Swallowing Disroders in Adult Populations

HEAD & NECK CANCER

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INFECTIONS

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MECHANICALLY BASED DYSPHAGIA

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MUCOSAL INJURIES

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DYSPHAGIA RELATED TO SURGICAL COMPLICATIONS

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ALIGNMENT OF C-SPINE TO PHARYNGEAL STRUCTURES (5)

C3- aligns with the tip of the epiglottis C5- aligns with PES Clinical implications? Surgery in the region of c3 can impede epiglottic retroversion Surgery in the region of c5 may impede PES opening My notes: · pay attention to where the spinal column is lining up to the structures · the epiglottis is roughly right across from C3 · the PES is roughly at the level of C5 · let's say you have a Pt who had some sort of spinal surgery st C4 and so the surgeon did a stabilization and put some hardware between C3-C5 · now the pharyngeal wall will be all swollen from the surgery · the implication is that sometimes bc of all the hardware and swelling, the epiglottis has nowhere to go · the epiglottis is really trying but it's almost like it's hitting a brick wall · it can't release and retroverted to let the bolus that's collecting in the vallecula to go through the hypopharynx and into the esophagus

More on inhalation injuries

· (Ward et. Al, 2001) studied 30 thermal burn patients · Patients mechanically ventilated for average of 24 days · 80% had tracheostomy tubes · Initial dysphagia assessment occurred approximately 20 days after admission · First safe oral intake achieved approximately by 30 days · Time to achieve oral intake without supplementation = 54 days with 90% tolerating normal diet · Clinical significance? · It may take these patient's quite awhile to recover. May need peg tube until can swallow safely My notes: · this gives you some outcomes to look for in terms of the expected trajectory/course of recovery for these patients · likely this person is going to take a lot longer to recover · an NG tube is not recommended to stay in for more than 21 days (3 weeks) · a lot of these Pts aren't going to start their swallow assessment until around that 3 week · these types of Pts may need some extra supplementation through a PEG tube

EFFECTS OF CERVICAL BRACING (continued)

· 82% demo radiographic changes under one or more of the bracing conditions · 47%- changes in point of swallow initiation response · 59% had increased pharyngeal residue · 23.5% demonstrated changes with bolus flow and laryngeal penetration · Bracing may produce subtle mechanical alterations in swallowing · Mandibular pad of SOMI brace appeared to restrict hyoid movement because of external pressure on the neck/hyoid bone region Also, bracing forced subjects into strict 90 degree head-spine alignment. Many people eat with head flexed slightly forward as food is often positioned on a table at waist level. My notes: most people do not eat sitting straight up, you usually are looking down when you're eating

HEMILARYNGECTOMY (4)

· A vertical resection of structures. · Extent of removal depends on size of the lesion · Tissue bulk is reconstructed on the operated side · Pharyngeal deficits are going to be unilateral in nature

Multiple Sclerosis (6)

· Abnormal immune response directed against the central nervous system that leads to destruction of myelin · Demyelinization causes nerve impulses to be slowed or halted · May have some difficulty with lingual control of bolus manipulation, chewing, and oral transit (if hypoglossal nerve has been affected) · Delay of swallow initiation · Reduced pharyngeal stripping · Reduced laryngeal closure My notes - if CN X has been affected then you will see problems with swallow initiation, pharyngeal stripping, etc.

Myasthenia Gravis (MG)

· Affects how nerve impulses are transmitted to muscle at the neuromuscular junction where the immune system attacks skeletal muscles · Can be life threatening when respiration is affected · Often affects face, lips, eyes, tongue, throat, and neck. · Condition worsened by muscle exertion, extremes of temperature, viral/other infections, and excitement · Sudden inability to swallow or breathe at any time · Patient's swallow may fatigue over the course of meal · Evaluate via fluoroscopy at the beginning of meal and 15-20 minutes after consecutive swallowing · Decreased pharyngeal stripping, in severe cases, no pharyngeal contraction may be seen · Treatment is conservative- mainly compensatory strategies My notes: · with this disease a person could be perfectly fine one minute, and then unable to swallow in the next minute · swallowing can fatigue over the course of a meal · they may have to cease the meal and rest · a lot of times with this Dx, sometimes we want to try to fatigue them in order to try and catch what the problems are - we might say "before you do your swallow study, go down and eat lunch" · there's no point in doing excessive exercise to try to strengthen this bc it's only going to make them worse · typically we just provide the Pt with strategies

