Dysphagia Exam 2

What happens when the sensory properties of the bolus change? (select all the apply)

-It changes the mastication pattern (as the bolus breaks down, you chew differently) -It changes the duration of the respiratory pause (swallowing apnea). The apnea is longer for solids and shorter for liquids

Possible complications of a trach tube on swallowing include:

-the trach tube may anchor the larynx during the swallow making it difficult for hyolaryngeal elevation for some (not all) patients. -positive, subglottic pressure can't be generated during swallowing -because there is no longer airflow through the vocal folds and supraglottic airway, there is now reduced sensation in the larynx and the pharynx. **all of the above

Why is aspiration PNA over diagnosed?

1. ."Aspiration Pneumonia" is a vague diagnosis that may be the result of a pulmonary infection, gastroesophageal reflux, or prandial aspiration. There are 13 or more syndromes labeled as "aspiration pneumonia." These include community-acquired pneumonia, hospital-associated pneumonia, ventilator-associated pneumonia, and pneumonitis. A diagnosis of aspiration pneumonia refers to any substance entering the lungs, including a virus or bacteria. Because of the lack of specificity of the terminology, some medical professionals have advocated for the term to be eliminated, as it can be misleading. 2. Physicians do not have a standard gold test for the diagnosis of aspiration pneumonia. SLPs, most often have access to, and rely on a chest x-ray alone, the accuracy of which is poor.

Be able to write out (list) ALL of the parts of a CSE (hint: I have 11 steps in my 30 minute CSE) Be sure to not only know what to do but what you are looking for.

1. Case history/chart review/nursing interview/patient interview/kitchen sink 2. Quick Oral Mech (teeth, mucosa, oral hygiene, CN exam, dentures or not) 3. Check 02 levels (only to see if they change after eating/drinking after a meal) 4.Observe EVERYTHING (and respiratory pattern). Listen (cervical auscultation) to respiratory sounds at the level of the thyroid cartilage 5. Dry swallow (with CA), listen/feel for L. elevation (noting only if laryngeal elevation was present or not) 6. Volitional cough (strength of VF closure) 7. Introduce liquids, small amount, via straw or spoon (with CA). Ask pt to say /a/ or talk to assess change in voice quality. 8. Continue with thick liquids, pudding, and soft solids (no CA) Check for oral residue. 9. 3 ounce water swallow test 10. Feel for laryngeal elevation and tongue movement (comment on presence/absence only) 11. Observe for s/s of aspiration 12. EAT-10 or another questionnaire.

What information can we gather from doing a CSE that we can NOT get using a MBSS?

1. It can give us much information regarding our patients' cognitive status, their ability to follow commands, their level of awareness of the feeding situation and whether they are independent or dependent for feeding. 2. It informs us about their dentition, the strength and range of motion of their oral structures and which cranial nerves may be leading to deficits in strength and range of motion of those structures. 3. We can assess their ability to orally handle their own secretions, their vocal quality prior to and after the swallow, their willingness and ability to accept food into the oral cavity.

What are the three "pillars of pneumonia" (i.e. the 3 areas that when affected likely lead to PNA?)

1. Poor oral care 2. Weak immune system 3. Aspiration

___% of pts with CVA die within the first year from aspiration PNA.

20

What is the normal respiratory rate for elderly (how many breaths per minute should an elderly person take?)

20 breaths per minute. For young people, 16 breaths/min. Respiratory rate is much higher in COPD.

What is optimal positions for swallowing for most individuals.

70-90 degrees

How long does swallowing apnea typically last?

750 ms, just under a second

What is "normal" 02 levels (in general)?

95% or higher for normal people. For COPD patients, the normal O2 level is 88%-92%.

What is this called (see the picture below) and causes it? What movement problems would you look for?

