Flashcards: *****PRAXIS DYSPHAGIA

a swallowing disorder involving the oral cavity, pharynx, esophagus, or gastroesophageal junction.

malnutrition and dehydration, aspiration pneumonia, compromised general health, chronic lung disease, choking, and even death.

-Targeted outcome: Increase muscular activation of the pharyngeal constrictors and base of tongue

-push your tongue to roof of mouth, swallow hard

- Targeted outcome: increased contraction of the superior pharyngeal constrictor muscle

-hold tongue between teeth, swallow your saliva w/ your in this position

-volitional laryngeal vestibule closure

-take a breath & hold it, swallow w effort, cough

- strengthening of hyolaryngeal elevation muscles

- lie flat on back, lift only with head & look at your toes, hold this position for 1 second & then lower your head

-volitional prolonging of hyolaryngeal elevation and upper esophageal sphincter opening

-regular swallow, feel larynx move in upward direction, squeeze your muscles, maintain position for 5 secs, relax & finish swallow

-shortening and constriction of pharynx

-take a deep breath, say "eee" w effort moving from low pitch to high pitch

sucking, chewing, and moving food or liquid into the throat

starting the swallow and squeezing food down the throat. You need to close off your airway to keep food or liquid out. Food going into the airway can cause coughing and choking.

opening and closing the esophagus (the tube that goes from the back of your throat to your stomach). The esophagus squeezes food down to the stomach. Food can get stuck in the esophagus. You may also throw

up a lot if there is a problem with your esophagus or if you have acid reflux

(commonly known as indigestion or heartburn).

lateral or A/P view

limited positioning

in radiology

radiation exposure

visualized

evaluation only

views oral, pharyngeal, and esophageal phases

noninvasive

esophageal transit

superior view

real food

flexible positioning

portable, in clinic/bedside

no radiation

no time limit

inferred after swallow

evaluation or treatment

pre/post pharyngeal phase, real anatomy, secretions

invasive

superior view of UES

can be with flex laryngoscopy

- sucking & swallowing observed

- opens mouth to suck fist

- gag response

- moves tongue in & out, up & down

-show open mouth for food

-can move food from a spoon to the back of the mouth

- gag response decline

-can move food from side to side

eruption of front teeth

can chew softer lumps & keep food in mouth

can close lips to clear the spoon

can bite into harder foods when teeth have erupted

can cope with most textures offered but chewing not fully mature

can cope with most foods offered as part of a family meal

brings hand to mouth & opens mouth in preparation to suck

holds objects

holds objects & puts them in mouth

holds, mouths & shows visual exploration of objects

begins to sit with some support and then unaided

pincer grasp with finger and thumb, sits without support

says first words, context specific, might say word for known food

-recognizes food by sight, smell & taste

-uses words to ask for or name foods they want

visually groups food into categories

starts to hold food and bring food in mouth

begins to try and feed from spoon without spilling from eight months

begins to drink from closed cup

begins to drink from open cup

most infants can feed themselves with a spoon

stroke (the most common cause of dysphagia); traumatic brain injury; cerebral palsy; Parkinson disease and other degenerative neurological disorders such as amyotrophic lateral sclerosis (ALS, also known as Lou Gehrig's disease), multiple sclerosis, progressive supranuclear palsy, Huntington disease, and myasthenia gravis.

V - Trigeminal

XII - Facial

IX - Glossopharyngeal

X - Vagus

XII - Hypoglossal

Motor: Jaw movements, muscles of mastication

Sensory: Oral, lingual (anterior 2⁄3), and facial general sensory

Motor: Muscles of the face, Visceral Motor: submandibular, sublingual,

and mucous glands of mouth, pharynx, and nose.

Special sensory: Anterior 2⁄3 of tongue

Motor: Stylopharyngeus muscle, Visceral motor: Parotid Gland

Sensory: Posterior 1⁄3 of the tongue, tonsils, upper pharynx

Special sensory: Posterior 1⁄3 of tongue

Pharyngeal Branch

Motor: muscles of the pharynx and soft palate, Visceral: pharyngeal mucosa

Sensory: Lower part of pharynx

Superior Laryngeal Branch:

Motor: Cricothyroid muscle

Sensory: Epiglottis, base of tongue, aryepiglottic folds, larynx - to level of VFsRecurrent Laryngeal Branch:

Motor: intrinsic muscles of the larynx (except cricothyroid)

Sensory: the vocal folds, the larynx beneath the vocal folds

Motor: Innervates all intrinsic muscles of tongue and all extrinsic

muscles of the tongue except palatoglossus (X).