LAMBERT EATON SYNDROME (2)

· Autoimmune disease which typically manifests in pelvic, thigh, shoulder, and arm muscle weakness · Cranial nerves may be affected resulting in dysphagia and respiratory distress

INFLAMMATORY MYOPATHIES (POLYMYOSITIS & DERMATOMYOSITIS)

· Autoimmune diseases resulting in muscular weakness · Dermatomyositis accompanied by skin rash · Xerostomia · Trismus · Decreased pharyngeal stripping wave · Reduced pes relaxation My notes: - the difference b/w polymyositis & dermatomyositis is that dermatomyositis also has a skin rash associated with it

SJOGREN'S SYNDROME (5)

· Autoimmune disorder that results in severe dryness of the mucous membranes in the mouth, eyes, pharynx, larynx, and digestive tract · Treatment is compensatory directed at reducing xerostomia- · Increased hydration · artificial saliva · "slick" diet (adding moisture to foods)

HERPES SIMPLEX VIRUS

· Can cause cranial nerve palsies · Can cause blisters on the skin, in the mouth, or in the pharynx that can cause irritation and pain My notes: - if any CNs for swallowing are affected by the virus then they could have issues there with swallowing

CANDIDIASIS (THRUSH) (4)

· Caused by an overgrowth of yeast · Appears as white patches or small red spots on the tongue, hard palate, gums, pharynx, and esophagus · Common in NPO population, patients with xerostomia, prolonged use of antibiotics · Causes odynophagia, alterations in taste My notes: - very common in head and neck cancer population

DYSPHAGIA FOLLOWING CERVICAL SPINAL CORD INJURY (SCI) ANTERIOR CERVICAL FUSION

· Cervical fusion occurs when there is a need to stabilize the cervical vertebrae (cervical injuries, degenerative changes) · Fusion may be anterior or posterior · Usually have some type of hardware, which is implanted, in or between vertebrae. · Post-op course significant for swelling, reduced laryngeal elevation, reduced airway closure, reduced cricopharyngeal opening. My notes: · fusion could be due to an injury or some sort of arthritis that is impinging on the spinal cord itself · anterior approach where they make a lateral incision on the neck to get to the anterior spine · posterior approach is when they put a big incision up the back of the neck so they can go in and stabilize that way · these Pts are usually going to have some sort of hardware implanted

Inhalation injuries continued

· Damage to the mucous membranes of mouth and pharynx leading to pharyngitis or acute laryngitis · Laryngeal edema or spasm can occur requiring need for intubation or tracheostomy Airway obstruction may not be initially apparent but may worsen over first 24 hours post exposure · Patients with smoke inhalation may have direct thermal burns to the upper respiratory tract · Singed nasal hairs and carbonaceous sputum should suggest possible inhalation injury in a fire victim My notes: - sometimes these Pts need to be watched for a while to make sure that they don't go into respiratory distress

Parkinson's Swallowing (6)

· Decreased laryngeal elevation · Decreased pharyngeal clearing with thicker consistencies (thicker is not always better!) · Decreased laryngeal closure during later stages of the disease resulting in penetration/aspiration · Pes dysfunction · May complain of xerostomia secondary to medications · Coordinating drug therapy with mealtimes may be beneficial My Notes: ▪ there's kind of a misnomer that thicker consistencies are easier to swallow - that is NOT always the case ▪ if they're having an issue with hyolaryngeal elevation and opening/distension of the PES, as they're trying to swallow something thicker, you might have material that partially goes through the PES and then it just kind of closes up before the entire bolus makes it all the way through ▪ sometimes these Pts actually do better with thin liquids ▪ PES dysfunction bc of poor hyolaryngeal elevation ▪ if they're taking medications for parkinson's taking them at mealtime with the SLP might be helpful just to help their overall function

