion (on and off) for a year or more History of temperature spikes Gurgly voice chronic , copious, clear secretions Green secretions (sign of infection)

mastication

the process of chewing food. This process is one stage of the act of deglutition or swallowing

Oxygen saturation levels

the reading should be 90 or above before doing a FEES (normal is 95-100) if at 90 then they are not in distress and are breathing ok if in 80's - don't do it

MBS with tracheostomized and/or ventilator dependent patients

the respiratory therapist and/or nursing should be present to monitor respiratory status

peristalsis

the wave like motion that conducts the bolus through the esophageal structures

older adults are more susceptible to having dysphagia when they become ill because

they have less pressure reserve for swallowing

thicker liquids

thicker liquids are easier to control, make for a more cohesive bolus Patients are placed on thickened liquids after demonstrating a cough on thin liquids BUT the effectiveness should be confirmed with an instrumental exam Use of thickened liquids may increase pharyngeal residues, increase level of fatigue, and increase risk for dehydration (possibly due to the patient not drinking a sufficient amount of liquids due to dislike for viscosity (thickness) of the liquids).

GERD is the failure of the LES to tighten or relax

tighten

a safe swallow requires

tipping of the epiglottis laryngeal excursion raising of the soft palate adduction of the vocal folds

the main purpose of an MBS is

to assess the physiology of the oral and pharyngeal stages of the swallow in order to plan treatment

Cognitive impairment is a confounding factor in dysphagia secondary to traumatic brain injury (TBI). true/false

true

Stroke is the most common cause of neurogenic dysphagia.

true

the larynx and pharynx are not at rest during the oral transit of swallow

true

patent tube

tube that collapses against itself, does not remain open but opens to receive a substance like food. The esophagus is a patent tube that brings food to the stomach

aspiration pneumonia

type of pneumonia that results from food, liquid, or other foreign matter from entering the lungs. This type of pneumonia is often the cause of death for patients with dysphagia. *the relationship between pneumonia and aspiration is not clear - not everyone who aspirates gets aspiration pneumonia

an instrumental eval should be recommended if

upon a clinical bedside eval the patient is determined to have pneumonia, coughs with liquids and/or has multiple swallows with all boluses.

variations in a normal swallow can be caused by

volume and viscosity effects

When would you perform a FEES instead of an MBS

when you want a good view of the pharynx and larynx

patients with mechanical causes of dysphagia are good therapy patients (yes/no)

yes

Limitations of the FEES

• can only see 1 part of the swallow - not all phases like MBS • can only see the pharyngeal-laryngeal phase of swallow • can't see the esophageal phase •Can't see the oral cavity or esophageal cavity • can't see UES issues •When the swallow occurs there is a whiteout and you can't see the swallow take place •View of pharynx is obscured briefly during the swallow •Can observe aspiration, residue, sensitivity after the swallow •May lead to request for videofluoroscopy •Not used at this time with patients on Passy-Muir valve or those with a trach

Murrays rating scale for secretions

•0 = no visible secretions •1 = any secretions evident on entry or following a dry swallow in channels surrounding laryngeal vestibule bilaterally represented or deeply pooled. Includes transitions •2 = any secretions that changed from a 1 to a 3 during observation period •3 = Any secretions seen in the area defined as laryngeal vestibule You can predict aspiration from secretions: •All hospitalized patients with secretions rating of 2 or above were observed to aspirate on FEES •0 = 21% aspirated •1 = 53% aspirated •2 = 100% aspirated •3 = 100% aspirated

penetration-aspiration scale Rosenbek's 8 point scale to measure penetration/ aspiration this is used during the MBS (1) means no problems up to (8) meaning problems

•1-Material does not enter the 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 (this is PENETRATION) •4-Material enters the airway, contacts/rests on 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 (this is ASPIRATION) •6-Material enters the airway, 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 (this is SILENT ASPIRATION) #3 and #5 are concerning because material isn't ejected from airway *if the material is not ejected from the airway then the pt is not aware it is there, no coughing reaction has been activated