Includes - Genioglossus: protrusion

Styloglossus: Elevation and retraction

Hyoglossus: Depression

Also innervates:

One suprahyoid muscle: Geniohyoid

One infrahyoid muscle: Thyrohyoid

The purpose of the Oral Preparatory Phase is to accept, manipulate, break down, and mix the bolus with saliva in the mouth.

The Oral Preparatory Phase of swallowing is almost entirely voluntary.

Putting food/liquid in the mouth

Keeping food/liquid in the mouth

Manipulating the bolus and mixing it with saliva

Chewing food thoroughly

Re-collecting the bolus to form a cohesive mass on the tongue

The purpose of the Oral Transport Phase is to transport the bolus from the anterior to the posterior part of the oral cavity, towards the oropharynx.

The Oral Transport Phase begins with the movement of the tongue.

A pharyngeal swallow response is typically triggered at the end of the Oral Transport Phase.

Bolus propulsion and drive are major contributors to the efficiency of bolus transport during the Oral Transport Phase.

● Anterior faucial arches

● Posterior tongue

● Valleculae

● Pyriform sinuses

● Laryngeal aditus (entrance to the larynx)

Although a swallow response is most commonly triggered by

the time the bolus reaches base of tongue there is

VARIABILITY with this in normal adults and with aging.

The Pharyngeal Phase of swallowing begins with a trigger/response mechanism.

The bolus is moved into the pharynx by the pressure exerted by the tongue.

During the Pharyngeal Phase, the bolus is prevented from entering both the nasal cavity and the larynx/airway.

After passing through the pharynx, the bolus is moved into the esophagus.

The apnea period, characterized by the prefix "a" (meaning no/not) and "Pne(a/o)" (meaning breathing), indicates a temporary cessation of breathing. This apnea period prevents the bolus from entering the airway.

The term "pneumonia" can help you remember the apnea period during the Pharyngeal Phase, as it relates to breathing and the avoidance of aspiration.

After completing the Pharyngeal Phase of swallowing, there is typically little to no residue remaining in the throat.

During the Pharyngeal Swallow phase, the VP port closes.

In the Pharyngeal Swallow phase, both the hyoid and larynx elevate.

During the Pharyngeal Swallow phase, the airway closes to prevent entry of the bolus.

In the Pharyngeal Swallow phase, the pharynx shortens and elevates, contracting behind the bolus.

During the Pharyngeal Swallow phase, the upper esophageal sphincter (UES) relaxes and opens, allowing the bolus to enter the esophagus.

Hyolaryngeal elevation involves the upward and forward movement of the hyoid bone, larynx, and related muscles/ligaments. It contributes to opening the upper esophageal sphincter (UES) and inverting the epiglottis to protect the airway.

The airway closes through the adduction of the true vocal folds and the approximation of the false vocal folds. Additionally, the laryngeal vestibule closes via the anterior movement of arytenoids and the approximation of the base of the epiglottis. Epiglottic inversion also aids in airway closure.

The final line of defense in airway protection is a reflexive cough, which can be triggered to protect the airway if any material attempts to pass beyond the closed airway during swallowing.

SLPs may refer individuals with oropharyngeal and esophageal problems to specialists such as Gastroenterologists (GI), Radiologists, and Otolaryngologists (ENT) for further evaluation and management.

The cricopharyngeal muscle helps to keep the opening to the esophagus closed at rest. It holds the upper esophageal sphincter (UES) closed when not actively swallowing.

The opening of the UES is achieved by the combined effects of movement of the hyolaryngeal complex forward and upward, relaxation of the cricopharyngeal muscle, and the enlargement of the opening as the bolus is pushed into the esophagus (bolus propulsion). Mechanical and pressure forces also play a role in allowing the bolus to be propelled into the esophagus.

The main goal of bolus efficiency in swallowing is to move the bolus from the oral cavity to the esophagus in a timely manner without significant residue, effort, or the need for repeated swallows.

The primary focus of the airway protection aspect of swallowing is to prevent the bolus or any material from entering the larynx and trachea, thereby protecting the airway from aspiration and potential harm.