Brain Injury- Pharyngeal Deficits (4)

· Delayed or absent pharyngeal swallow · Reduced hyolaryngeal elevation · Reduced airway closure · reduced PES opening My Notes ▪ think about the CNs ▪ if their BI has created issues with CN X, then all of these different things that happen in the pharyngeal stage can be affected

Reasons for Dysphagia (6)

· Dysphagia is a sign of an underlying disease or medical problem. Dysphagia does not arise by itself! - Neurologically induced dysphagia - Mechanically based dysphagia - Dysphagia related to surgical complications - Infections - Mucosal injury

EFFECTS OF XRT

· Effects of XRT treatment are cumulative- the longer the treatment progresses, the more patient will experience symptoms · Patients may not begin to show difficulty with swallowing until the 3rd week of treatment and progressively worsen. · Symptoms may not start relieving until 4-5 weeks after the end of XRT · Patients will complain of · Odynophagia · Xerostomia · Dysgeusia · Candida · Trismus · Patients receiving concurrent chemotherapy may also complain of mouth sores My notes: · symptoms get worse the more treatments they undergo · there symptoms may persist for up to month after their treatment - odynophagia (describe it as worse sunburn in your life but in your throat when you swallow) - xerostomia bc the submandibular glands are kind of the main producers of serous saliva - dysgeusia - taste perception changes - candida (thrush) - shows up bc of dry mouth symptoms that they have - mouth sores = painful blisters on the tongue

ANTERIOR CERVICAL FUSION (Continued) (4)

· Greater risk for dysphagia when performing anterior cervical fusion on the right side · The right RLN has a shorter loop than on the left and is at greater risk for stretching injury during surgery. · During a right side approach, the larynx is displaced to the left causing a significant strain on the right rln. · Animal studies have demonstrated that such strain over the course of an hour can cause loss of function with only partial recovery. This could account for an increased incidence of dysphagia and aspiration. My notes: · ACDF - Anterior Cervical Discectomy and Fusion · the left side of the RLN goes down and wraps around the aorta so typically surgeons like to go in on the right side (may be higher risk of nicking the aorta) · the RLN is a lot shorter on the right and when the surgeons go in, in order to get to the spine, they essentially have to take the whole larynx and shift it forward · essentially that creates a stretching of the right RLN... just from pulling and retracting the larynx forward · animal studies have shown that such strain on a nerve can cause loss of function with only partial recovery · 45% of all people who undergo the ACDF will end up with a post surgical dysphagia - usually it's due to swelling and stretching injury of the right RLN

ORAL CANCER AFFECTING THE TONGUE

· Greater than 95% of cancers affecting the tongue are squamous cell carcinoma (SCC) · Surgery is the preferred treatment of these lesions and maybe followed up with C/XRT if lymph node involvement · Partial glossectomy (less than one third of tongue) · Hemiglossectomy (one third to half of tongue) · Near-total glossectomy (half to three quarters of tongue) · Total glossectomy (greater than three quarters of tongue) · The goals of reconstruction include restoration of mastication, deglutition, and speech, as well as an acceptable aesthetic result. My notes: · C = chemo · XRT = radiation therapy · a lot of times they will do reconstructions of the area from different parts of the body like the forearm or thigh

PARTIAL GLOSSECTOMY (5)

· If the lesion is small, the surgeon can complete a primary closure (no need for additional tissue to close the surgical site) · If lingual resection is small (less than 50%) and no other structures are involves, swallow difficulties may be temporary in nature · may have difficulty · Initiating pharyngeal swallow secondary to edema · changes on tongue mobility (affecting oral prep and transit)

Brain Injury- Anticipatory Stage Deficits (4)

· Impulsivity · Decreased initiation · Agitation · Decreased understanding/recall of compensatory strategies My notes: ▪ agitated Pts cannot focus on the task at hand , you need to be careful bc they might throw food at you or on the floor ▪ they just might not want to eat ▪ they may need a lot more one on one supervision, for someone to actually sit there and remind them of their strategies when they're swallowing

