Difficulty moving food from the mouth to the stomach. Patients with dysphagia may be unable to recognize food, difficulty placing it in the mouth, inability to control saliva, or food in the mouth.
Entry of food or liquid into the airway below the level of the true vocal folds, usually there is choking and coughing in response to aspiration.
Entry of food or liquid into the larynx at some level down to but not below the level of the true vocal folds.
Define silent aspiration
Food or liquid below the level of the true folds due to reduced sensitivity who do not choke or cough in response to this aspiration.
What are the anatomic structures of the oral cavity?
lips anteriorly, the teeth, hard palate, soft palate, uvula, mandible, floor of the mouth, and faucial arches, anterior and lateral sulcus.
What is the purpose of saliva?
To maintain oral moisture, prevents tooth decay and helps digestion.
________ can be used to help observe tongue function and measure oral transit time and motion of the hyoid bone.
Ultrasound (not used often clinically)
What are the drawbacks to using ultrasounds?
Cannot visualize pharynx, limited application because of the things you can't see.
What does FEEs stand for?
Flexible fiber optic examination.
Can FEES show you the oral stage of swallowing?
Can VP closure be observed using FEES?
What is the problem with FEES?
It's difficult to define exactly whats going on because its directed largely at motor activity.
FEES endoscopy can be performed with a __________ or __________ scope?
Rigid or flexible
Can you swallow with a rigid scope in place?
With Endoscopy the patient has to help ____________ the scope, so this is _______ great for young children with cognitive disorders, dementia or those who can't follow directions well.
What does information from FEES give you?
Great upper view of the pharyngeal anatomy.
What is the advantage of using FEES?
What is videofluroscopy most frequently used for?
The assessment of the oropharyngeal swallow, movement of the bolus, frame by frame analysis
Does Videofluroscopy use radiation?
Yes, but low doses
What does the modified Barium Swallow tell us?
Helps us to understand why we aspirate
What does the barium taste like?
Chalky, can be grainy in texture.
Scintigraphy is a __________ __________ test?
What has Scintigraphy been largely used for?
For research purposes rather than clinical purposes, rescanned every 15-20 min waiting for reflux. (Non-imagining)
Cervical Auscultation is what?
Listening to and recording the sounds of swallowing. (Not done a lot)
With Cervical auscultation you are listening for the ________ and ________ of the ______ and _________ _____ ______.
Click and chunk of the ET and the upper esophageal sphincter.
What are the downfalls of Cervical Auscultation?
You may not be able to tell the difference between normal and disordered swallow.
What does Pharyngeal Manometry measure.
Allows measurement of the bolus pressures and how the pharynx contracts.
Lateral and interior sulci are in the __________ __________?
What purpose does the larynx serve?
Protection of the airway????
What are the characteristics of the esophagus?
- Collapsed muscular tube 23-25 cm long
- Has a sphincter or valve at each end
- 2 layers of muscle
- It passes through the neck, then the chest, through the diaphragm to attach to the stomach.
Explain the Oral Preparatory Phase of swallowing?
- Its voluntary
- You can breathe at this stage
- Food is chewed and mixed with saliva
- A bolus is formed and kept in the front of the mouth
- Labial seal is maintained to prevent food from leaking out of the mouth
- Buccal muscles are tense
- Duration is variable
Explain the oral transport stage?
- Starts with jaws and lips closed and tongue tip at the alveolar ridge.
- Food is moved to the back of the mouth
- When the bolus passes the anterior faucial pillars/touches the posterior wall of the pharynx, the oral stage ends and the pharyngeal stage begins.
Explain the pharyngeal stage?
- Its involuntary
- Most critical stage of the swallow
- Airway closure necessary to prevent the bolus from entering the respiratory system.
- Receptors send sensory info to the medulla via CN IX
- Phalatopharyngeal folds pull together to form a slit
- Bolus passes through this slit
- Velum raises
- Glottis folds down
- Tongue is retracted to keep food from reentering the mouth.
