1
Q
Dysphagia results in: 5
A
- Dehydration
- starvation
- aspiration pna
- airway obstruction
- death
2
Q
dysphagia anatomy is comprised of: 4
A
oral cavity
pharynx
larynx
esophagus
3
Q
Normal swallowing has three phases:
A
- oral phase (oral preparatory, oral propulsive)
- Pharyngeal phase
- Esophageal phase
4
Q
Oral cavity anatomy.
Name muscle and associated nerve:
1. Lip closure:
2. Tongue: divided into ___ and ___
A
- Orbicularis oris (CNVII)
- Intrinsic muscles CN XII (hypoglossal)
Extrinsic muscles CN XII & CN IX (Glossopharyngeal)
5
Q
Name the four intrinsic muscles of the tongue
A
- superior longitudinal
- verticalis
- transversus
- inferior longitudinal
All CN XII - hypoglossal
6
Q
name the 4 extrinsic muscles of the tongue (with nerves)
A
- genioglossus - CN XII
- Hyoglossus - CN XII
- Palatoglossu - CN IX
- Styloglossus - CN XII
7
Q
_____ is the perception and cognition regarding nutritional materials prior to introduction to the mouth.
A
Anticipation
8
Q
Describe the four concepts associated with anticipatory phase of swallowing
A
- size of bolus
- fine motor control for placing bolus on fork/spoon, sipping from straw/cup
- instructions for feeding
- speed presented to mouth
9
Q
Oral phase is divided into two phases for solids:
and two phases for liquids:
A
Liquids:
- Oral preparatory phase - food mixed with saliva. Tongue keeps it in a swallow-ready
- Oral propulsive phase - bolus from oral to pharynx through faucial isthmus
Solids
- Stage I transport - bite moved into a chewing position. Tongue rotates and deposits on occlusal surface of lower molar teeth
- Stage II transport - swallow ready consistence positioned on tongue and squeezed into pharynx
10
Q
Food in mouth stimulates mechanoreceptors for ____ nerve thereby activating ______
A
trigeminal nerve - activating central pattern generator for mastication. (saliva secreted helps food break down and stimulate taste buds) Consistency continuously monitored by oral mechanoreceptors
11
Q
In the pharyngeal phase of swallowing,
_____ propels food from the mouth to the pharynx without compromising the airway.
This occurs by blocking _____ and _____.
_______ relaxes.
_____ occurs
A
- the involuntary phase,
- blocking nasopharynx: soft palate is pulled upward to create passage for food.
- Blocking trachea - epiglottis moves and covers opening to larynx and larynx moves against the eipglottis creating a tight seal.
- The upper esophageal sphincter relaxes as food enters the esophagus
- Peristalsis occurs and propels food through the open sphincter into the esophagus
12
Q
What is swallow apnea
A
breathing pauses briefly during swallow. Normal is 0.3-1.0sec
13
Q
- The esophageal phase is an ____ phase.
- bolus continues as _____ through ____ into stomach
- Assisted by ____ and requires relaxation of ____
- Reflux of the stomach prevented by ______ and ____
A
- Involuntary phase
- primary peristaltic wave through the lower esophageal sphincter (LES)
- gravity; relaxation of the LES
- tonic contractions of LES; reflex esophageal swallowing triggered by distension. (secondary peristalsis)
14
Q
Tongue elevation and propels bolus to pharynx and soft palate elevation to seal nasopharynx marks distinction between what two phases?