EPIGLOTTITIS

· Inflammation of the epiglottis and supraglottic structures commonly associated with bacterial infection · Symptoms · Abrupt onset of fever · Sore throat · dysphagia · Drooling · Decreased vocal intensity · respiratory distress · Lethargy · Airway patency is primary concern My notes: - it's almost creating an upper airway obstruction

Parkinson's Continued (7)

· May see lingual tremors, repetitive tongue pumping, disorganized tongue movement affecting a-p movement of the bolus · Oral transit may be slow secondary to tongue muscle rigidity · Minimal jaw opening (trismus) · Abnormal head/neck posturing · Piecemeal deglutition (disorganized lingual motion) · May see swallow delay · Decreased pharyngeal stripping wave with increasing residue in vallecula and pyriform sinuses with consecutive swallows My notes: ▪ these would be good Pts that you would want to get a jaw measurement on ▪ piecemeal deglutition - swallowing little pieces of the bolus at a time - like a teaspoon amount of liquids, but they only swallow a tiny little bit back a time ▪ Swallow delay- bolus aggregating in the valleculae and pyriform before the Pt actually swallows ▪ poor pharyngeal stripping waves - leaves residue - may need to take consecutive swallows to clear that material

Cerebrovascular Accident- Left Hemisphere

· More difficulty with oral stage · May have delay in initiating oral swallow with no tongue motion in response to bolus presentation or groping motions of the tongue prior to swallow initiation (swallowing apraxia) · Perform best when feeding themselves and eating automatically as opposed to verbal commands to swallow. Why? · Exhibit delay of oral transit and pharyngeal swallow delays My notes: ▪ remember how we talked about oral apraxia ▪ Why do they feed themselves better? - bc there's a certain amount of a learning effect - if you've ever had somebody feed you, just see what that does to your swallowing timing - likely you won't be able to alert to that bolus as well bc you don't know how fast that bolus is coming at you

Cerebrovascular Accident- Right Hemisphere (7)

· More difficulty with pharyngeal stage · Oral transit delays · Pharyngeal swallow delays · Because of the pharyngeal delay, aspiration may occur before or during initiation of pharyngeal swallow · Cognitive impairments · May have difficulty integrating use of compensatory strategies · Impulsive My Notes: ▪ they may have a harder time remembering that they're supposed to use strategies ▪ impulsive - they might eat too much food or eat it at too fast of a rate

PILL INDUCED ESOPHAGITIS

· Nearly 80 substances that are known to cause esophageal injury · Antibacterial and agents are major meds causing esophageal injury anti-inflammatory · 3 drugs- tetracycline, doxycycline, and clindamycin cause 50% of esophageal injury Usually caused by taking medication with too little water or lying in a supine position soon after taking medication My notes: - they make barium tablets so we can assess how well a pill is traveling through the esophagus

Neurologically induced dysphagia: Cerebrovascular Accident (CVA/STOKE)

· Number 1 cause of dysphagia · 13-94% of stroke patients are affected by dysphagia annually (large discrepancy in number due to lesion size and location in the brain) (langdon, 2010) · Lesion size as opposed to location of the lesion may be most important determinant of whether patient develops dysphagia or not (paciaroni et al, 2004) · Swallow function if not recovered in 10-14 days, may take a mean of 69 days to resolve (paciaroni et al, 2004)- implication for prediction of non-oral nutrition? · Most experience no dysfunction after 6 months My notes: ▪ depending on the literature you'll see a very wide range of incidents of dysphagia in stroke - it's safe to say on average about half of the patients ▪ Swallow function typically can recover fairly quickly in - this population , roughly 10-14 days, but for some people it may take longer, 60-90 days. this is important bc having an understanding of general course of recovery can help us have a useful discussion about whether or not Pts are going to need some sort of non-oral nutrition to supplement as they're recovering from dysphagia ▪ there's a new app that came out called PRESS calc , which helps you calculate the likelihood that your Pt will have dysphagia a month out from their stroke and the likelihood that they will need non oral nutrition - you have to put in their age, the severity of their stroke as measured on the national institute of health stroke scale, where the stroke legion was, what their risk of aspiration is, their impairment of oral intake which is measure don the Foyce scale?? - you put all these numbers in and it will give you the likelihood of if this person is going to have dysphagia 30 days out ▪ If the Pt is going to need like 10-14 days to recover, then maybe we might recommend a Dobhoff tube just temporarily inserted in the nose going down to the stomach - as opposed to a surgical process of putting a PEG tube in for someone who is going to take longer to resolve swallowing