A Cricopharyngeal Spasm is caused by the cricopharyngeus segment not fully opening/dilating. You will see a CP "bar" (CP spasm). You must check these four areas to figure out what might be causing the spasm. (CNS error, physiological area, air pressure problem) 1. UES Relaxes 2. UES is pulled down by the larynx (& shortening of the posterior pharyngeal wall) 3. BOT drives the bolus back and pharyngeal contraction squeezes the bolus (driving force of muscle pressure) 4. Air pressure changes draw the bolus into the esophagus You would look for if there is a neuro problem that the UES isn't getting signals from the CNS to relax, is the UES not being pulled because the larynx isn't elevating, is the BOT not driving the bolus back hard enough, is the pharyngeal constrictors not squeezing hard enough, or do we have an air pressure problem.

Ms. Patient has recently had surgery to remove a precancerous thyroid nodule. Following the surgery she reports changes to her voice and coughing when drinking thin liquids. You do a CSE and suspect possible aspiration. Which of the following statements provides the BEST follow-up instrumental exam to recommend and rationale.

A FEES so that vocal fold function can also be assessed.

What causes people with a trach tube to aspirate?

A reduction of airway resistance. Decreased laryngeal elevation (laryngeal tethering), Air pressure differential interfering with oral bolus driving force, increased pharyngeal residue, Decreased vocal fold closure.

How do you do a swallowing screening?

A typical swallowing screening include the following: 1. Complete a short questionnaire on exclusion criterion, in which if any of the risk factors have been identified will result in a deter the administration of the screening and referral to swallow assessment. 2. Brief cognitive screen. What is your name? Where are you now? What year is this year? (briefly look at the cognition, language and speech abilities. Observe for gurgly voice, face/tongue weakness, drooling, slurred speech) 3. Oral mechanism Examination. The clinician look at labial closure, lingual range of motion, facial symmetry(smile/pucker) 4. Perform 3-ounce water swallow challenge.

In _________ the food is coming from the esophagus back into the pharynx, whereas in _____ the material comes from the stomach.

Achalasia GERD

____________ occurs when nerves in the esophagus become damaged. As a result, the esophagus becomes paralyzed and dilated over time and eventually loses the ability to squeeze the bolus into the stomach.

Achalasia (failure to relax)

What happens when the sensory properties of a bolus change? What does this affect (change)?

As sensory properties of the bolus change, the mastication pattern, timing of the swallow, duration of the respiratory pause and duration of UES sphinctor opening change. All of this is based on sensory information coming in about the swallow.

What factors affect the length of swallowing apnea?

Bolus consistency and size. Onset faster and duration shorter in liquids. Onset slower and duration longer in thicker solids and pastes.

What is osteoradionecrosis?

Bone death due to radiation. The bone dies because radiation damages its blood vessels. It usually occurs in the mandible.

Which of the three areas, if damaged by a stroke, is most likely to results in aspiration? (hint: all three can lead to aspiration but which one will typically cause aspiration if the stroke is located here?)

Brainstem

Which of the three areas, if damage by a stroke, is most likely to results in aspiration: left hemisphere, right hemisphere, brainstem?

Brainstem stroke

What foods should people with GERD avoid?

Chocolate, fatty foods, onions, peppermint, garlic, nicotine

What is CAP?

Community-acquired pneumonia is generally used in reference to a viral pneumonia. These are generally pneumonias that start with some sort of viral illness and progress to a more serious lung infection.

PAS Score 4

Contrast contacts vocal folds, no residue.

PAS Score 5

Contrast contacts vocal folds, visible residue remains.

PAS Score 1

Contrast does not enter the airway

PAS Score 2

Contrast enters the airway, remains above the vocal folds, no residue.

PAS Score 6

Contrast passes glottis, no sub-glottic residue visible.

PAS Score 7

Contrast passes glottis, visible sub-glottic residue despite patient's response.

PAS Score 8

Contrast passes glottis, visible sub-glottic residue, absent patient's response.

PAS Score 3

Contrast remains above vocal folds, visible residue remains.

What are signs/symptoms of aspiration? What are NOT?

Coughing/ throat clearing, choking, wet/gurgly voice quality. A running nose, the general temperature is elevated, and a drop in O2 sats is not sign of aspiration.

List 3 things that impact the swallowing in patients with trach tubes.

