Dysphagia 101: A Review of the Basics - Ohio Speech

Dysphagia 101: A Review of
the Basics
Angela S. Dubis-Bohn M.A.,
CCC/SLP, BRS-S
Objectives
• Identify anatomy and physiology as
pertaining to the swallowing mechanism
• Describe the basic components of a
clinical examination for swallowing
• Identify appropriate compensatory and
rehabilitation techniques based on
swallowing dysfunction
Stages of Swallowing
• Anticipatory Stage
• Oral Stage
– Oral Preparation
– Oral Transit
• Pharyngeal Stage
• Esophageal Stage
Anatomy of Oral Cavity
Muscles of Mastication
• Temporalis- contraction
elevates and retracts the mandible
(closing of the jaw). Innervated by
c.n. V
• Masseter-contraction
elevates the jaw (closes the
jaw). Innervated by c.n. V
• Buccinator-Contraction
tenses the cheek, thus
maintaining food between the
molars. Also active during
sucking. Innervated by c.n. VII
Muscles of Mastication
• Medial PterygoidContraction closes the jaw by
raising mandible against maxilla,
Innervated by c.n. V
• Lateral PterygoidContraction assists in opening
mouth and rotary movement of the
jaw. Innervated by c.n. V
Floor of the Mouth
• Geniohyoid
Floor of the Mouth
• Mylohyoid
Floor of the Mouth
• Anterior Belly of the
Digastric
Anatomy of the Tongue
• Hyoid bone is the
foundation of the
tongue body
• Composed of muscle
fibers going in all
directions
• Divided into an “oral”
portion and
“pharyngeal portion”
Oral Tongue
• Composed of:
Tip
Blade
Front
Center
Back
• Active during speech and oral stage of
swallow and is under voluntary cortical
control
Intrinsic Muscles of the Tongue
• Superior Longitudinalbilateral contraction shortens
tongue and curls tip and sides
of the tongue upward.
Innervated by c.n. XII
• Inferior Longitudinalbilateral contraction shortens
the tongue and curls the tip
and sides of the tongue
downward
Intrinsic Muscles of the Tongue
• Verticalis- contraction
flattens and widens the tongue.
Innervated by c.n. XII
• Transversus- contraction
narrows and elongates the
tongue Innervated by c.n. XII.
Extrinsic Muscles of the Tongue
• Genioglossuscontraction protracts and
depresses the tongue.
Innervated by c.n. XII
• Hyoglossus- contraction
depresses the tongue and
pulls it backwards towards the
hyoid bone. Innervated by c.n.
XII
Extrinsic Muscles of the Tongue
• Palatoglossuscontraction elevates the floor
of the tongue and
approximates the tongue to the
palatoglossal arch thus closing
off the oral cavity from the
oropharynx. Innervated by c.n
IX
Extrinsic Muscles of the Tongue
• Styloglossus• Retracts and elevates the
tongue.
• Innervated by c.n. XII and by
pharyngeal plexus (c.n. IX & X)
Tongue Base
• Active during the
pharyngeal swallow
• Under involuntary
control coordinated in
the brainstem
• Motor- c.n. XII
Salivary Glands
• Three main salivary
glands
Parotid
Submandibular
Sublingual
Parotid Gland
•
•
•
Produces serous (thin and watery)
saliva, which makes up 25% of our saliva
production.
Excreted through Swenson’s ducts near
the second maxillary molar.
Particularly important when eating and
drinking
Submandibular Gland
•
Produces both serous and mucoidal
saliva (mostly serous) which makes up
60% of our saliva production
•
Secreted through Wharton’s duct,
which is located on either side of the
frenulum of the tongue
Sublingual Gland
•
Produces both serous and mucoidal
saliva (mostly mucoidal) which is
secreted through several ducts in the
floor of the mouth and makes up 15% of
our saliva production
Functions of Saliva
•
•
•
•
•
•
•
Protects the teeth and gums and assists with oral
hygiene
Lubricates food to assist with chewing and prepares
the food into a bolus for ease of swallowing
Lubricates the tongue and lips for speech
Facilitates taste
Destroys micro-organisms
Initiates carbohydrate digestion
Regulates acidity in the esophagus
Xerostomia
• Reduction in salivary function
• Can be a problem for geriatric patients
secondary to polypharmacy
• Drugs that can cause xerostomia
Antihistamines
Antihypertensives
Diuretics
Antipsychotics
Oral Preparation- Solids
• Bolus acceptance and oral transit to
posterior teeth for mastication
Fracture- breaking food by two directly
opposing forces
Involves anterior to posterior movement of
tongue
Bolus Reduction-Mastication
•
Reduction of the bolus occurs in three phases – Opening, closing,
and power stroke or “Crushing phase”
•
Along with mastication, the parotid/submandibular glands produce
serous saliva which is mixed with the bolus during reduction
•
The buccinator flattens the cheek and holds the bolus in contact
with the teeth
•
The tongue will tilt its dorsal plane toward the working side, while
the jaw opens and closes to keep food between the teeth.