Residue refers to bolus or material that remains in the oral cavity, pharynx, or esophagus after the swallow has occurred.

Penetration in swallowing refers to the situation where the bolus or material enters the laryngeal vestibule but does not pass below the level of the vocal folds.

Aspiration occurs in swallowing when the bolus or material passes below the level of the vocal folds and enters the trachea, potentially causing harm to the airway.

Dysphagia can result from anything that affects the timing, speed, strength, or coordination of the muscles or structures involved in the oral or pharyngeal phase of swallowing. This can lead to difficulties in the swallowing process.

Lack of sensory input, delayed swallow trigger, incomplete epiglottic inversion, and poor bolus hold (due to coordination or tongue strength issues) can all contribute to a swallowing deficit before the swallow.

The potential consequences include penetration, aspiration, and the presence of bolus or material in the pyriform sinuses prior to the swallow.

During the swallow, potential issues include penetration and aspiration.

Muscle weakness, incomplete epiglottic inversion, lack of sensory input, muscle miscoordination, and structural abnormalities can all contribute to the occurrence of penetration and aspiration during the swallow.

After the swallow, potential issues include residue in valleculae, pyriform sinuses, and the oral cavity, as well as reflux from the upper esophageal sphincter (UES).

Muscle weakness, muscle miscoordination, and esophageal problems can contribute to the occurrence of residue in valleculae, pyriform sinuses, and the oral cavity, as well as reflux from the UES.

Possible etiologies of swallowing disorders include neurogenic diseases such as Parkinson’s Disease, ALS, and dementia; neurological events like stroke and traumatic brain injury (TBI); structural issues like ACDF hardware and osteophytes; head and neck cancers with radiation and post-surgery effects; post-intubation issues (often transient); age-related swallowing changes known as presbyphagia; and cases with an unknown etiology.

Compensatory strategies are used to manage symptoms and prevent aspiration or swallowing difficulty by modifying something, without changing the underlying swallow physiology. They provide immediate and short-term benefit to mitigate signs or symptoms of dysphagia. On the other hand, rehabilitative strategies involve treatment to improve the functioning of a swallow through exercises that target strengthening the muscles of swallowing and addressing the underlying disordered or impaired process. The choice between these strategies should match the physiological findings and can depend on the etiology of the disorder.

-Difficulty with premature spillage

-Pharyngeal swallow delay if limited to

valleculae-Widens valleculae

-Improves base of tongue contact with

posterior pharyngeal wall.

-Difficulty with oral phase

anterior-posterior transit and clearance

-Glossectomy-Gravity assists in transit

-Narrows valleculae

-Unilateral pharyngeal/laryngeal deficits

-Reduced UES opening-Most often turn to weaker side.

-Closes off weaker side, bolus directed to

stronger side.

-Increased UES diameter.

-Unilateral oral phase deficits

-Unilateral pharyngeal phase deficits

-Head & neck cancer patients, partial

glossectomy, stroke patients-Most often tilt to stronger side.

-Goal: direct bolus to stronger side

-Gravity assists

Compensatory strategies are techniques used to manage dysphagia symptoms and prevent aspiration by modifying aspects of the swallowing process. These strategies do not change the underlying swallow physiology but aim to optimize oral intake and safety.

Compensatory strategies for altering/enhancing oral sensation involve modifying sensory aspects of the food or liquid being consumed. This can include changes in taste, temperature, volume, consistency, spice, and mode of delivery. The goal is to improve awareness and sensory input to drive a more coordinated motor response during swallowing.

Compensatory strategies for altering/enhancing oral sensation can address deficits such as reduced awareness of food, delayed or absent pharyngeal swallow, and other issues related to sensory input during the swallowing process.

The underlying concept is that sensory information plays a crucial role in initiating and coordinating motor responses. By modifying sensory aspects of the food or liquid, compensatory strategies aim to improve the sensory input and, subsequently, the effectiveness of the motor response during swallowing.

The research on the effectiveness of compensatory strategies that alter/enhance oral sensation is inconsistent. While these strategies are based on the idea of sensory-motor interaction, their impact on dysphagia management varies, and individual responses may differ.