Decreased laryngeal elevation (laryngeal tethering), Air pressure differential interfering with oral bolus driving force, Increased pharyngeal residue

This esophageal disorder can be very painful and cause dysphagia and regurgitation. If it's severe, the patient may need an esophagectomy. What is it?

Diffuse Esophageal Spasms: a loss of normal peristaltic coordination. Instead of relaxing and contracting the muscles are uncoordinated. (corkscrew/ nutcracker)

What is laryngeal or "digital palpation" and why do we do it? (this is explained fully in the "read me")

Digital Palpation is a practice used by SLPs to gauge laryngeal elevation and excursion during the swallow by placing fingers on the thyroid notch of the patient. With digital palpation, SLP can comment whether the elevation or excursion is present/absent but not whether or not it is normal/abnormal.

What are the limitations of using a FEES?

Does not address oral & esophageal stages. Inferences are made about the oral (containment) & esophageal stages (reflux). Some pts will not/cannot tolerate nose insertion with nasoendoscope. "White out" period at the moment of swallow. May miss seeing aspiration/penetration.

__________ is a chronic disorder in which large numbers of a particular type of white blood cell called eosinophils are present in the esophagus.

Eosinophilic Esophagitis (EoE)

It's important to do a MBSS for stroke patients as soon as possible within the first week following their stroke to prevent aspiration (T/F)

False

It's not appropriate for SLP to involved in dysphagia management during the first week (T/F)

False

We can definitively state that aspiration occurred because our patient coughed after the swallow. T/F

False

We can diagnose aspiration using a CSE. T/F

False

We can skip the CSE and go straight from the swallow screening to a MBSS/FEES. T/F

False

Pt's who aspirate thin liquids will not aspirate thin carbonated liquids.

False because patients are just as likely to aspirate carbonated thin liquids.

An "effortful" swallow and a "volitional/cued swallow" are the same thing. T/F

False, A cued swallow is done without effort.

A PAS score of 5 represents "aspiration" because the bolus contacted the true vocal folds with visible residue (no ejection).

False, because PAS 5 is still "Penetration". It's not aspiration until the bolus falls below the TVF.

What causes GERD?

Gastroesophageal Reflux Disease (GERD) is caused by a delayed gastric emptying (food is remaining in the stomach for too long). It can also be caused by low LES tone, medication (antidepressants, anticohlinergic (treat nausea), sedatives, potassium/iron pills, antibiotics/NSAIDs, oral contraceptives & estrogen) or certain types of food. delayed gastric emptying the muscle tone of the lower esophageal sphincter is low the diaphragm is weak

Fred is a 70 year old male who lives with his wife, Edna. Fred has no health problems other than he had a stroke 3 days ago. He has moderate - severe dysphagia is now aspirating all liquids/foods and is receiving 100% of his nutritional orally. What factors are likely to predict Fred's natural recovery from the stroke. (choose all that apply)

He lived with his wife so he was independent before his stroke. He does not have any cardiac issues. He is still in early recovery from the stroke (less than 1 week).

Because of their treatment for oral cancer, your patient has profuse spilling of even small amounts of food/liquids onto their chin through open lips but otherwise has a "normal" swallow with no aspiration. What strategy would you chose to treat this?

Head back (chin up)

What information does the CSE give you?

Helps you define a potential because you are looking at the history in the chart. It allows you to develop a hypothesis. It allows you to plan for therapy. Pt's oral structure/function. Pt's ability to participate. Overt signs/symptoms of aspiration. Red flags of dysphagia. It helps to figure out if the patient needs FEES or MBSS. It also tells you whether or not the results of the FEES or the MBSS is really going to inform your patient's practice and your intervention.

What can you NOT assess with a CSE?

If or why the person is aspirating. Extent/timing of hyolaryngeal excursion. Whether swallow is really "delayed". Anything about pharyngeal stage.

What information can we gather that we can NOT get using a CSE?

If or why the person is aspirating. Extent/timing of hyolaryngeal excursion. Whether swallow is really "delayed". Anything about pharyngeal stage.

What is a cervical osteophyte?

Is a bony growth (like a bone spur) that presses into posterior pharyngeal wall.

What is Barrett's esophagus?