A
Oral and oro-pharyngeal
15
Q
Upper esophageal sphincter relaxes, bolus passes to esophagus marks start of what phase and end of what phase
A
start of esophageal phase and end of oro-pharyngeal phase
16
Q
Oro-pharyngeal phase lasts approx:
esophageal phase lasts approx:
A
1 sec
8 seconds
17
Q
Name the major nerves of dysphagia
A
V, VII, IX, X, XII
18
Q
Dysphagia:
Name the 4 major muscles associated with Trigeminal nerve
A
- masticatory muscles
- mylohyoid
- tensor veli palatini
- anterior belly of digastrics
19
Q
Dysphagia:
Name the 3 major muscles associated with facial nerve VII
A
- facial muscle
- stylohyoid
- posterior belly of digastrics
20
Q
Dysphagia
Name the major muscle associated with glossopharyngeal nerve (IX)
A
stylopharyngeus
21
Q
Dysphagia
Name the 6 major muscles associated with the Vagus nerve (X)
A
- Levator Veli Palatini
- Palatopharyngeus
- Salpingopharyngeus
- Intrinsic laryngeal muscles
- Cricopharyngeus
- pharyngeal constrictors
22
Q
Dysphagia
Name the 6 major muscles associated with the hypglossal nerve (XII)
A
- intrinsic tongue muscles
- hyoglossus
- geniohyoid
- genioglossus
- styloglossus
- thyrohyoid
23
Q
Controlled by:
- Mastication, swallowing and respiration:
- CPG pharyngeal swallowing:
- swallowing and airway protection
- Sensation:
- Contraction of striated muscle fibers in oropharynx.
- Name the LMN cell bodies of swallowing
A
- central pattern generagtors (CPG)
- Brainstem reticular formation
- sensory info (see 4)
- Maxillary and mandibular branch of CN V, IX, X to a CPG located in nucleus tractus solitarius of medulla
- MOtor neurons in BS produce contraction of striated muscle fibers in oropharynx
- Cell bodies: CN V, VII, XII and nucleus ambuguus (IX and X)
24
Q
Swallowing requires ____ muscles
A
> 50
25
Nucleus ambiguus is comprised of what nerves
IX and X cell bodies
26
Swallow in infants:
1. lower jaw is: 2
2. oral cavity is: 2
3. Buccal pads referred to as:
4. Larynx rests:
5. Epiglottis overlaps:
1. retracted, smaller
2. smaller, filled with tongue
3. "sucking pads"
4. higher in neck
5. soft palate
27
____ and ____ descend during infancy
hyoid bone and larynx
28
Explain suckling and sucking with regard to swallow in infants
suckling begins as backward and forward licking motion, then labial strength increases into an upward and downward movement, then jaw movement pattern evolves.
29
```
describe oral phase in infants as it progresses:
6-9 months:
~24 months:
24 months:
6-7 years:
```
1. early phasic up-down evolves into diagonal movement
2. rotary chewing pattern
3. mature oral motor control for swallowing liquids
4. mature chewing pattern
30
Swallow in elderly:
| 10
1. decreased labial strength, lingual strength, coordination
2. slower oral manipulation of food
3. reduced dentition - increased mastication time and reduced efficiency
4. Increased latency - pharyngeal bolus entry until onset of laryngeal elevation
5. decreased amplitude of esophageal paristaltic waves
6. increased incidence of sliding hiatus hernia
7. altered respiratory patterns
8. early onset, longer duration of swallow apnea
9. increased swallow initiation in inspiratory phase
10. increased respiratory rate after swallow
31
Increased frequency of laryngeal penetration in older adults on consecutive swallow is ____
not always pathological (it might be a normal variatioN)
32
9 signs of neurogenic oral dysphagia
1. drooling
2. leakage of food/liquid
3. food residue in the mouth
4. pocketing of food in the mouth
5. reduced bolus formation and transfer
6. poor mastication
7. slowness of eating/drinking
8. reduced velar closure/nasal regurgitation
9. watery eyes/runny nose during PO intake.
33
6 things that might be hindered in oropharyngeal dysphagia
1. maneuvering solids and liquids
2. determining if bolus is ready for swallow
3. contain in the oral cavity
4. leakage from lips or pharynx
5. propel food
6. initiate swallowing
mastication deficits include tongue weakness or incoordingation
34
Type of dysphagia?
impaired swallow initiation
ineffective bolus propulsion
retention in the pharynx after swallowing
Impaired opening of Upper esophageal sphincter, UES
pharyngeal dysphagia
Velopharyngeal incompetence: inability to close nasopharynx
Result: nasal regurgitation
35
What is velopharyngeal incompetence?
| Result?
inability to close nospharynx
nasal regurgitation
36
5 pharyngeal neurogenic sx
1. coughing with swallow
2. regurgitation of foods/liquids through the nose
3. wet/gurgly voice
4. complaint of something stuck in throat
5. Hx of aspiration pna
37
_____ is a common comorbidity with dysphagia
GERD with heartburn and retrosternal pain
38
____% of thoracic chest pain can be esophageal disorders
50%
39
What is globus sensation with relation to dysphagia
causes?
feeling a "lump inthe throat" in absence of actual retention. Causes: distal esophageal lesions, hiatal hernia
40
Type of dysphagia?
