Dysphagia Exam 2: Instrumental Evaluation of Dysphagia

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Dysphagia Exam 2: Instrumental Evaluation of Dysphagia
2014-07-26 17:16:53
instrumental evaluation dysphagia

Different techniques and instrumental evaluations
Show Answers:

  1. What is manometry?
    What does it assess and how?
    • Assessment of esophageal motility, pressures, coordination
    • Sphincter functions, motility disorders (achalasia, esophageal spasm, motor abnormalities)
    • Thin catheter inserted transnasally--wet and dry swallows, LES and UES measures
  2. What is videomanometry?
    What is it used for?
    • Manometry plus video recording
    • ID disorders, effectiveness of postures
  3. What is ultrasound and what/how does it measure?
    • Dynamic image of soft tissues using sound waves
    • Soft tissue of oral cavity and oropharynx only
    • Bolus prep and transfer- non-invasive
    • Tongue, intrinsic tongue and mouth
  4. MRI--what does it assess?
    • Pharyngeal stage; oropharyngeal area, laryngeal lumen
    • Poor resolution, ingest contrast, costly and in supine position
  5. Scintigraphy: What is it? Pros/cons
    • Tracks movement of bolus; quantify residual bolus; ingest food with radionuclide material
    • Nuclear medicine test with trained personnel
    • Cooperative patient
  6. Modified Barium Swallow Study
    What is AKA? What is NOT?
    • VFSS, deglutition study, MBS, cookie test
    • DOES NOT/IS NOT: Examine esophagus, use large amounts of liquid, patient positioned supine, AP viewing only, Follows bolus
  7. MBS- Dx Rehab Test
    ID of: (3)
    Evaluation of efficacy of (3):
    • Normal/abnormal anatomy
    • Discrete structural movements
    • Temporal coordination of anatomic movements relative to bolus propulsion

    Adjustments to bolus volume consistency, rate of delivery, adjustments in positioning, maneuvers
  8. MBS equipment: Name some
    • Spoons/cups/straws
    • Puree/solids with BaSO4
    • Premixed BaSO4 liquids of varying viscosity
    • BaSO4 tablet or pill
    • Digital recording
    • Microphone
    • Lead shielded protection
    • Time/date generator
    • Table/chair
  9. Standard procedure for MBS
    • ID structures (lips, velum, posterior pharyngeal wall, 7th cervical vertebrae)
    • Deviations in structures
    • lateral view
    • AP view (visualize bilateral structures, tvc visualization) 
    • Oblique view
  10. Standard procedures/measures
    • Facility based
    • MBSImP (rating of 17 components); training required, good reliability 
    • Penetration-Aspiration Scale (good reliability with MBS and FEES)
    • Dysphagia Outcome Severity Scale (DOSS); rate severity on 7 point scale using objective measure (like FIM); recommendations for diet, independence level and nutrition
  11. MBS procedure cont. 
    Presentation of liquid first (mL?)
    Bolus measured into spoon
    Request hold in mouth, observe leakage, then swallow--what to look for?
    If aspiration/penetration, trial strategies/maneuvers
    • 1, 3, 5, 10
    • Presence of aspiration/penetration, use of dry swallow to clear residue (spontaneous or not), cough? productivity, timing
  12. MBS procedure cont.
    Cup drinking if no significant aspiration or residue
    Straw drinking, saliva swallow to reduce coating
    Puree and masticated bolus: 2 parts pudding/1 part barium; 2 trials, third if 1st two are different; ¼ cookie with barium paste, chew and swallow when ready, other foods if necessary
    Pill-adminster pill if ℅ of difficulty
  13. Variations to MBS
    Bolus volume (4)
    Bolus viscosity (3)
    Delivery methods/devices (3)
    Coordination & propulsion deficits, based on capacity of structural barriers to penetration (vallecular space, lateral channels, pyriforms), premature spillage--capacity of pharyngeal barriers, can speed initiation, increase tongue to PPW duration, increase laryngeal closure, increase sustained PES opening, increase # swallows, increase effort

    • Slow bolus flow just enough that trigger occurs with bolus at or above vallecular space, thin nectar thick, honey thick, pudding thick
    • Increase tongue effort, increased amplitude of sEMG sub mental signal, increased peak pharyngeal pressures, decreased delay, increased hyoid elevation, increased laryngeal elevation