Is a type of esophageal cancer that can be caused by GERD.

Why do we use pulse oximetry as part of the CSE? (what information does it give us that is relevant to the pt's risk for aspiration?)

It gives a measure of respiratory status before and after swallowing/eating. Can tell the "workload" of eating on the respiratory system.

What is a nissen fundoplication?

It wraps the upper part of the stomach around on each other on itself and then suture it together to help the LES relax.

What are 3 pharyngeal stages problems that pt's with PD may have?

Limited pharyngeal contraction, abnormal pharyngeal wall motion, impaired pharyngeal bolus transport, and often show incomplete upper esophageal sphincter relaxation.

Where are CPGs located?

Located in the brainstem and they coordinate the respiratory and swallowing systems.

Why do we want to ask a patient with dysphagia related to stroke to take 3-4 swallows in a row (serial swallows) during our MBSS?

Looking at sequential swallows can give the clinician a clear picture of how the patient will be doing in everyday swallows. And some impairments may not be obvious when the patient is doing one single swallow.

The best compensatory tx to address oral/pharyngeal residue

Multiple swallow

What is one way we can definitely prevent aspiration of food and liquids in patients with severe dysphagia?

NPO with G-tube for all nutrition

Can we diagnose aspiration using a CSE?

No

What is another term for 'hospital acquired PNA?"

Nosocomial/healthcare-associated pneumonia

You need be very cautious about overly recommending a chin tuck for patients with a delayed initiation of the pharyngeal swallow because...

Not everyone can do it. It isn't always effective. Too much neck flexion can actually impede the swallow.

What swallowing "pathophysiology' can you determine with a CSE?

Nothing. The pathophysiology is the impairment.

What is the BEST defense against PNA?

Oral health care, consisting of tooth brushing after each meal, cleaning dentures once a day, and professional cleaning.

Which can not be assessed using a CSE?

Oral preparation and transport of the bolus (we can see someone chewing)

Which PAS score is the first to denote "aspiration" (not penetration)?

PAS 6

How do you report the results of a swallow screening?

Patient passed the swallow screen. Will rescreen upon referral. Patient fail the swallow screen. Recommend follow-up clinical swallow exam.

Pts with PD have (shorter/longer) respiratory pauses during the swallow, and they had a (inspiratory/exhiliatory) pattern after the swallow.

Patients with Parkinson's Disease have shorter respiratory pauses during the swallow, and they had an inspiratory pattern after the swallow. This placed them in a greater risk of inhaling post-swallow residue.

What are the predictors of 'natural' recovery in dysphagia following stroke?

Patients with no comorbidities (no heart disease), more independence pre-stroke (active and independent) can recover faster

What information can you get on a CSE that you can NOT get on an MBSS/FEES?

Patients' cognitive status Level of independence during meals Ability to follow directions

PAS Scores

Penetration is numbers 2-5 Aspiration is numbers 6-7 Silent Aspiration level 8

What side effects of radiation treatment can affect swallowing?

Persistent xerostomia, Mucositis (an inflammation of the lining of the mucosal membranes), Dental caries, Hardening of muscle fibers, Osteoradionecrosis (bone death, especially of mandible)

What is the leading cause of death in PD?

Pneumonia

Quiz: What are some causes of dysphagia in patient who had ACSS?

Post operative swelling

Look through the questionnaires discussed in your textbook. You don't need to know the details per se but you DO need to be familiar with their names and what they assess. For example, what questionnaire could you use to determine the impact of dysphagia on someone's QOL? Reflux symptoms?

QQL: SWAL-QOL and SWAL-CARE. Reflux: Reflux symptom Index (RSI), Reflux Finding Score(RFS)

What does a bird's beak sign of the esophagus mean?

Refers to the tapering of the inferior esophagus that is associated with achalasia.

Which of the following treatment approaches is aimed at changing/improving swallowing function?

Rehabilitative strategies

What are the limitations of using a MBSS?

Relatively restricted in the radiology room unless a portable C-arm fluoroscope is in place. More requirements on patients. To reduce radiation exposure, fluoro is turned on & off with each swallow trial & prone to miss behaviors after the swallow. Unable to view laryngeal surface anatomy. Barium is mixed with foods changing viscosity.