•
Sensory feedback coordinates the tongue position and shape to
the moving mandibular arch
Oral Preparation-Liquids & Purees
•
Bolus is placed on the dorsum of the tongue
•
The intrinsic muscles of the tongue create a groove for
the bolus to rest
•
With puree, there may be compression where the
bolus is pressed against the hard palate and mixed
with saliva.
•
The flattening action of the buccinator assists in
returning the bolus to a medial position
Oral Transit Sequence
•
Bolus is medialized on the dorsum
•
The velum (soft palate) elevates (via levator veli
palatine and superior pharyngeal constrictor) to close
off the nasopharynx
•
Obicularis oris, Buccinators, and Superior Pharyngeal
Constrictor contract creating a circular musculature
“sling” to support the positive pressure built up by the
posterior 1/3 of tongue during bolus propulsion by
closing off the mouth and nasopharynx.
Chamber and Valving Action of
Swallowing
• From Vital Stim training
manual, 2008
• Bolus is transited through the
various chambers from areas
of higher pressure to lower
pressure as it moves through
the GI tract
Oral Transit Sequence
•
The posterior tongue depresses
•
The remainder of the tongue presses
against the hard palate
•
Bolus is propelled toward the pharynx
Pharyngeal Swallow- Neural
Control
• Effective function of the pharyngeal
swallow is dependent on specific mobile
structures as well as precise timing
• The mechanisms of the larynx/pharynx
require extensive neural control in order to
switch between the functions of respiration
and deglutition
Requirements for “Time-Sharing” of
the Laryngopharynx
• Intact sensory receptors (afferent
pathway)
• Muscle effectors (efferent pathway)
• Central control to coordinate the sensory
input and muscle control
Central Control of the Swallow
• Central control processors are in the brainstem
(medulla) adjacent to the sensory and motor
nucleus of the vagus
• Pharyngeal swallow takes only 750 milliseconds
(approximately three-fourths of a second)
• Reflexes of this short of duration must occur at
lower brainstem levels without higher cortical
involvement
Cranial Nerves- Pharyngeal Stage
• Vagus Nerve- c.n. X
Provides motor and
sensory innervations to the
palate, pharynx, larynx,
esophagus, and stomach
Branches of Vagus
• Superior Laryngeal
Nerve (SLN)
• Recurrent Laryngeal
Nerve (RLN)
Divisions of the Pharynx
• Nasopharynx
• Oropharynx
• Hypopharynx
Musculature of the Pharynx
• Pharyngeal Constrictors
• Superior (c.n. X & XI)
• Middle (c.n. X)
• Inferior (c.n. X & XI)
Pharyngeal Constrictors- Function
• Assist in laryngeal elevation and stripping the bolus inferiorly
• Arises from the median raphe in the midline of the posterior
pharyngeal wall and runs laterally to attach to the bony and soft
tissue structures including
•
•
•
•
•
•
Pterygoid plates of the sphenoid bone
Soft palate
Base of the tongue
Mandible
Hyoid bone
Thyroid cartilages – NOTE: as the fibers of the inferior constrictors attach to
the sides of the thyroid cartilage anteriorly, a space is formed between these
fibers and the sides of the thyroid cartilages. These spaces are known as
the pyriform sinuses. The pyriforms end at the cricopharyngeus muscle,
the most inferior structure of the pharynx.
• Cricoid cartilage
Musculature of the Pharynx
• Cricopharyngeus
• Serves as the valve at the top
of the esophagus
• At rest, the CES is in tonic
contraction to prevent air from
entering the esophagus during
respiration and to prevent
reflux of material into the
pharynx
• At the appropriate moment
during the swallow, the fibers
relax to allow bolus passage
into the esophagus.
Anatomy of the Larynx
• Epiglottis
• Valleculae
• Laryngeal Vestibule
• Laryngeal Ventricle
(space between the false
and true vocal folds)
Cartilages of the Larynx
• Epiglottis
• Cuniform cartilages
(support and stiffen the
aryepiglottic folds to maintain
opening to larynx)
• Hyoid Bone
• Thyroid Cartilage
• Cricoid Cartilage
Intrinsic Muscles of the Larynx
• Aryepiglottic Muscle– Sometimes credited with depressing epiglottis in initial
stages of swallowing
• Interarytenoids- Approximates arytenoid cartilages
• Lateral Cricoarytenoids- adducts vocal folds
• Thyroarytenoid- regulates longitudinal tension
Extrinsic Muscles of the Larynx
• Digastric
– Raises the hyoid and
may assist in
depressing the
mandible
Extrinsic Muscles of the Larynx
• Geniohyoid
– Draws hyoid bone
upward and forward
Extrinsic Muscles of the Larynx
• Mylohyoid– Elevates hyoid, floor of
the mouth, tongue
Extrinsic Muscles of the Larynx
• Stylohyoid
– Draws hyoid bone
upward and backward
Extrinsic Muscles of the Larynx
• Posterior Belly of the
digastric
– Draws the hyoid
upward and backward
Extrinsic Muscles of Larynx
• Thyrohyoid– Contraction elevates
the thyroid cartilage
and decreases
distance between
thyroid cartilage and
hyoid bone
Extrinsic Muscles of the Larynx
• Sternohyoid
• Sternothyroid
• Omohyoid
Physiology of the Pharyngeal
Swallow
• Bolus division at the level of the vallecula
-1/2 flowing down either side of the
pharynx (lateral channels)
• Swallow reflex is triggered at anterior
facial arches or at the level of vallecula
• Brief period of apnea
• Arytenoids medialize and tilt towards
epiglottis, TVC are still open
Physiology of the Pharyngeal
Swallow
• Tongue base retracts towards the
posterior pharyngeal wall
• Velopharyngeal port closes
• Hyolaryngeal elevation with simultaneous
pharyngeal squeezing and shortening
occurs
Physiology of the Pharyngeal
Swallow
• Epiglottis retroflexes during laryngeal
elevation
• TVC contract .63 seconds AFTER the
arytenoids begin medialization
• Airway closure is not complete at the level
of the glottis until midway through the
swallow
Physiology of the Pharyngeal
Swallow
• Relaxation of the cricopharyngeus to allow
passage of the bolus into the esophagus.