Inhalation injuries

· Occur as a result of chemical release or smoke inhalation · Type and severity of injury depends upon · Type and physical properties of the toxin · duration and intensity of exposure · health status of the individual · Upper respiratory tract defends against injury to lower respiratory tract via reflex responses · Mucous secretion · Cough · Sneeze · glottic closure, · Apnea)

Parkinson's (5)

· PD is a slowly progressive disease of the basal ganglia. · Cause is unknown, but immediate cause for motor changes is the depletion of neurotransmitter chemical dopamine. · Dysphagia prevalent in 63-81% of patients with PD · Patients with PD may be unaware or deny dysphagia symptoms despite distinct pathology - bradykinesia (slowness to initiate movement) underlies volitional stage of swallowing My notes: ▪ sometimes the Pt may be having issues with chewing ▪ they are often very unaware of deny that they have dysphagia despite signs and symptoms - they may say they don't have any trouble swallowing even though they're constantly coughing

LONG TERM EFFECTS OF XRT

· Patients develop fibrosis (stiffening of structures) post XRT · Fibrosis can continue to progress over a patients lifetime (the gift that keeps on giving) · Patients may have late onset of XRT induced dysphagia 5-10 years post completion of XRT · Patients can minimize these complications through daily completion of swallowing exercises · Xerostomia continues to be a long-term consequence · Most challenging textures- meats and breads. · Trismus may also be a consequence My notes: · radiation kind of acts like a burn injury · over time, that tissue is going to scar and scarred tissue just does not move as normal healthy tissue once did · it can become very inflexible and fibrotic · most of them will tell you that their biggest challenge with swallowing is meat & bread - Pts can sometimes come back years later with complaints of dysphagia

CAROTID ENDARTERECTOMY (2)

· Procedure to remove plaque from carotid arteries · Surgery could result in damaged rln causing paralyzed vocal cord resulting in deficit of airway protection My notes: CEA · this could end up damaging the RLN · another complication is that little pieces of plaque may break off and go up to the brain and the person may have a stroke

Amyotrophic Lateral Sclerosis (ALS)

· Progressive neurodegenerative disease of unknown etiology that attacks brain and spinal nerves that control voluntary movement affecting both upper and lower motor neurons which results in muscular weakness, atrophy, and eventual paralysis. · Pattern of dysphagia patterns the location of degenerative changes · May develop malnutrition and weight loss over time which accelerates muscle weakness · Progressive lingual weakness resulting in decreased oral control of bolus · Swallow reflex delay (worsening as disease progresses) · Inadequate laryngeal elevation · Decreased pharyngeal stripping wave · Stasis in vallecula, pyriforms, and coating pharyngeal walls · Incomplete laryngeal closure · Pes dysfunction · May benefit from compensatory strategies and diet modifications · Exercises are contraindicated My notes: ▪ typically exercises are contraindicated for this population ▪ there is a little bit of research that says that maybe light to moderate exercise may be beneficial in trying to maintain function for a little bit longer, but we do know that these Pts are going to progress ▪ they're Pts who we will periodically check in with to keep them swallowing for as long as they can for better QoL