How would chemotherapy be considered an iatrogenic cause of dysphagia?

Repeated vomiting can irritate the lining of the esophagus and the hypopharyngeal region. The side effects of chemotherapy include: 1. Fibrosis, which is scarring or stiffness in the throat, esophagus, or mouth. 2. Infections of the mouth or esophagus. 3. Swelling or narrowing of the throat or esophagus. 4. Physical changes to the mouth, jaws, throat, or esophagus after surgery. 5. Mucositis, which is soreness, pain, or inflammation in the throat, esophagus, or mouth. 6. Xerostomia, commonly called dry mouth. These side effects will have a negative impact on the oral preparation, oral and pharyngeal stage of swallowing.

What two systems must be coordinated during a swallow?

Respiratory center and swallowing center

A _________ _________ is a specific type of "esophageal ring "causing narrowing of the lower esophagus.

Schatzki's Ring

If a bolus remains in the esophagus because of poor esophageal transit, we call this:

Stasis

When teaching effort swallow, you should tell you patient to:

Swallow and squeeze the muscles of your tongue/throat

CN X, NTS, and NA are part of what CPGs?

Swallowing center, respiratory center, cardiovascular center.

What is cervical auscultation? What does CA tell us?

Take a stethoscope and place it along the thyroid cartilage. Listen to the patient breathe. CA during oral intake of thin liquids revealed changes in the respiratory sounds following the swallow which may be indicative of aspiration.

An 85 year old male with past history of CVA and GERD is admitted from home to the hospital for RLL CAP and treated with Rocephin and Zithromax. Which of the following statements are true:

The CAP means that he developed the PNA outside of the hospital but he still could have an aspiration PNA if aspiration is found during the MBSS.

A physician questioned your regarding the necessity of doing a CSE. Which of the following is the BEST response?

The CSE is part of a comprehensive swallowing assessment. It provides information that can't be gleaned from a FEES or MBSS alone.

What is the best therapy for dysphagia?

The best therapy for swallowing is swallowing.

What are some causes of dysphagia in patient who had ACSS?

The patient may have dysphagia preoperatively, which may worsen after the surgery. A person may have dysphagia postoperatively, because of postoperative swelling the patient may be aware of symptoms after surgery leading to a fear of swallowing/choking. Neurological damage may result from direct trauma.

What is the "blue dye" test?

The use of drops of dye to tinge secretions, foods and/or liquids when performing a bedside swallow evaluation on patients with tracheostomies, in hopes of visually detecting aspiration in tracheal secretions at the trach site or upon suctioning. Blue dye was added to food or drink during a CSC. Placing blue dye on the patient's tongue or in the bolus during a CSC then patient's trach tube are suctioned look to see if presence of the dye.

What a classic pharyngeal symptom exhibited by patients who have had a stroke?

There is unilateral transit of the bolus through the pharynx as seen on the A/P view.

Why are SLPs interested in blood lab results? Vital signs?

These results give us insight regarding the efficiency of oxygen transport, and this may tell us how swallowing demands may affect swallowing. Also they let us know the pt's nutritional status and if the patient's immune system is compromised. To learn more about their breathing and what is normal for them. Blood work can tell us if their immune system is down, which puts them at a greater risk of PNA if they are aspirating.

Why do we suspect that stroke patients are more likely to get aspiration PNA if they aspirate?

They are at a higher risk because of Immunodepression, Oral flora is altered after stroke (different types of bacteria in mouth), increased colonization overall; changes in bacteria type. Usually depressed immune systems.

What is 'silent aspiration'?

They don't cough and we don't catch a change in voice quality in smaller amounts, but it does elicit a cough when drinking larger amounts.

The most commonly observed respiratory phase pattern is (expiration, pause, expiration) and why is the important.

This is a protective mechanism that can further prevent foreign objects if any from entering the trachea. It also potentially ejects the objects in the vestibule to the hypopharynx. It blows it out.

What is the difference between a tracheotomy and a tracheostomy?