```
burping throughout/after meals
complains of food stuck in lower throat
feeling of fullness during/after meal
burning in mouth or throat
regurgitation after lying down
chest pain during swallow that goes away after bolus passes
```
esophageal dysphagia
41
Describe the effect on oropharyngeal swallowing
1. CNS depressants
2. neuromuscular blockade
3. dopamine antagonists
4. anticholinergic mediations
5. anesthesia
1. depressed brainstem function and control of swallowing
2. weakness of oropharyngeal musculature and cough
3. extrapyramidal reactions (dystonia, dyskinesia)
4. salivary changes, impaired esophageal paristalsis
5. suprressed laryngeal cough reflex
42
How does a trach alter swallowing?
Does cuff assist with aspiration risk?
alters normal pharyngeal aerodynamics, eliminating positive subglottic pressure, hampering laryngeal protective reflexes.
inflated cuff does not eliminate aspiration
43
_____ trach tube is often better tolerated in dysphagia patients.
cuffless trach
use of unidirectional valve can improve swallow safety
44
principles of treatment of dysphagia: 5
1. amelioration of underlying process
2. prevention of complication
3. improvement of swallowing via therapy
4. compensatory strategies
5. environmental modifications
45
In dysphagia treatment ____ is the increase in resistive load, number of repetitions and duration of loading
intensity
46
in dysphagia treatment ___ speaks on how closely the task being performed is related to desired behavior
specificity
47
in dyshpagia treatment _____ describes how well a non swallow exercise might generalize to improve swallow skill and safety
transference
48
Types of increased intensity exercises for dysphagia (6)
1. isometric lingual exercises
2. expiratory muscle strength testing (EMST)
3. effortful swallow
4. mendelsohn maneuver
5. masako maneuver
6. shaker exercise
Table 27-3 braddom
49
List transference exercises when pertaining to dysphagia 4
1. lee silverman voice treatment
2. isometric lingual strengthening
3. shaker exercise
4. expiratory muscle strength training
50
Most common compensatory strategy used is for dysphagia is
modification of food and liquid properties and presentation
postural and behavioral comp strategy should be performed with ever swallow or just before a meal as per Japanese physiatrists
51
Surgery considered in following groups:
1. UES stenosis, when rehab unsuccessful:
2. Zenker diverticulum
3. reducing UES pressure
4. oromandibular or lingual dystonia, trismus, cricopharyngeal dysfunction with failure of UES relaxation
1. dilatation
2. not listed
3. cricopharynx myotomy
4. botox
52
Pharyngeal bypass surgeries. List indication and possible complication
1. Nasogastric
2. Orogastric
3. Gastrostomy
4. Jejunostomy
1. short term feeding; easily dislodged, can lead to ulceration and stricture
2. short term feeding; NG unable; easily dislodged; canlead to ulceration and stricture
3. long-term nutrition and hydration; infection, bleeding, perforation, clogging, aspiration
4. abscess/unable to use stomach, severe reflux aspiration; clogging, diarrhea, questionable benefit for reducing aspiration
53
Penetration of substance into the laryngeal vestibule and below vocal folds (true vocal cords) into trachea causing infection:
aspiration pna
54
____ is inhalation of gastric contents which causes inflammation without the subsequent development of bacterial infection
aspiration pneumonitis
55
The prevalence of aspiration pna in bedridden gastrostomy fed patients is reported to be ____
10-22%
56
RIsk factors for aspiration pna 7
1. decreased LOC
2. trach
3. emesis
4. reflux
5. NGT feeding
6. dysphagia
7. prolonged pharyngeal transit time
57
Aspiration is missed on bedside eval in ____ % of patients
reliably diagnosed on:
diagnosed in ____% of stroke patients on VFSS
40-60% (ie silent aspiration)
40-70% stroke patients on VFSS
on VFSS
58
Predictors of aspiration on VFSS (2)
1. delayed initiation of swallow reflex
| 2. decreased pharyngeal parstalsis
59
Predictors of aspiration on BSE (6)
1. abn cough
2. cough after
3. dysphonia
4. dysarthria
5. abn gag,
6. voice change after swallow
60
Severe dysphagia can cause significant QOL issues;
Acutely:
chronically:
worry most about choking to death
debilitating social imbarrassment and loss of enjoyment insharing meals with family and friends
61
drugs affecting swallow (3)
CNS sedating properties
Diuretics can cause xerostomia
Cancer treatments resulting in drug-induced mouth ulcers
62
oral motor exam assess what? 5
Assess movement and function of lips, tongue, jaw, soft palate, and hyolaryngeal excursion
63
Clinical swallow evaluation: 6
1. Oral Motor Exam - Assess movement and function of lips, tongue, jaw, soft palate, and hyolaryngeal excursion
2. Vocal quality assessment
3. Food/liquid trials
4.Swallow strategy recommendations
5. Determine water/ice chip protocol candidacy
6. Determine need for instrumental exams
If unable to determine physiological disorder that is causing the dysphagia what needs to be treated?