Brain Injury-Oral Stage Deficits

· Reduced lip closure · Decreased rom of the tongue with poor bolus control · Abnormal oral reflexes (tonic bite) · Patient may also have facial fractures (jaw fractures requiring wiring) which may need to be accounted for during assessment My notes: ▪ with disorders of consciousness they might have abnormal reflexes - if the Pt has a tonic bite, you would not want to introduce the spoon into the oral cavity bc they could bite down into it so hard that they break their teeth - likely we will not introduce utensils into the oral cavity until that tonic bite goes away ▪ very common in this population to have jaw wiring - that needs to be accounted for when doing assessment - you're going to be limited in what you can do for them, these are the Pts that likely the best that you will be able to do is a liquid to assess or maybe some sort of puree that's really almost liquidized ... able to drink through a straw

TOTAL LARYNGECTOMY (5)

· Removal of entire larynx. · Separation of the airway from the mouth, nose and esophagus. · Pros: swallowing is restored due to the separation of the airway from the neopharynx and esophagus · Cons: loss of natural voice · Strictures may form resulting in need for dilation or surgical revision pseudoepiglottis may form from scar tissue at the base of the tongue creating a pocket where food can collect. May widen and occlude the pharynx when the patient attempts to swallow. My notes: - neopharynx = the newly created larynx

SUPRAGLOTTIC LARYNGECTOMY (3)

· Removes the epiglottis, aryepiglottic folds, false vocal folds affecting airway protection · Benefits- natural voice is retained · Cons: swallowing becomes problematic due to loss of 2 levels of airway protections My notes: · we've lost two forms of airway protection - the epiglottis & false vocal cords · Pts have to learn very specific strategies to try and keep their airway closed

SLP INTERVENTION FOR PATIENTS UNDERGOING XRT

· SLP intervention consists of · Educating patient of compensatory measures to manage symptoms of XRT on swallowing · Swallowing exercises to be completed before, during, and after XRT to minimize dysphagia complications · Ongoing swallow reassessment with patient's changing swallowing needs · At OSU James- SLP's will follow patients throughout XRT and beyond to assist patients with managing their dysphagia My notes: · might give them different strategies to deal with dry mouth · educate on swallowing exercises

EFFECTS OF CERVICAL BRACING ON SWALLOWING

· Sambolis Et. Al (2003) conducted study on the effects of cervical bracing on young, normal healthy volunteers · Subjects were evaluated radiographically at baseline and then with 3 common cervical orthoses · Philadelphia collar · Sternal occipital mandibular immobilizer (SOMI) · Halo

Brain Injury (7)

· Swallow severity may be related to the length of coma, with swallowing problems becoming more severe in patients whose coma lasted longer. · Neurologic damage may be a result of · the direct head injury · The effect of the brain bouncing against the opposite side of the skull (contra-coup injury) · The effects of twisting on the brainstem · Puncture wounds in the neck, laryngeal fracture may also have consequence. · 60% of patients with TBI may have some degree of dysphagia in the acute stages of recovery My notes: - fistulas could also be a consequence - with these Pts a lot of times when they wake up and start being able to follow commands, then essentially they can clear with their swallow pretty quickly

Guillian Barre Syndrome (GBS) (7)

· Symptom onset begins a few days after an acute infection by an antibody-mediated attack on peripheral nerves. · Weakness progresses rapidly and may result in flaccid quadriparesis with involvement of respiratory muscles and cranial nerves. · 2/3 of patients will recover completely, most within 6 months · 70% of patients peak at worst state at 2 weeks post onset. Clinical implication for assessment? · Permanent weakness can occur in 5-10% of patients · Swallowing deficits in acute phase: generalized weakness affecting oral and pharyngeal stages · Respiratory support should be stable before beginning treatment My Notes: · not every Pt with GBS has respiratory and cranial nerve involvement · so if you get a Pt that they're GBS actually does impact the respiratory muscles then likely these are the people that will have dysphagia as a result of that · sometimes we might get a consult on these Pts too soon · if they're only 10 days into their course, they may not hit they're worse performance until 2 weeks after the symptoms onset - you might need to defer or keep watching them bc it may get worse before it gets better · respiratory support should be stable before we begin treatment - if they're still having respiratory symptoms they're likely not ready/stable enough for us to really start treatment with them