    • Presentation to stronger side based on AP view, larger volumes for oral sensory deficits
    • Straw of reflexive suck/swallow is more effect than volitional
  14. **TEST**Delivery methods/Indications (Give indication for each)
    Small volumes per swallow (5 mL)
    Large volume per swallow
    Syringe or glossectomy spoon
    • Severe/mulitple pharyngeal/laryngeal abnormalities
    • Oral sensory deficits
    • VPI (can't use straw)
    • suck/swallow better than volitional
    • severe tongue prep and bolus formation signs
    • Pharyngeal/laryngeal abnormality
    • Isolated problem with PE opening 
    • Sensation losses or reductions
  15. Postural changes
    Head Rotation
    To what side?
    What view?
    For what? How does it work?
    • Toward weak side, test via AP view
    • Unilateral pharyngeal weakness; diverts bolus toward intact side (squeezes off damaged site)
    • Can reduce resting pressure in PES aiding in opening
  16. Postural changes
    Chin tuck
    For what?
    How does it work?
    • Reduce aspiration/penetration due to pharyngeal delay or premature spillage
    • Widens valleculae, improves laryngeal vestibular closure, brings PPW closer to tongue base
  17. Postural changes
    Head tilt backward
    For what?
    How does it work?
    Who should you not do this with?
    • Gravitational drainage of food out of oral cavity
    • Poor tongue control or glossectomy
    • May need supraglottic swallow
    • NEVER do this with patients with reduced airway protection
  18. Posutral changes
    Lying supine or on one side
    For what? 
    How does it work?
    • Reduced pharyngeal contraction (reside throughout pharynx) 
    • Eliminates gravitational effet on pharyngeal residue
    • Maintains residue in pharynx
  19. Postural changes
    Head tilt
    For what?
    How does it work?
    Unilateral oral and pharyngel weakness of same side; directs bolus down stronger side
  20. Postural changes
    Head rotated to damaged side plus chin tuck
    For what?
    How does it work?
    • Unilateral laryngeal dysfunction
    • Places extrinsic pressure ont thyroid cartilage, increasing adduction
  21. **TEST** Compensatory Techniques Compensation/Indication (Give each indication)
    Neck flexion (chin tuck)
    Neck rotation (head turn)
    Supraglottic swallow
    Consecutive throat clear swallow
    Multiple swallow
    Nose occlusion
    Rate of intake slowed
    • Laryngeal protection problems
    • Unilateral pharyngeal or laryngeal weakness signs
    • Laryngeal protection problems (reduced or delayed); delayed initiation of pharyngeal swallow (volitional closure of vf)
    • Intermittent wet hoarseness sign
    • Pharyngeal weakness signs
    • Signs of VPI
    • Cognitive limitations and/or sensory loss
  22. Increasing sensory input (tactile, auditory, visual)
    • Reduced recognition of food
    • Slowed oral transit due to apraxia
    • incase downward pressure of spoon against tongue blade during bolus delivery
    • Cold, textured, strong flavored bolus (lemon)
    • Bolus that requires chewing 
    • Thermal tactile sensation to anterior faucial arches--when delay occurs on 2 consecutive swallows
    • Larger volume bolus
  23. Voluntary Airway Protection Maneuvers
    Supraglottic Swallow 
    Why is it used?
    • Reduced or delayed laryngeal vestibular closure or delayed initiation of swallow); to protect airway but must try under VFSS
    • Take deep breath and hold; Keep holding breath while swallow; immediately after swallow cough or clear throat
  24. Voluntary Airway Protection Maneuvers
    Super Supraglottic Swallow
    • Reduced laryngeal vestibular closure
    • Close airway entrance by tilting arytneoid cartilages toward base of epiglottis before and during swallow
    • Can improve tongue base retraction
    • Can be used as exercise
    • Inhale and hold breath very tightly, bearing down
    • Keep holding breath as you swallow, immediately after swallow, cough
  25. Voluntary Airway Protection Maneuvers
    Extended supraglottic swallow
    • Severe reductions in tongue mobility or severely reduced tongue bulk due to surgical resection
    • "Dump and swallow"
    • Begins with small amounts then increases w/ practice

    Hold breath tightly, take bolus into mouth, continue to hold breath and toss head back "dumping" liquid into pharynx as whole, swallow 2-3 times to clear majority of liquid while holding breath; cough to clear residue from pharynx
  26. Voluntary Airway Protection Maneuvers
    Effortful swallow
    • Engagement of pharynx
    • Reduced posterior moment of tongue base, decreased pharyngeal contraction, decreased pharyngeal stripping 
    • Effort increases posterior tongue base movement
    • Squeeze hard all the way through the swallow
  27. Voluntary Airway Protection Maneuvers
    Mendelsohn Maneuver 
    • Reduced hyolaryngeal motion
    • Sustain elevation of larynx during swallow, augment UES opening, teaching required
  28. 8 point Penetration-Aspiration Scale
    What is the premise?
    Relevant factors? (general, 7)
    • Presence of aspiration is clinically relevant
    • Aspiration does not affect all patients in same manner
    • Use w/ VFSS, present/absence, before, during, after swallow, amount of aspiration, how fair into airway does material pass, ability of patient to expel aspirated material, effect depends on pulmonary, oral, general health, mobility, cognition, frequency of aspiration, and type of material aspirated
  29. Describe the A-P scale
    • Multidimensional
    • Depth into airway (1-4)
    • Response to bolus (3)
    • Aspects of bolus expulsion (3)

    • Ordinal
    • Score of 1-8 with 8 being most severe, 1 is best swallow
  30. Describe the A-P scale qualitatively. (Remember 1 is best swallow, 8 is more severe)
    • 1. Material does not enter airway. 
    • 2. Material enters airway, remains above vf, is ejected from airway.
    • 3. Mateiral enters airway, remains above vf, is not ejected from airway.
    • 4. material enters airway, contacts vf, is ejected. 
    • 5. Material enters airway, contacts vf, is not ejected
    • 6. Material enters airways, passes below vf, is ejected into larynx or out of airway
    • 7. material enters airway, passes below vf, is not ejected from trachea despite effort
    • 8. material enters airway, passes below vf, no effort made to eject
  31. What are potential uses of PenAsp scale?
    • Requires better observation of VFSS
    • Better communication among clinicians regarding client similarity
    • More precise reporting of aspiration/penetration
    • Better to detail aspects of aspiration/penetration (depth of aspiration, bolus expulsion)
    • Outcome measure for research or clinical practice
    • *Dont look at the barium, look at the structures