Tracheotomy is a surgery to make an opening in the trachea called a tracheostomy. A tracheostomy is the artificial hole created during a surgical procedure. The tube that is put into the tracheostomy to keep it open is called a tracheostomy tube (trach tube).

"Cyclic ingestion" is just a fancy way of saying "alternate among the different consistencies as you eat a meal. Take a bit of one thing, then a bite something else and then a sip of your drink." T/F

True

"No physiologic change" means that the movements for the swallow stay the same. So if movements are impaired, therapy compensates for the impairment, but doesn't 'fix' the impaired movement. T/F

True

A bird's beak sign of the esophagus means that achalasia is present.

True

Both pts with ALS and PD have issues with drooling (T/F)

True

Coughing, throat clearing and changes in vocal quality during or after a swallow are signs of aspiration. T/F

True

Esophageal stage problems may present as a "pharyngeal" problems (T/F)

True

For safety, the head of the bed should be at minimum at a 45 degree angle when a person is eating in bed. T/F

True

Health professionals may use both "webs" and "rings" to refer to the same structure.(T/F)

True

Modifying diets, like downgrading to pureed, changes the way the bolus flows and increases swallowing safety. T/F

True

Technically GERD causes esophagitis. (T/F)

True

The EAT-10 is a 10-item outcome measure of dysphagia symptom severity.

True

The NTS receives sensory information from the cardiovascular system and respiratory BS nuclei in addition to be involved in swallowing. This means that the NTS has to coordinate breathing, heart rate and the timing of the swallow. (T/F)

True

The best therapy for dysphagia is having the patient swallowing! If the patient is NPO then you start with oral care then introduce ice chips and try to get the patient to swallow. Using principles of exercise physiology, you can help the patient advance to effortful swallow and other exercise-based interventions that can help improve functional swallowing necessary for eating/drinking and overall quality of life. T/F

True

The onset of swallowing apnea becomes later and lasts longer in older patients (T/F)

True

You swallow during the expiratory phase of respiration (T/F)

True

The terms "stricture" and "stenosis" mean narrowing and are often used interchangeable (T/F)

True means blocked off

Pts with COPD can have a diagnosis of emphysema (T/F).

True. Emphysema is a lung condition that causes shortness of breath. In people with emphysema, the air sacs in the lungs (alveoli) are damaged.

Enteral support (PEG tube) can prolong life in patients with ALS (T/F)

True. It is important to monitor the weight and nutrition status of dysphagic patients with ALS and to begin discussions of percutaneous endogas- trostomy (PEG) before the patient becomes severely deteriorated.

Left-sided pharyngeal weakness with residue in left pyriform: Which tx is best?

Turn head to LEFT and swallow

What are the advantages of using an MBSS.

View: lateral & anterior view; Stages of the swallow assessed: Oral, pharyngeal and esophageal stages. Locations performed: Hospital radiology suite, mobile radiology van, & sometimes with portable C-Arm fluoroscope at bedside. Patient requirements: Pts are able to leave bed, room, or ward, and able to position in upright position. Pts need to be cooperative and are not using a ventilator. Best indicators: Pt complaints of oral stage preparation problems; suspicion of aspiration or larynx penetration; complaints of food sticking in throat. Other information gathered: Screening of esophagus to lower esophageal sphincter during swallow.

What are the advantages of using a FEES for assessing swallowing?

View: superior view; Stages of the swallow assessed: Pharyngeal stage before, during, & after the swallow. Locations performed: Any location: hospital, SNF, OP clinic, pt's home; bedside, wheelchair, chair. Patient requirements: Very few. Problems may occur with craniofacial trauma, dementia, brain trauma, confused or comatose pts. Best indicators: Pt complaints of choking on food; suspicion of aspiration/larynx penetration. Pt. Need for diet consistency up or downgrade. Other information gathered: Secondary assessment of velopharyngeal closure and/or laryngeal/pharyngeal surfaces & functions, Bilateral cavity residue; therapy biofeedback

"Recommending that a patient have an MBSS to objectively rule/out aspiration" is not a good reason to do an MBSS. Why? (hint: do we use MBSS studies for the sole purpose of detecting aspiration? Why do we do them?)