• Without the triggering of the swallowing
reflex, none of these physiologic activities
can occur
Anatomy of the Esophagus
• Hollow muscular tube apprx. 23-25 cm long
composed of skeletal and smooth muscle with a
sphincter at each end (UES and LES)
• Innervated by Vagus nerve
• Begins at the 6th cervical vertebra inferior to the
UES
• Anterior border = cricoid cartilage; posterior and
lateral borders = cricopharyngeus muscle
Anatomy of the Esophagus
• The proximal 5% of the esophagus is striated
muscle, the middle 30-40% is mixed, and the
distal 50-60% is entirely smooth muscle.
• The esophagus has 3 layers:
– Squamous epithelium
– Lamina propia
– Muscularis mucosa which has 2 layers of muscle
(inner circular and outer longitudinal muscle layer)
which act in peristaltic fashion to move bolus into
stomach
Physiology of the Esophagus
• “Peristaltic wave” Concept
A ring of contraction appears in the wall of the
esophagus
At the same time, the muscular wall just
ahead of the ring relaxes in a phenomenon
called “receptive relaxation”
As the peristaltic wave moves along, it
propels the contents of the bolus ahead of it
Physiology of the Esophagus
• Peristalsis begins once the bolus enters the esophagus and
expands the esophageal lumen
• Primary peristaltic waves- progressive contractions in the
esophagus initiated by the swallow. Allows the bolus to be propelled
at a velocity of 2-4 cm/sec
• Secondary Peristaltic Waves- elicited at any level of the
esophagus and is initiated by intraesophageal bolus distension to
clear the esophagus without a secondary swallow. Helps with solid
transport as primary wave may not fully propel the bolus to the
stomach
• Tertiary Contractions- simultaneous, non-peristaltic waves that are
a physiologic response to esophageal distension. They are not
sufficient in clearing the esophageal body. May arise separately of
swallowing events as in gastroesophageal reflux and stress
The Normal Swallow
Disorders of Swallowing
Penetration/Aspiration
•
Penetration= Any material penetrating the
laryngeal vestibule but not passing the level of
the true vocal folds
•
Aspiration= Any material penetrating the
larynx and entering the trachea below the true
vocal folds
–
Aspiration may occur before (before the swallow
reflex has triggered, when the airway has not
elevated or closed), during (laryngeal valves are
not functioning adequately), or after (when the
larynx lowers and opens for exhalation) the swallow
Penetration-Aspiration Scale
•
•
Created by Rosenbeck et. Al. (1996)
Attempt to describe and provide reliable quantification of
penetration/aspiration events
•
•
Description of the Scale
8-point multi-dimensional scale (more than one behavior is being
judged)
Depth of the bolus invasion into the airway
Patient’s response to the bolus
The expulsion of the material
A higher score in the scale assumes to be a more severe sign of
dysphagia
•
•
•
•
Penetration-Aspiration Scale
• 1 = Material does not enter the airway
• 2= Material enters the airway, remains above the vocal folds, and is
•
ejected from the airway
• 3= Material enters the airway, remains above the vocal folds, and is
not ejected from the airway
• 4=Material enters the airway, contacts the vocal folds, and is ejected
from the airway
• 5=Material enters the airway, contacts the vocal folds, and is not
ejected from the airway
• 6= Material enters the airway, passes below the vocal folds, and is
ejected into the larynx or out of the airway
• 7=Material enters the airway, passes below the vocal folds, and is
not ejected form the trachea despite effort
• 8= Material enters the airway, passes below the vocal folds, and no
effort is made to eject
Oral Stage Disorders
•
Reduced labial closure
•
Reduced lingual movement
•
Reduced range or coordination of
lingual movement to hold bolus
consistencies
Oral Stage Disorders
•
•
•
•
Reduced oral sensitivity
Tongue thrust
Reduced lingual elevation
Reduced anterior-posterior (A-P)
movement of the tongue
• Disorganized A-P tongue movement
• Tongue pumping
Oral Stage Disorders
•
•
•
•
•
•
Piecemeal deglutition
Reduced ability to seal tongue to palate laterally
Reduced buccal tension
Reduced range of lateral mandibular movement
Poor alignment of the mandible/maxilla
Poor dentition, Ill-fitting dentures, edentulous
Pharyngeal Stage Disorders
•
•
•
•
•
•
Delayed swallow reflex
Absent swallow reflex
Inadequate velopharyngeal
Reduced pharyngeal peristalsis
Unilateral pharyngeal weakness
Cervical osteophyte and cervical
dislocations
Pharyngeal Stage Disorders
•
Reduced laryngeal elevation
•
Reduced laryngeal closure
•
Cricopharyngeal dysfunction
Compensatory Strategies
Goals of Compensatory Strategies
•
•
•
Immediate but transient effect on
efficiency or safety of swallowing.