64
What is blue dye swallow screen for?
| How performed?
To screen for gross aspiration in patients with tracheostomy tubes
Various food & liquid consistencies colored with blue dye are given on successive days with periodic suctioning to check for evidence of blue dye
If no evidence of aspiration is seen, instrumental evaluation should be recommended
Speaking valve should be worn by patients with trachs while eating if possible
65
An instrumental assessment of swallow function where the patient eats and drinks foods and liquids coated with barium and the swallowing process is viewed via flourouscopy:
MBS
66
benefits of MBS: 6
Various textures and compensatory strategies are assessed
Able to view oral phase
Better able to view movement of structures
Able to view aspiration before, during and after the swallow
Able to view cricopharyngeal opening
Able to screen esophageal phase of the swallow
67
An instrumental assessment of swallow function where a lighted scope is passed transnasally and the swallow is viewed superiorally:
Fiberoptic Encoscopic Evaluation of Swallowing (FEES)
68
6 benefits of FEES
Can be done at the bedside
No radiation is used so can be done over a longer period of time to assess for fatigue
No barium related complications
Provides a direct view of laryngeal structure and functions
Can better view amount and location of residue
Can be used for biofeedback in dysphagia thearpy
69
Name 8 swallow compensatory strategies
```
Upright during and 30 minutes after all meals
Small bites/sips
Multiple swallows
Alternate solids/liquids
Chin tuck
No straws
Tongue/finger sweep
Head turn
```
70
Specific food and liquid textures that are easier and safer to swallow (9)
```
Regular
Soft
Mechanical soft
Puree
Mixed consistencies
Thin
Nectar thick
Honey thick
Pudding thick
```
71
describe exercise approach of direct treatment of dysphagia by SLP`
```
Labial/lingual exercise to resistance
Tongue base strengthening
Laryngeal closure
Hyolaryngeal excursion
McNeill Dysphagia Treatment Protocol
```
72
describe Experia for dysphagia
Neuromuscular electrical stimulation with sEMG
| Biofeedback to increase effectiveness of exercises
73
describe direct treatment strategies for dysphagia (4)
1. Exercise based approach:
- Labial/lingual exercise to resistance
- Tongue base strengthening
- Laryngeal closure
- Hyolaryngeal excursion
- McNeill Dysphagia Treatment Protocol
2.Tactile/thermal/gustatory stimulation – lemon ice
3 Neuromuscular Electrical Stimulation (NMES) VitalStim – improve muscle strength, endurance and coordination
4. Experia -Neuromuscular electrical stimulation with sEMG. Biofeedback to increase effectiveness of exercises
74
why would a patient need 1 on 1 supervision for meals?
To ensure follow-thru of swallowing compensations due to decreased cognition
To cue for impulsivity or decreased initiation
75
Theory behind water protocol: 4
1. Small amounts of water taken into the lungs is quickly absorbed
2. Water has a neutral pH and is free of bacteria and contaminants and chemicals founds in other beverages
3. Water provides a safe means of assessing thin liquids
4. Can use in therapy for practice
76
rules for water protocol: 9
1. Excellent oral care must be provided twice daily – before breakfast and before bed. Oral bacteria colonizes in 24 hours so twice a day keeps you ahead of colonization.