- The pharyngeal stage ends when the cricopharyngus muscles relaxes, allowing the bolus to enter the esophagus.
Explain the Laryngeal substage?
- 3 actions occur simultaneously to protect the airway.
- The larynx and the hyoid bone are both pulled upward and forward.
- The true vocal folds adduct
- The epiglottis drops down over the top of the larynx, protecting the airway and diverting the bolus into the pyriform sinuses.
Explain the esophageal stage?
- Bolus is moved down the esophagus via peristaltic wave motion with the help of gravity.
- At the beginning of this phase the larynx lowers, returning to its normal position.
- The cricopharyngus muscle contracts to prevent reflux and respiration fumes.
- Last about 8- 20 secs
90% of the swallow occurs during ___________?
Food that is left behind in the mouth or the pharynx after the swallow is called?
Food from the esophagus into the pharynx and or from the pharynx into the nasal cavity-reflux.
Aspiration should be kept to a minimum but no clear guidelines exist as to the amount of aspiration that can be tolerated before pneumonia occurs.
Any patient who aspirates over ____% of a bolus of a particular consistency should be restricted from eating that consistency orally?
Safety of Patient for oral feeding include?
- identify presence of aspiration
- define the etiology of the aspiration
- Examine immediate effects of treatment procedures/design appropriate therapy for the patient
- Determine the best method of nutritional intake (oral, non oral, combo)
________ ________ are procedures to improve the oral stage of swallow (includes textures, placement etc.)
___________ ___________ are techniques to improve triggering of the swallow.
Bolus enters the mouth via concentrated oral motor suction and suction continues as soft palate elevates to close off nose, and then swallow is triggered.
Lips are sealed-tongue propels consecutive swallows from oral cavity to facial archers and triggers a swallow.
Breath is held to close larynx, larynx is pulled forward, and material is dumped into oral cavity and moves by gravity into the esophagus.
Swallow should be triggered whenever the head of the bolus passes any point between the anterior faucial arches and the point where the tongue bases crosses the lower rim of the mandible. T or F
The exact spot of where the swallow occurs varies by ________ and __________.
Age and physiology
Human _________ swallow without something in their mouths?
Cannot (water/liquid, saliva, food) But you do not automatically swallow just because these things are in your mouth.
When can mucosal injury occur?
When a patient uses potassium chloride tablets and other drugs.
What do you look at during a physical examination?
- look at oral motor and laryngeal mechanisms
- direct observation of lip closure, jaw closure, chewing and mastication, tongue mobility, and strength, palatal and laryngeal elevation, salivation and oral sensitivity is necessary.
- Check patients level of alertness and cognitive status
- inspect the oral cavity and the pharynx for mucosal integrity and dentition.
- Examine the soft palate for position and symmetry during phonation and at rest.
- Evaluate pharyngeal elevation
- Check the gag reflex
- Evaluate the cervical auscultation
- Assess respiratory function
- Final step is direct observation of the act of swallowing.
_____________ Swallowing disorders are encountered more frequently in rehabilitation medicine than in most other medical specialties.
What is the leading cause of neurologic dysphagia?
The pockets or side cavities created by the normal juxtaposition of structures are important in swallowing because in patients with swallowing disorders, these natural cavities or spaces are usually where food or liquid collects and may remain after the swallow.. These are called?
Valleculae and pyriform sinuses.
The tongue is composed almost entirely of __________ _________ going in all directions.
For swallowing the tongue can be divided into an ____________ portion and a __________ portion.
Oral and pharyngeal
The oral tongue consists of the ___________, ___________, ____________, _________, and __________.
Tip, blade, front, center and back
Where does the oral tongue end at?
Where does the pharyngeal portion of the tong begins at the __________ ___________ and extends to the __________ bone?
Circumvallate papillae, extends to the hyoid bone
The tongue base is under ____________ neural control coordinated in the brainstem, but can be under some degree of voluntary control.
The oral tongue is ________ during speech and during the oral stages of swallow and is under _____________ or __________ neural control.