Changes the flow and gravitational
direction of a bolus to allow safe passage
into the stomach.
Reimbursement for long-term
intervention is typically not supported.
Postural Strategies
• Chin Tuck
–
–
–
–
–
Also called “chin flexion” or “chin down”
First introduced by Logemann (1983) to treat observed delays
in triggering the pharyngeal swallow, poor tongue control,
reduced tongue base retraction, and/or reduced closure of the
laryngeal vestibule and vocal cords as assessed by MBS
Symptoms observed on MBS include pre-swallow vallecular
pooling (secondary to a swallow delay) and/or aspiration
during a swallow
Contraindicated for patients with poor lip closure or poor oral
control
Patient is asked to place the chin to the chest during
swallowing.
Postural Strategies
• Head Rotation
–
–
–
–
Rotation, or turning, the head toward the weaker,
hemiparetic side can direct the flow of the bolus
toward the stronger more sensate side of the
pharynx
Size of the pharyngeal cavities on impaired side will
be reduced, and thus the bolus will be directed
toward the more functional side
May benefit the patient who has diffuse weakness
and residual
Patient must be able to rotate head 90 degrees
Postural Strategies
•
Head Tilt
–
–
–
Tilting the head toward the stronger side may help
to direct the bolus to the stronger, potentially more
sensate oral and pharyngeal side
Increased sensation and motor
strength/coordination on the unaffected side may
facilitate improved oral control, bolus formation and
propulsion with a stronger pharyngeal swallow.
Pt. is instructed to tilt head toward the stronger nonimpaired side during PO intake.
Postural Strategies
•
Side lying
–
–
–
Described by Logemann (1996) as an effective
posture to compensate for reduced pharyngeal
contraction that results in diffuse residue in the
pharynx
Rationale is that a lateral head/trunk position will
reduce the gravitational force on any residue that is
left in the pharynx after the swallow.
Pt. is placed laterally in a bed or in a semi-reclined
or fully reclined chair
Postural Strategies
• Neck extension
–
–
–
–
The posture of leaning the head back utilizes gravity to propel
a bolus into the pharynx and is primarily used when oral motor
deficits inhibit efficient anterior to posterior transit of a bolus
into the pharynx.
Pt must have prompt, efficient swallow response
Pts. are instructed to take a breath, hold it, then bring chin up
and allow gravity to move the bolus back towards the pharynx.
Contraindications – can decrease the patient’s ability to close
laryngeal vestibule effectively. Also, decreases UES’s ability
to relax – directly related to the degree of extension. May
increase aspiration risk in neurogenic dysphagia pt’s who may
be forced into this position unintentionally.
Bolus Control Strategies
•
Lingual sweep
–
–
–
Most practical and “normalized technique”
Goal is to actively use the tongue to clear residue
from oral cavity and redirect to the tongue blade for
bolus development
Patient is cued to use the tongue purposefully to
sweep the entire oral cavity with special focus to the
area of weakness.
Bolus Control Strategies
•
Cyclic ingestion (alternating
solids/liquids)
– Indicated for patients with bolus
manipulation deficits, especially those who
exhibit post swallow residue
– Patient is instructed to alternate solids and
fluids to clear the oral cavity of residue
unable to be managed with lingual sweeping
Bolus Control Strategies
•
Dry swallows (multiple swallow)
–
–
Can be used with a patient who exhibits post
swallow residue somewhere within the digestive
tract (oral residue, vallecular residue, pyriform sinus
residue)
Pt. is instructed to dry swallow after every bolus
swallow – as many times as indicated by
instrumental assessment
Bolus Control Strategies
•
Bolus placement
– Position the bolus in the more sensate,
unimpaired side of the oral cavity for
preparation
– Patient is instructed to angle utensil toward
the unimpaired side.
Bolus Control Strategies
•
Modification of bolus size
– Smaller boluses may allow for greater
control and less scatter of the bolus to oral
recesses
– In some patients with decreased sensitivity,
larger bolus can provide increased sensory
input – especially with heavier bolus with
variable texture – allows for better oral
awareness (dementia)
Bolus Control Strategies
•
Adaptations in the rate of intake
–
–
Slower rate may give pt. with neurologic deficits
more time to manage the bolus
External controls may need to be employed may be
required to slow rate of TBI or right CVA pt.
(Impulsivity)
Volitional Airway Protection
Strategies
•
Supraglottic Swallow
–
–
–
Provides volitional airway protection when patient is a silent
aspirator or has delayed reflexive airway protection
Pt. is instructed to take a deep breath and hold it firmly while
swallowing the bolus. On completion of the swallow, patient is
instructed to cough prior to inhalation. The patient swallows
and coughs for a second time.