-Deficits with oral control / premature

spillage into pharynx

-Delayed pharyngeal swallow

-Impulsivity-Using utensils with smaller capacities

(small spoons/forks)

-Using low flow straws or restricted cup

-Oral or pharyngeal residue-Swallow a bite of food 2-3 times and / or

take a sip of liquid before taking another

bite

-Oral residue-Use tongue, finger, or sips of liquid after

each bite to reduce residue

-Attentional deficits

-Impulsivity

-Reduced independence-Reducing distractions in the environment

-Supervision when eating

-Assistance with oral care after meals

-Delay in oral/pharyngeal phase of

swallow1. Bolus is placed in mouth

2. Counts to 3 with bolus in mouth

3. Transfer bolus posteriorly

-Aspiration

-Patients with supraglottic laryngectomy

Helps with: Closure of airway at the level

of true vocal folds1. Hold breath

2. Swallow during breath hold

3. Cough / throat clear immediately after

swallow before inhalation

4. Swallow again

-Same indications as supraglottic swallow

-Aspiration

Helps with: Closure of airway at the level

of the laryngeal vestibule (more complete)1.Hold breath

2. “Bear down” while holding breath

(contracting muscles of laryngeal

vestibule)

3. Swallowing with holding breath and

bearing down

4. Cough / throat clear immediately after

swallow

5. Swallow again

-Residue caused by reduced base of

tongue retraction / reduced pharyngeal

constriction

Helps with: Increasing tongue pressure-Swallow “with effort”

Swallow if you have something thick in the

back of your throat, like peanut butter” and

you have to swallow hard to get it down.

The purpose of using diet modifications as compensatory strategies is to optimize swallowing safety and efficiency by altering the texture and consistency of foods and liquids. This can address specific swallowing difficulties and reduce the risk of aspiration.

Thickened liquids can reduce bolus speed, assist with anterior leakage, and help manage poor oral control and pharyngeal swallow delay. Before recommending thickened liquids, the speech-language pathologist (SLP) should consider the patient's quality of life and assess the risk/benefit ratio of potential issues like aspiration, dehydration, and fatigue.

No, thickened liquids are not a long-term solution for dysphagia management. While they can help address certain swallowing difficulties, they may not be suitable for every patient with aspiration. The SLP should evaluate the individual's needs and consider other options to improve swallowing safety and quality of life.

Modifications of food can include altering its texture and consistency to accommodate swallowing difficulties. These modifications can be helpful for individuals with poor mastication, reduced tongue strength, and significant pharyngeal residue.

A recommended approach for modifying diets based on texture and consistency is to follow the International Dysphagia Diet Standardisation Initiative (IDDSI) framework, which involves a sequential shift from least to most restrictive diet levels. This includes categories such as soft and bite-sized, minced and moist, pureed, and liquidized foods.

Aspiration pneumonia is a type of pneumonia caused by inhaling foreign substances, such as food, liquid, or oral secretions, into the lungs. It can be related to dysphagia when individuals have difficulty swallowing and coordinating their oral and pharyngeal phases, leading to the risk of material entering the airway.

No, oropharyngeal dysphagia alone is not necessarily a significant risk factor for aspiration pneumonia. While dysphagia can increase the risk of aspiration, other factors, such as altered oropharyngeal flora, aspiration into the lungs, and host resistance, also play a role.

Colonization of altered oropharyngeal flora refers to changes in the normal microbial environment in the mouth and throat, often due to factors like dependency for oral care. This altered flora can increase the risk of aspiration pneumonia by introducing potentially harmful microorganisms into the respiratory tract.

Aspiration into the lungs occurs when foreign substances, such as food, liquid, or oral secretions, enter the respiratory tract. These substances can irritate the lungs and trigger an inflammatory response, potentially leading to aspiration pneumonia.

Host resistance factors that can contribute to aspiration pneumonia include the individual's systemic immunologic response and any underlying medical conditions they may have. Multiple medical diagnoses can weaken the body's ability to fight off infections and increase the risk of pneumonia following aspiration events.

-May be indicated for patients with vallecular residue due to reduced

contact/pressure between base of tongue and posterior pharyngeal wall-Purpose is to improve posterior pharyngeal wall to meet base of tongue

-Reduced anterior hyoid movement, reduced laryngeal elevation

-weakened cough-May improve cough effectiveness and/or swallow function in patients with

Parkinson’s, H&N cancer, healthy but sedentary elderly, and multiple sclerosis.