2. No water/ice chips allowed:
3. During a meal or until 30 minutes after meals
4. Thickened liquids must be used during meals/meds
5. No gum, candy, chocolate or chewing tobacco allowed
6. Offer patients water throughout the day
7. Meds are not given with water
8. Must be given with appropriate thickened liquid, applesauce, pudding, etc.
9. Liquid meds. should be changed to pill form when possible
77
purpose of oral care protocol
Reduce the risk of aspiration pneumonia by decreasing bacteria in the oral cavity
Minimize a major source of bacterial pathogens
78
what is the oral care protocol
Consistent and effective oral care is essential for patients with dysphagia who are NPO or drink thickened liquids
79
importance of oral care: 7
```
Decrease pneumonia
Increase the desire to eat
Increase oral awareness
Increase oral movement
Increase alertness
Increase sensation and saliva production
```
80
oral care protocol. which toothbrush and when?
Regular toothbrush is recommended for patients who:
Can follow directions
Have good oral control of saliva and liquids
```
Plak-Vac is recommended for patients who:
Have depressed consciousness
Difficulty following directions
Poor oral control
NPO
```
81
How many muscles are involved in swallowing (excited or inhibited)?
a. 35
b. 50
c. 20
d. 5
Answer: B
When a swallow is initiated, motor neurons in the brainstem produce coordinated contraction of striated muscles in the oropharynx. Swallowing consists of coordinated excitation and inhibition of more than 50 muscles.
82
How does the muscle of the esophagus differ from that of the pharynx?
a. The pharynx is all striated muscle; the esophagus is all smooth muscle.
b. The esophagus is all smooth muscle; the pharynx is smooth and striated.
c. The pharynx is striated, and the esophagus is striated proximally and smooth distally.
d. They have smooth and striated muscle
Answer: C
The esophagus is quite different from the pharynx because it is primarily composed of striated muscle in its cervical portion and smooth muscle in its thoracic portion.
83
Breathing pauses during swallowing: What is the typical duration of this pause?
a. 0-300 ms
b. 1-3 sec
c. 0.3-1 sec
d. 3-5 sec
Answer: C
Breathing stops briefly during swallowing. The duration of this interruption is typically 0.3-1 seconds and increases with bolus volume. It can be longer when eating solid food.
84
When do infants develop an almost mature oral motor control for swallowing liquids?
a. 24 months
b. 6 months
c. 12 months
d. 36 months
Answer: A
The early phasic up-down jaw motion pattern evolves into a diagonal movement by 5 months and to a rotary chewing pattern around 24 months. Oral motor skills continue to mature, and by 24 months infants have established an almost mature oral motor control for swallowing liquids. Maturation for chewing is slower. A mature pattern is reached at 6 or 7 years of age.
85
Which alteration of swallowing mechanisms occurs in the elderly population?
a. Shortened time of swallow apnea
b. Reduced respiratory rate immediately after swallowing
c. Increased amplitude of esophageal peristaltic wave
d. Increase in mastication time
Answer: D
| Dentition is often reduced in the elderly, resulting in reduced masticatory efficiency and increased mastication time.
86
What are causes of oral or pharyngeal dysphagia?
a. Stroke and neurologic disorders
b. Spinal cord injuries (thoracic level)
c. Diabetes mellitus type 1
d. Inflammatory bowel disease
e. All of the above
Answer: A
| Oral or pharyngeal dysfunction most commonly results from stroke or neurologic disorders.
87
What would be a result of fibrosis at the upper esophageal sphincter?
a. Retention of food in the pharynx after swallowing
b. Regurgitation of food into the proximal esophagus
c. Reduced swallow apnea time
d. Better protection of airway
Answer: A
One cause for retention of food in the pharynx is impaired opening of the upper esophageal sphincter. This can be caused by increased stiffness of the upper esophageal sphincter by fibrosis or inflammation.