Caution: Cardiac patients- Chaudhuri et al. (2002) – fitted
stroke patients with holster monitors to measure the
cardiovascular impact of supraglottic and super-supraglottic
swallow. 86.6% (13/15 patients) showed abnormal cardiac
readings (arrhythmias) during the maneuvers.
Volitional Airway Protection
Strategies
•
Super-supraglottic swallow
–
Patient is instructed to take a deep breath and
tightly hold, then swallow “hard” or with greater
effort than usual. Following swallow. Pt. should
follow with a cough prior to inhalation
–
See supraglottic swallow for cardiac precautions
Sensory Strategies
•
Thermal stimulation
– Used as antecedent to the bolus
– Apply stimulation cyclically throughout the
meal
Sensory Strategies
•
Vocal quality checks
– Pt. is instructed to monitor vocal quality
during oral intake
– If “wet”, dysphonic, aphonic pt. should cough
or clear throat and swallow. Vocal quality
should be reassess until clear vocal quality
is achieved
– Warms et al. (2000) –
Dietary Modifications
• Dysphagia Diet Project, 1999
– Task force initiated by dieticians in 1996
secondary to frustrations over lack of
standardization for solids and liquids
– Task force members included: clinical and
consulting dieticians, clinical and research
SLP, food scientists, food industry
representatives
Dietary Modifications
• Food Textures
– NDD Level 1 - puree
– NDD Level 2 – mechanically altered,
cohesive, moist, semi-solids, no bread
– NDD Level 3 – soft-solid
– Regular
Dietary Modifications
• Liquids
– Thin
– Nectar-like
– Honey-like
– Spoon-thick
Clinical Evaluation of
Swallowing
Clinical Evaluation of SwallowingPurpose
• a.k.a. “the bedside swallowing evaluation”
• Evaluate patients for the likelihood and
seriousness of a swallowing impairment
• Information gathering opportunity prior to
objective instrumental assessment
Clinical Evaluation of SwallowingInformation Gathering
• Must have physician consult prior to evaluation
• Chart review
–
–
–
–
–
–
–
–
–
–
–
–
H&P (history and physical)
Onset of the problem
Reason for hospitalization
ROS (review of systems)
Respiratory status
PMH or PSH
Behavior
Level of responsiveness
Current method of nutrition
Medications
Review of previous eval reports/tx. notes from previous level of care
Nursing notes/observations
• Pt/family interview
Clinical Evaluation of SwallowingSupplies
•
•
•
•
•
•
•
•
•
•
Textures/consistencies representative of possible diet levels
Cups
Several spoons
Tongue depressors
Cotton Tip Applicators
Thickener
Stethoscope (elective)
Flashlight/Penlight
Laryngeal mirror (elective)
Protective equipment (gloves) – note latex allergies or isolation
precautions
• Evaluation forms
Clinical Evaluation of SwallowingProcedure
• Style variability depending on clinician, patient,
circumstances
• Make sure that an order has been specifically written for
swallow eval prior to the evaluation – clarify order if
questions
• Check with RN first before performing the evaluation
• Eval at meals when possible
• Pt. Interview
• Oral-peripheral exam
• Laryngeal examination
• Behavioral observations
• Presentation of consistencies
Clinical Evaluation of SwallowingOral Stage Observations
•
Oral Preparation
–
–
–
Clearing of bolus from utensil/apparatus (lip closure)
Anterior loss of bolus
Mastication
• Style – rotary vs. “munching” & Duration
– Bolus formation
•
Oral transit
–
–
–
Tongue pumping
Oral stasis
Cough before swallow
Clinical Evaluation of SwallowingPharyngeal Observations
•
•
•
•
•
•
Somewhat limited at bedside – looking for any
clinical signs of aspiration
Swallow initiation
Laryngeal elevation
Cough responses – note 40% of aspirations
are silent!
Changes in vocal quality
Subjective complaint of stasis
Clinical Evaluation of SwallowingModifications During Evaluation
•
Will depend on response of the patient
– Texture modification
– Postural modification
Clinical Evaluation of SwallowingDetermining Next Options
•
•
•
•
No clinical signs of aspiration – proceed
with/continue/advance diet
Continue NPO or recommend NPO until
further evaluation
Need more objective data – MBS, FEES
Other referrals – ENT, GE
Clinical Evaluation of SwallowingDocumentation
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Medicare requires several pieces of info in report
Medical w/up (MD)
Dysphagia criteria
LOA
Motivation
Cognition
One of these conditions – h/o aspiration, OM d/o, structural lesions, neuromuscular
disturbance, post sx. Reaction, weight loss
Assessment
History
Current nutritional status
Clinical observation
Definitive diagnosis
Id of the swallow phase affected
Recommendations/tx. Plan
Care planning
Goals
Type of care planned
Reasonable expectation of improvement
Safety issues
Need for skilled rehab
Clinical Evaluation of SwallowingDocumentation
• May be able to give severity level to oral stage
• Will not be able to give severity level to pharyngeal stage
because not enough info
•
EXAMPLE: Pt. Exhibits moderate oral stage dysphagia
characterized by orofacial and lingual weakness resulting in anterior
loss of bolus, ineffective bolus preparation, and oral stasis.