Anatomy of the esophageal stage esophagus UES LES

•A sphincter at the upper end of the esophagus is made of fibers of the cricopharyngeal muscle and other muscles. It is also called the UES (Upper Esophageal Sphincter) •The UES remains closed or tightened until the swallow reflex/pharyngeal response is initiated. As the bolus travels through the pharynx and the larynx raises and moves anteriorly, the UES opens to receive the bolus, closes around it and the bolus is moved by peristalsis until it reaches a sphincter at its lower end called the LES (Lower Esophageal Sphincter) •The LES connects the esophagus with the stomach and intestinal tract

Neurological assessment of CN IX - X

•CN IX-X Reflexive spontaneous swallow and Pharyngeal sensation -Gag -Palatal movement -Cough reflex -Ask them to voluntary cough - looking for elevation of the larynx -Voice - hoarse or gurgly (dry/wet)

Damage to the brain stem

•Closer damage is to the brain stem, more likely swallow will be affected •Very high probability of dysphagia if brain stem in directly damaged

Cerebral Hemispheres

•Damage to the motor or sensory areas of the cerebral hemispheres can interfere with the swallow process. Sensory and motor information needed for the initiation, coordination, and cessation of the swallow may be interrupted.

FEES

•Developed by Langmore •Uses endscope to view swallowing •Excess secretions visualized with FEES® have high predictive value for aspiration ------ex: Murray's rating scale for secretions

hyoid bone

•Free floating bone - in place by muscular connections with -scapulae, sternum, cervical vertebrae, temporal bone, mandible, laryngeal cartilage and tongue •These connections = anatomical link between sucking, swallowing, chewing, breathing, cranio-cervical posture •Swallow - Hyoid moves upward and forward, mechanical traction on UES (opens the esophagus)

Indications for Fluoroscopy: MBS and/or Barium Swallow

•Globus complaints - do both •Esophageal symptoms - do both or just barium swallow •Fistula after surgery? barium swallow alone

aspiration pneumonia mortality rates

•Highest mortality rate of any infection •Among hospitalized elderly, development of pneumonia is associated with 43% mortality rate •Pneumonia 2nd most common infection in nursing homes •Even mildly dysphagic patients are at risk for developing aspiration pneumonia •Up to 80% of nosocomial pneumonia may be aspiration pneumonia

treatment options

•Modification of quantity, taste, texture, and temperature of food may be necessary to ensure safe swallow. •Providing the patient with adapted eating utensils may also facilitate safe swallow.

non nutritive sucking

•NNS: 2 sucks per second •Calming, increases O² levels in blood •Pair this with gavage feeding/tube feeding •Use a variety of nipples especially the one to be used on the bottle

Indications for fluoroscopy

•Need comprehensive view of all structures -- Unknown medical etiology; anything possible •Visualize reported regurgitation/ backflow - site of origin •Visualize oral phase •Visualize UES

FEESST

•Not widely used •Aviv has written the most about it •The scope has a second channel that delivers an air pulse to "test sensation" •Other than that, performed the same as FEES®

MBS positioning - anterior-posterior view (AP)

•Patient is placed in true frontal position •Record hard palate to cervical esophagus without contrast •Patient instructed to vocalize "eeeee" while radiologist pans to assess vocal cord function •Assess swallow function with contrast. If aspirated barium outlines vocal folds, record during dry swallow and phonation •If needed, assess esophageal stage looking for GERD. •Place patient in compensatory positions thought to be useful to the patient for a safe swallow and asses swallow in those positions with the contrast •Asses swallow while implementing patient controlled facilitative exercises or other therapeutic techniques

Pros of the FEES

•Portable procedure and can be used at bedside •Non-radiographic (no radiation) •Can be repeated often (unlike MBS where there is radiation exposure) • it is shown in color •can see the vocal cords

mechanics of sucking

•Positive & negative pressure = sucking -Positive pressure: extracts fluid from breast/bottle, baby compresses nipple with gums against base of nipple or with tongue against palate. Pressure on nipple pushes fluid out of the mouth -Negative pressure: suction that draws fluid into the nipple and then out the bottle into mouth, tongue depresses, enlarging oral cavity = intraoral pressure •Two different acts: -Bottle feeding: baby has to draw milk out of nipple with compression and suction -Breast feeding: breast tissue is deep within the mouth, the milk lets down and fills the mouth, baby closes lips to STOP flow of milk Expect a transitional phase