Active, cortical or voluntary
The opening into the larynx is known as the ___________ ___________ or laryngeal additus and is bounded by the epiglottis, aryepiglottic folds and arytenoid cartilage and ends at the superior surface of the false vocal folds.
The false vocal folds are ________ to but __________ with the true vocal folds.
Individuals of all ages should trigger the pharyngeal swallow by the time the bolus head reaches the point where the _________ crosses the tongue base.
In some neurologically impaired patients the pharyngeal swallow is not triggered until the material has fallen into the _________ __________.
What should therapist be able to explain to a patient?
- Why each procedure would or would not be appropriate for the patients particular swallowing problem, in the context of his age, language, cognition, and medical diagnosis.
____________________ is used more in research than in clinical situations.
What technologies can be used to image the oropharyngeal region?
Ultrasound, videoendoscopy and videofluroscopy.
_______________ enables visualization of food being swallowed, but not the anatomy and physiology of the oropharyngeal region during deglutition.
What techniques can be used to observe tongue function and to measure oral transit times, as well as motion of the hyoid bone?
Ultrasound (cannot visualize the pharynx)
What technique is used to examine the anatomy of the oral cavity and pharynx from above and to examine the pharynx and larynx before and after swallow?
Videoendoscopy (endoscopy does not visualize the oral stage of swallowing)
Because treatment for oropharyngeal swallowing disorders is directed largely at the motor activity during the swallow, ______________ makes it difficult to define the exact nature of the patients physiologic disorder and the effectiveness of treatment strategies?
_____________ evaluation recorded on videotape can provide and excellent superior view of the pharyngeal anatomy, including the relationship between the epiglottis, airway entrance, valleculae, aryepiglottic folds and pyriform sinuses.
Videoendoscopy (no radiation)
The most frequently used technique in the assessment of oropharyngeal swallow is ______________________.
Videofluroscopy (can provide a frame-by-frame analysis)
______________ studies provide information on bolus transit times, motility problems, and amount and, most important, etiology of aspiration.
This type of technique records the bolus during swallowing and is recorded by a gamma camera.
With this technique the amount of aspiration and residue can be measured, but the physiology of the mouth and pharynx is not visualized so that the dysfunctions causing the residue and aspiration are not identified.
Scintigraphy (good for esophageal aspects of swallowing and reflux disease.) (used more for research)
Nonimaging procedures provide a wide variety of types of information about swallowing but do not result in pictures of the swallowing process or the food being swallowed. T or F
These procedures result in amplitude over time displays of the swallow parameters being examined, such as pressure generated at specific locations in the pharynx, or amount of electrical energy generated by muscle contractions.
What is used to measure the electrical activity in muscles for a biofeedback technique during therapy for patients with dysphagia?
Electromyography (also used is surface electromyography)
______________ is designed to track vocal fold movement by recording the impedance changes as the vocal folds move toward and away from each other during phonation.
A clinician can use a _____________ to listen to respiration and define the inhalatory and exhalatory phases of the resp. cycle as well as the moment when the pharyngeal swallow occurs and in which part of the resp. cycle the swallow occurs.
Stethoscope (Cervical Auscultation)
___________ _____________ requires solid-state pressure sensors that have a fast enough frequency response to react to the rapid pressure changes during the pharyngeal swallow is called what?
Pharyngeal manometry allows measurement of ______________ pressures and the timing of the pharyngeal contractile wave.
If understanding the patient's pharyngeal anatomy is the question, such as in postsurgical oropharyngeal cancer patient then what procedure should be used?
If defining the presence but not necessarily the cause of aspiration of saliva is the desired goal, then what procedure should be used?
Flexible Fiberoptic Videoendoscopy (FEES)
If understanding the pharyngeal physiology in relation to symptoms such as aspiration is the issue of interest, then _____________ should be used?
If the pressure generated during swallowing is the information needed then ___________ ____________ should be used in combination of maybe ___________.