• EXAMPLE: Pt. Appears to exhibit pharyngeal dysphagia (or
pharyngeal dysphagia suspected) as evidenced by delayed swallow
initiation, reduced laryngeal elevation, multiple cough responses
during evaluation placing the patient at risk for aspiration.
Recommend MBS for further objective measures to determine pt’s
ability to protect the airway prior to the initiation of p.o. intake
Clinical Evaluation of SwallowingDetermining Severity
• 3rd party payers are challenging SLP to prove validity
and reliability of dysphagia assessments and treatment
• Clinical bedside eval. and MBS have come under much
scrutiny because of the subjective nature and lack of
inter and intrajudge reliability
• Dysphagia Outcome and Severity Scale (DOSS)
• Developed by O’Neil et. Al., 1999 to create a reliable
and uniform measure of dysphagia severity
• Takes 4 factors into account – Level of independence,
level of nutrition, diet levels and diet modifications, and
swallowing impairments
Dysphagia Outcome and Severity
Scale
Rehabilitation Techniques
Goals of Rehabilitation
•
Restore to a condition of health or useful and
constructive activity.
•
Improve anatomy/physiology permanently so
that the significance of the disorder is
minimized or eliminated
•
Rehabilitation techniques may improve the
swallow function to such a level that
compensatory strategies may be applied
Rehabilitation-Premises of
Treatment
• Effective rehabilitation relies on an accurate diagnosis
and individualization of the treatment plan and to the
specific physiology
• Symptoms are usually easy to observe (e.g., pooling or
residue, premature spillage)
• Underlying etiology that leads to symptoms requires a
more critical eye
• Rehabilitation approaches will be different depending on
the etiology
• Inappropriate treatment due to inaccurate diagnosis of
physiology is not efficacious, not cost effective, and may
be contra-indicated.
Rehabilitation- Oral Motor
Inefficiency
•
OM inefficiency may result in various
dysphagic symptoms
–
–
–
–
–
•
Anterior loss of bolus
Posterior loss of control of bolus
Incomplete development of a cohesive bolus
Decreased mastication effectiveness
Decreased ability for lingual sweep to clear stasis
from buccal, sublingual or general oral cavity
Efficacy data of OM exercises is increasing in
literature as of late
Rehabilitation- Lips
•
Increased or decreased labial tone may result in difficulty removing bolus
from utensil, inability to maintain bolus in oral cavity, may inhibit bolus
acceptance all together (especially in the case of abnormal reflexes)
•
•
These exercises may help with bolus control, decreased anterior loss of
bolus
If hypertonic – slow, progressive stretching in effort to relieve spasm.
Provide firm directed pressure to lips and move laterally and
superior/inferior positions
•
If hypotonic – pursing, retracting lips either in rote ROM or against
resistance
– Facial Muscle Exercise Program (FMEP)
– Tongue Depressor “Exerciser”
– Oral Motor Exercises
Rehabilitation-Tongue
• Deficits of lingual control can result in premature spillage or bolus
formation difficulties
• These exercises may help with lingual strength or ROM
• Hypertonic – Gloved hand, gauze pad – light stretching.
• Hypotonic – ROM x all planes with resistance against tongue blade.
Resistance can be progressively increased.
– Life saver on a string – manipulate in all planes in oral cavity
– Tongue Depressor “Exerciser”
– Robbins, J et. Al (2005). Studied effects of lingual strength training in
normal elderly adults and elderly stroke patients.
Rehabilitation- Jaw
•
Decreased strength in masseter,
temporalis, pterygoids can result in
decreased ability to masticate
– Gum on a string – tie a piece of gum on to a
piece of dental floss. Have patient chew the
gum focusing on keeping the gum in a “ball”
form.
– Tongue Depressor “Exerciser”
Rehabilitation- Velum
•
•
Data to support palatal strengthening are scant
Exercises which may help with palatal strengthening
–
–
–
–
Straw suck – Have patient suck through a straw while
occluding the other end with fingertip
DPNS (evidence unavailable)
Use of CPAP (Liss, Kuehn, & Hinkle, 1994)- Patient wears
CPAP while producing various phonemes against positive
airway pressure
Velopharyngeal Closure Test (VCT) (Hagg, 2004)- Patients
asked to inhale deeply, then exhale through a straw at a
constant pace for as long as possible against 12 cm water
pressure. Generally accepted lower normal limit is to exhale
against 5 cm of water pressure for at least 5 seconds. Straw
should be 1 cm in diameter. Straw must be at the bottom of
the container. Repeat 3 times. Increase the amount of water
for challenge.