HEMIGLOSSECTOMY/NEAR TOTAL GLOSSECTOMY

· The preferred method of reconstruction is free tissue reconstruction · Radical forearm flap · Anterolateral thigh free flap · Oral prep and transit are affected along with sensory deficits My notes: · this tissue doesn't move as freely/naturally as a tongue would but by putting bulk in there, the idea is to over time help the Pt improve oral prep and transit · may also have a lot of sensory deficits

TOTAL GLOSSECTOMY (2)

· Total glossectomy defects benefit from reconstruction with the rectus abdominis or anterior lateral thigh free flap due to the need for increased bulk, which is difficult to achieve with the radial forearm flap · Deficits in the area of oral prep and transit My notes: · they need a bigger heavier muscle to do this reconstruction · it's anchored more to the floor of the mouth... not going to move around like a normal tongue would · these types of Pts are usually going to need a chin lift maneuver to kind of allow gravity to assist with the oral transit

PILL INDUCED ESOPHAGITIS (continued)

· Typical symptoms · Sudden onset of odynophagia · Retrosternal pain within a few days of initiating medication · Identified by endoscopy · Lesions typically proximal or mid-esophageal · Mid-esophagus most prone to injury due to extrinsic pressure of the left atrium and aortic arch on the esophageal wall which increases transit time in this region · Treated with cessation of the offending drug, antacids · Usually recover within 3-10 days

Cerebrovascular Accident- Medulla (10)

· Unilateral lesions - Near-normal oral control - Significantly impaired initiation of the pharyngeal swallow - Neuromotor control of the pharyngeal swallow · Pharyngeal swallow may be so weak in the first week post stroke, that it may appear absent. · When pharyngeal swallow begins to appear, there can be a significant delay (10-15 sec. Or more) · May exhibit reduced hyo-laryngeal elevation (superiorly and anteriorly) which contributes to reduced pes opening. · Also, may see unilateral pharyngeal weakness, which results in residue in the pyriform sinus. · Swallow function may improve by week 3 to allow for p.o. intake. · May take 4-6 months to resolve My Notes: ▪ medulla is where all of the CNs for swallowing run through ▪ when the swallow initiation begins, there can be significant delays ▪ the bolus may be aggregating in the pharynx for maybe sitting in vallecular space or down in pyriformis for 10-15 seconds or greater before the swallow motor response actually happens ▪ the longer the bolus remains in the hypopharynx the higher the risk of aspiration is present ▪ these Pts are kind of variable. you might see someone who could improve in a 3 week time frame, but it may potentially take 4-6 months with a medullary infarct - these are the Pts we would expect to take longer to recover ▪ you'll often see these Pts come down to therapy with a cup to spit into bc if they're having issues with hyolaryngeal elevation and opening of the PES, and they're generating a lot of saliva, the saliva has nowhere to go - sometimes when they become less reliant on their cup, they're managing their secretions better and they might be ready for another swallow study

RADIATION (XRT) AND ADJUNCT CHEMOTHERAPY (C/XRT) (4)

· XRT given to patients as primary treatment for benefits of organ sparing or in addition to surgical interventions if tumor is not localized · Chemo agents may be given as an induction treatment (prior to the start of XRT to shrink tumor size) and then concurrently with XRT treatment · Chemo - not the primary treatment to "kill" cancer cells- designed to make cells more receptive to the effects of XRT · Chemo may also be given as a palliative treatment if other options fail (recurrence) My notes: · example of primary XRT treatment would be tongue based or tonsil cancers ... typically they don't like to remove tumors from the tongue base bc they would have to remove too much tissue · a lot of these tumors are caused by HPV

RADIATION TREATMENT (4)

· XRT is given 5 days/week over a 6-7 week timeframe · Patients meet with a radiation intervention specialist to plan XRT · Patients will have a mask made to allow for precision treatment · Treatment sessions approximately 10 minutes in length My notes: · they are seen by an intervention specialist · they will be fit with a mask that they have to wear throughout the treatment so that there's really not any movement during the treatment · treatments are only 10 minutes long but they're getting it 5x a week