We do not use MBSS studies for the sole purpose of detecting aspiration. With MBSS, we can see the subtle movements within a closed oral cavity during oral preparation stage as well as posterior and downward transport of bolus, pharyngeal contraction and elevation, laryngeal displacement, velar to palate contact, esophageal opening and other pertinent details of the swallow not visible to a naked eye. This information is extremely helpful and valuable for effective therapy planning. If the intervention plan is not going to change after the MBSS/FESS exam, then it is not necessary to do the instrumental swallowing study.

What was the pharyngeal symptom exhibited by Ms. Bolus that is classic of a person who has dysphagia related to stroke?

Weakness of the opposite side

What does it mean that patients who regain functional swallow and return to oral feedings have greater "pharyngeal representation?"

When we start to work with patients right after their stroke, we can get them swallowing right away with a clean mouth safely and using strategies we can start to change the brain on that unaffected side to start doing what the affected side is no longer able to do. Therapy does this and this therapy has to involve getting the patient to swallow something.

Why do we screen swallowing?

With standard swallow screening, we can better identify the patients who are at risk and provide treatments. It helps the clinician to determine the following: the signs/symptoms of dysphagia, the safety of any oral medication or food, the need for a full swallow assessment, the need for a nutritional assessment. Risk of pneumonia is 11 times higher for patients with severe dysphagia and aspiration.

Web/rings can cause you to cough because it triggers CN ____ even though you haven't aspirated.

X

Is it normal for you to occasionally have reflux?

Yes

This esophageal disorder is caused by a posterior herniation of esophageal mucosa into an area just above the cricopharyngeus (CP) muscle and below the inferior pharyngeal constrictor muscle.

Zenker's Diverticulum

A _____ _______ results from posterior herniation of esophageal mucosa into an area just _____ the cricopharyngeus (CP) muscle and _______ the inferior pharyngeal constrictor muscle.

Zenker's Diverticulum above below

When we swallow and stop breathing this is called swallowing ________.

apnea

How would you test the strength of glottic closure during a CSE?

ask the patient to cough 'hard'

How are Shaker and CTAR related?

both strengthen extrinsic laryngeal muscles and help increase laryngeal elevation

Fred has had a stroke is now has a reduced pharyngeal contraction (reduced stripping wave), reduced base of tongue retraction and significant residue that is causing him to aspirate after the swallow. What compensatory therapy might you try to address pharyngeal stripping wave?

effortful swallow

The term _________ is used interchangeable with GERD.

esophagitis

A swallow ends and then you inhale/exhale?

exhale

A person with right-sided pharyngeal weakness may benefit from postural changes when eating. Which of the following would be the most appropriate to consider?

head turn to the RIGHT

The ______ the area of infarction, the ______ the impairment of swallowing for CVA patients.

larger greater

The onset of swallowing apnea is faster and short with ________.

liquids

The most common sign of an esophageal web is difficulty swallowing solid foods especially _______ and _______ that stick.

meats bread

Why do you want to the patient to avoid sequential swallows?

multiple swallows can increase aspiration risk multiple swallows in a row is more challenging multiple swallows in a row require longer periods of time when the patient is NOT breathing

The N in the TNM classification stand for _______. T=tumor, M=metastisis

node

Which consistencies are easiest for pts with ALS to swallow (in general)

pureed or soft foods are much easier to swallow

A CSE can assess which of the following pathophysiologies?

reduced base of tongue retraction extent of hyolaryngeal excursion timing of the swallowing response *NONE OF THE ABOVE

When the vocal folds close during a swallow, ________ air pressure builds up below them.

subglottic

The esophagus sites behind the _____ and isn't a straight shot down like we see in anatomical drawings.

trachea

The esophagus sites behind the ________ and isn't a straight shot down like we see in anatomical drawings.

trachea

ALS is a progressive disease involving the degeneration of ____ and _____.

upper and lower motor neurons

Oral prep and oral stage are under ________ control but pharyngeal and esophageal are _________.

voluntary automatic