Rehabilitation- Swallow Delay
•
•
•
Delayed pharyngeal swallow occurs when patient
volitionally transfers bolus posteriorly out of oral cavity
and pharyngeal response fails to occur in a timely
manner
This represents a deficit of the neurosensory system
in which inadequate sensory feedback mechanisms
fail to communicate with the oncoming bolus
Rehabilitation techniques
– Thermal gustatory stimulation
– DPNS
Rehabilitation- Laryngeal Elevation
•
•
•
Mendelson Maneuver
Shaker exercises
Expiratory Muscle Strength Training
Rehabilitation- Tongue Base
•
•
•
Masako Maneuver
Valsalva Maneuver (Effortful Swallow)
DPNS
Rehabilitation- Laryngeal Valving
•
Vocal adduction exercises
•
Vocal Function Exercises (Stemple,
1993)
Rehabilitation- UES
•
Mendelson maneuver
•
Shaker exercises
Correspondence
•
•
•
•
•
•
Angela S. Dubis-Bohn M.A., CCC/SLP, BRS-S
Dodd Rehabilitation Hospital
480 Medical Center Dr. Room 1145
Columbus, Ohio 43210
(614) 293-5275
angie.dubis-bohn@osumc.edu
References
•
References- Anatomy & Physiology
•
Bartoshuk, L.M., Duffy, V.B, Leder, S.B., &Snyder, D.J. (2003). “Oral Sensation: genetic and
pathological sources of variation”. Perspectives on swallowing and swallowing disorders. 12:4.
3-9.
Berkovitz, B, Kirsch, C., et. Al. (2003). Interactive head and neck CD-ROM. London: Primal
Pictures.
Butler, S.G., Psstima, G.N., Fischer, E. (2004). “Effects of viscosity, taste, and bolus volume on
swallowing apnea duration of normal adults”. Otolaryngology- Head and neck surgery. 131:6,
860-863.
Corbin-Lewis, K., Liss, J.M., Sciortino, K.L. (2004). Clinical anatomy and physiology of the
swallow mechanism. Clifton Park: Thompson/Delmar Learning.
Crary, M. (2003). Old and new strategies for assessing and treating adult dysphagia.
Cathy Chester Memorial Seminar: Columbus.
Crary, M.A., & Groher, M.E. (2003). Introduction to adult swallowing disorders.
St. Louis, MO: Butterworth-Heinemann.
Easterling, C.S. (2003). “Getting acquainted with the esophagus”. Perspectives on bean
swallowing and swallowing disorders. 12:2. 3-7.
Kaplan, M.D. & Baum, B.J. (1993). “The functions of saliva.” Dysphagia. 8:225-229.
Langmore, S. (2004). FEES and fluoroscopy. ASHA Health Care Convention 2004: Orlando.
•
•
•
•
•
•
•
•
•
•
•
References
•
References- Anatomy and Physiology (Cont)
•
Leopold, N.A., Kagel, M.C. (1997). “Dysphagia- ingestion or deglutition? A proposed paradigm”.
Dysphagia. 12: 202-206.
Logemann: J.A. (1998). Evaluation and Treatment of Swallowing Disorders (2nd Ed.).
Austin, TX:Pro-Ed.
Miller, R.M. & Groher, M.E. (1993). “Speech-language pathology and dysphagia: a brief
historical perspective.” Dysphagia. 8:3, 180.
Morgan, A. et. Al. (2004). “Clinical characteristics of acute dysphagia in pediatric patients
following traumatic brain injury”. Journal of Head Trauma and Rehabilitation. 19:3, 226-240.
Simmons, Mary. MBS: The Clear Picture. CIAO Seminars. Accessed 03/04/08.
VanDaele, DJ, McColloch, TM, Palmer, PM, Langmore, SE. (2005). “Timing of glottic closure
during swallowing:A combined electromyographic and endoscopic analysis.” Ann Otol Rhinol
Laryngol. 114, 478-87.
Ylvisaker, m. & Logemann, J.A. (1985). “Therapy for feeding and swallowing disorders following
head injury.” In Ylvisaker, M. (Ed). Head injury rehabilitation- Children and adolescents. Boston:
College Hill Press. 195-215.
Yorick, W. & M. Freed (2008). Vital Stim Certification Seminar. Columbus, Ohio. April, 2008.
Zemlin, W. (1988). Speech and hearing science anatomy and physiology.
New Jersey:Prentice-Hall.
•
•
•
•
•
•
•
•
•
•
•
References
•
References- Disorders of Swallowing
•
Carrau, R.L., & Murray, T. (1999). Comprehensive management of
swallowing disorders. San Diego, CA: Singular Publishing Group.
•
Logemann, J.A., (1998). Evaluation and treatment of swallowing disorders.
(2nd Ed.). Austin, TX: Pro-Ed.
•
Rosenbeck, J.C., Robbins, J.A., Roecker, E.B., Coyle, J.L., & J.L. Wood.
(1996). A penetration-aspiration scale. Dysphagia. 11:93-98.
References
Compensatory Strategies
•
•
•
•
•
•
•
•
Bulow, M., Olsson, R., & Ekberg, O. (2003). Videoradiographic analysis of how
carbonated thin liquids and thickened liquids affect the physiology of swallowing in
subjects with aspiration on thin liquids. Acta Radiologica. 44: 366-372.
Chaudhuri, G., Hildner, C.D., Brady, S., Hutchins, B., Aliga, N., & Abadilla, E. (2002).
Cardiovascular effects of the supraglottic and super-supraglottic swallowing
maneuvers in stroke patients with dysphagia. Dysphagia. 17: 19-23.
Huckabee, M.L., & Pelletier, C.A. (1999). Management of adult neurogenic
dysphagia.
San Diego, CA: Singular Publishing Group.