MBS positioning - Lateral position

•Record oral cavity, pharynx, neck to upper cervical-esophageal area without contrast •Radiologist will pan oral cavity, pharynx, neck to follow material through its course, some radiologists will view the esophagus --Esophageal view can find fistulas etc.

larynx

•Serves 3 functions: (1) Protect airway (Epiglottis, False VF, True VF) (2) Aids in respiration (3) Aids in phonation mostly cartilage Biological purpose of the larynx is to protect the airway from foreign matter. •Larynx - gatekeeper to the lower respiratory system •True VF, False VF & Aryepiglottic folds = Modify flow for phonation as well as protect the trachea •Hyoid & larynx moves up, forward, epiglottis is pushed down, arytenoid cartilages tilt forward and the False VF and True VF close.

sucking

•Sucking is the intake phase of eating liquids and soft solids. •Provides nutritive and non-nutritive support for calming/organizing body •Occurs in 2nd trimester

Neurological control of the swallow

•Swallowing is dependent on information from both afferent and efferent systems. •Both sensory and motor information are needed to initiate a swallow •Sensory feedback is more important in swallowing than in speech. Sensory input involved in the initiation in the swallow comes from the trigeminal, facial, and glossopharyngeal nerves. •Information about motor movement is received from the muscle spindles in the tongue via the hypoglossal nerve. •Sensory and motor information from these sources is carried to the swallowing center, which is believed to be located in the medulla, within the nuclei of the reticular formation; specifically the nucleus ambiguous. •When the swallow response is initiated, this center causes messages to be sent to the glossopharyngeal, the vagus, and the hypoglossal nerves.

FEES vs Fluoroscopy

•The View is Different: What do you Want to Visualize? •The Nature of the Exams are Different: What is your Reason for the Exam? • The objectives of the exams are similar - figure out what is wrong and what can help

esophageal dysphagia

•There is a close relationship b/t pharyngeal and esophageal phases •Based on patient c/o, at least screen esophageal phase in upright •Without a full barium swallow, you will not be accurately assessing the esophageal phase

aspiration precautions

•Upright for all PO (including meds) •Upright at least 30° if receiving tube feeding (-NG, PEG, PEJ) •Aggressive oral care

clinical evaluation

•Why do we conduct the clinical evaluation? -Adds to clinical diagnosis -Recommendation for instrument assessment -Helps with a treatment plan -Helps with a diet plan -Helps to monitor progress -How does it help with a Tx plan: Gives us a baseline Helps gain an understanding of client strengths and weakness -Can monitor their cognitive levels, level of alertness, ability to recall -Can monitor hearing, language, articulation, intelligibility (could be dysarthric) -Can screen for apraxia which can also cause problems with swallowing (because it impairs voluntary actions like talking and swallowing)

When to stop the MBS study

•stop the study once you have all of the info you need •when pt can no longer cooperate - falling asleep or wearing out

Neurological assessment of CN XII

•tongue protrusion and symmetry -Tongue movement -Tongue strength -Tongue coordination Can eval all of these at the bedside, can the tongue move in/out, laterally, between teeth and cheek to clear out food, is it coordinated, is there a hemiplegia (paralyzed on half), glossectomy

Aging swallow (60 - 80 years)

○ In oral prep stage =Loss of dentition and/or ill fitting dentures impacts ○ In oral stage=reduced tongue mobility and pressure, decreased jaw biting force to masticate ○ In pharyngeal stage = inadequate laryngeal movement, Pharyngeal delay times longer in older adults, Pharyngeal wall contraction is slower ○ poor oral hygiene ○ reduced / altered saliva flow ( thicker) ○ Lingual strength decreases but the pressure needed to push the bolus through the pharynx remains the same ○ Swallowing is generally "slowed" with age can impact on bolus flow outcomes and leads to decreased "pressure reserve" leaving older people more at risk for dysphagia resulting from insults directly or indirectly to the swallowing system ○. Penetration occurs more frequently ○. Aspiration rates are unchanged ○. Slightly higher amounts of residue ○ Muscle atrophy & incoordination ○ in some people, esophagus changes like achalasia, GERD and back flow

Diseases of the esophagus

➢ GERD ➢ Barretts esophagus ➢ Fistulas ➢ Zenkers ➢ Achalasia