88
What protects the airway during the pharyngeal stage of swallowing?
a. Closing of the upper esophageal sphincter
b. Backward movement of hyoid and larynx
c. Forward movement of hyoid and larynx
d. Downward movement of larynx
Answer: C
The hyoid bone and larynx are pulled upward and forward by contraction of the suprahyoid and hypothyroid muscles. These motions are important for protecting the airway and opening the upper esophageal sphincter
89
What would be the result of velopharyngeal incompetence?
a. Inability to close off the nasopharynx
b. Accelerating bolus to esophagus
c. Blocking of bolus at entry to esophagus
d. Inability to initiate the oropharyngeal phase of swallowing
Answer: A
Velopharyngeal incompetence is the inability to close the velopharyngeal isthmus by elevating the soft palate and contracting the pharyngeal walls around it to close off the nasopharynx
90
What medications can cause dysphagia?
```
a. Analgesics
b Sedatives
c Laxatives
d Immunosuppressives
e A & B
```
Answer: B (but could be E)
Dysphagia is often iatrogenic. Several medications can cause dysphagia through sedation. Medications can also cause pharyngeal weakness, impaired salivation, reduced sensation, and reduced movements
91
When taking a history, how does noting the location of the symptoms assist in diagnosis?
a. Cervical pain indicates esophageal dysphagia.
b. Coughing suggests pharyngeal weakness.
c. Thoracic discomfort after swallowing indicates esophageal dysfunction.
d. Bitter regurgitation indicates impaired opening of the upper esophageal sphincter
Answer: C
The location of the symptoms (neck or chest) is not always a reliable determinant for location of the pathology or dysfunction. Complaints of thoracic dysphagia are highly suggestive of esophageal dysfunction, but complaints of cervical dysphagia can be caused by either pharyngeal or esophageal disorders
92
What is a serious problem of dysphagia that cannot be reliably identified by clinical methods at the bedside?
a. Silent aspiration
b Nasal regurgitation
c Pharyngeal weakness
d Residual retained bolus
Answer: A
| Silent aspiration poses a serious problem in clinical assessments because there are no accurate clinical signs
93
What is a disadvantage of the so-called water test done at the bedside?
a. It causes coughing and pain.
b It cannot provide any information regarding dysphagia.
c It is very difficult to perform.
d It cannot detect silent aspiration
Answer: D
Although this test can be useful in screening for dysphagia, it does not detect silent aspiration or assess the mechanism of swallowing as well as instrumental examination.
94
What is the objective of Shaker exercises?
a. To strengthen the anterior suprahyoid muscles
b To strengthen neck extensors
c To stretch neck flexors
d To strengthen the upper esophageal sphincter
Answer: A
The Shaker exercise is an isotonic–isometric exercise, raising the head (neck flexion) performed in the supine position, which is designed to strengthen the anterior suprahyoid muscles and thereby augment upper esophageal sphincter opening.
95
What is the gold standard for diagnosis of dysphagia?
a. A clinical examination by an expert
b Videofluorography
c Fiberoptic endoscopic evaluation of swallowing
d Electrodiagnostic evaluation of pharyngeal muscles
Answer: B
| The videofluorographic swallowing study is the gold standard for the diagnosis and management of dysphagia
96
Which maneuver assists oral clearance (when the tongue is ineffective) during swallowing?
a. Rotating cervical spine
b Neck extension
c Neck flexion
d Breathing rapidly
Answer: B
The neck extension maneuver can assist oral clearance when the tongue is ineffective in oral bolus clearance. But this maneuver should be used with caution because it can increase aspiration in some people with dysphagia
97
Which is a compensatory maneuver to reduce aspiration?
a. Neck rotation
b Coughing
c Supraglottic swallow
d Valsalva
Answer: C
Compensatory swallowing techniques are used to reduce aspiration and/or improve pharyngeal clearance. The supraglottic swallow involves breath holding before swallow onset, to close the vocal cords, and an immediate cough after swallow
98
What position is best during and following meals?
a. Supine
b Semireclining to 45 degrees
c Sitting upright
d Side-lying
Answer: C
Upright positioning during and after meals is critical to reduce aspiration risk from food as well as refluxed material and to maximize the effectiveness of rehabilitation. Some individuals require modifications of posture, but this is determined by the dysphagia rehabilitation team
IAP part II
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