Logemann, J.A., Pauloski, B.R., Colangelo, L., Lazarus, C., Fujiu, M., & Kahrilas, P.J.
(1995). Effects of a sour bolus on oropharyngeal swallowing measures in patients
with neurogenic dysphagia. Journal of Speech and Hearing Research. 556-563.
Pelletier, C.A., & Lawless, H.T. (2003). Effect of citric acid and citric-acid sucrose
mixtures on swallowing in neurogenic oropharyngeal dysphagia. Dysphagia. 18:
231-214.
References
•
•
•
•
•
•
•
References- Clinical Evaluation of Swallowing
Addington, W.R., Stephens, R.E., Gilliand, K., Rodriguez, M. (1999).
Assessing the laryngeal cough reflex and the risk of developing pneumonia
after stroke. Archives of Physical Medicine and Rehabilitation. 80:150-154.
Aviv, J. (2002). The bedside swallowing evaluation when endoscopy is an
option: what would you choose? Dysphagia. 17:219.
Corbin-Lewis, K., Liss, J.M., Sciortino, K.L. (2004). Clinical anatomy and
physiology of the swallow mechanism. Clifton Park, NY: Thompson/Delmar
Learning.
Felt, P. (1999). The national dysphagia diet project: the science and
practice. Nutrition in clinical practice. 14:S60-S63.
Hendrix, T.R. (1993). Art and science of history taking in the patient with
difficulty swallowing. Dysphagia. 8:69-73.
Logemann, J. (1998). Evaluation and treatment of swallowing disorders.
(2nd Ed). Austin, TX: Pro-Ed.
References
•
•
•
•
•
•
•
•
References- Clinical Evaluation of Swallowing
Logemann, J., Veis, S., & Colangelo. (1999). A screening procedure for
oropharyngeal dysphagia. Dysphagia. 14:44-51.
Mann, G. (2002). The mann assessment of swallowing ability. San Diego,
CA: Singular Publishing.
Murray, J. (1999). Manual of dysphagia assessment in adults. San Diego,
CA: Singular Publishing.
O’Neil, K.H., Purdy, M., Falk, J., & L. Gallo. (1999). The dysphagia
outcome and severity scale. Dysphagia. 14:139-145.
Pearlman, A.L., Ettema, S.L., & J. Barkmeier. (2000). Respiratory and
acoustic signals associated with bolus passage during swallowing.
Dysphagia. 15:89-94.
Swigert, N. (2000). The source for dysphagia updated and expanded. East
Moline, IL: Linguisystems.
Tohara, H., Eiichi, S., Mays, K.A., Kuhlemeier, K., & J.B. Palmer. (2003).
Three tests for predicting aspiration without videofluroscopy. Dysphagia.
18: 126-134.
References
•
•
•
•
•
•
•
References- Rehabilitation
Clark, H.M. (2003). Neuromuscular treatments for speech and swallowing:
A tutorial. American Journal of Speech-Language Pathology. 12:400-415.
Corbin-Lewis, K., Liss, J.M., & K.L. Sciortino. (2004). Clinical anatomy and
physiology of the swallow mechanism. Clifton Park, NY: Thompson/Delmar
Learning.
Dworkin, J.P. (2002). Differential diagnosis and treatment of motor speech
disorders. Short-course presentation. OSLHA Convention. Dayton, Ohio.
Fink, B.R. & R.J. Demarest. Laryngeal Biomechanics. Cambridge, MA:
Harvard University; 1978.
Freed, M.L., Freed, L., Chatburn, R.L., & M. Christian. (2001). Electrical
stimulation for swallowing disorders caused by stroke. Respiratory Care.
46:5, 466-474.
Hagg, M., & B. Larsson. (2004). Effects of motor and sensory stimulation
in stroke patientrs with long lasting dysphagia. Dysphagia. 19:219-230.
References
•
•
•
•
•
•
•
•
•
References- Rehabilitation
Huckabee, M.L., & Pelletier, C.A. (1999). Management of adult neurogenic dysphagia. San
Diego, CA: Singular Publishing Group.
Kim, J. & C. Sapienza. (2005). Implications of expiratory muscle strength training for rehabilitation
of the elderly:Tutorial. Journal of Rehabilitation Research and Development. 42:2, 211-224.
Robbins, J. Et. Al . (2005). The effects of lingual exercise on swallowing in older adults. J Amer
Geriatrics Soc. 53:1483-1489.
Robbins, J. et. Al (2005- in press). The effects of lingual exercise in stroke patients with
dysphagia.
Saleem, A.F. et. Al. (2005). Respiratory muscle strength training: Treatment and response
duration in a patient with early idiopathic parkinson’s disease. NeuroRehabilitation. 20: 323-333.
Sapienza, C. (2005). Respiratory Muscle Strength Training. Presentation- Charleston Swallowing
Conference.
Shaker, R., Kern, M., Bardan, E., Taylor, A., ET.Al (1997). Augmentation of deglutitive upper
esophageal sphincter opening in the elderly by exercise. American Journal of Physiology. 272:
G1518-G1522.
Stephanakos, K. (1997). Deep pharyngeal neuromuscular stimulation. Seminar. Lexington, Ky.