Swallowing Management
in head/neck rotation, should you turn toward weak side or strong side?
Turn toward weak side so bolus goes through strong side
These are the four phases of swallowing
What are oral prep, oral transport, pharyngeal, and esophageal phases
what are the 2 main aetiologies of dysphagia?
1. Neurologic (acquired or progressive/degenerative)
2. Mechanical/structural
What is it called when there is not enough external respiration
Hypoxemia
What are some limitations of a clinical swallowing assessment
- can't evaluate UADT
- can't evaluate timing of events with pharyngeal phase
- can't evaluate pharyngeal strength
- residue status is unknown
- aspiration status might not be definitely known
What is the maximum length of time a nasogastric (NG) tube should be used for?
No longer than 4-6 weeks MAX
This cranial nerve is responsible for laryngeal closure during the pharyngeal phase
What is the vagus nerve (CN X - RLN)
If CN IX neuropathy, what might you expect to be disrupted in swallow function?
impaired oropharyngeal sensation resulting in delayed triggering of pharyngeal swallow
What are the symptoms and risk factors of COPD
symptoms - productive cough and sputum, dyspnea (SOB)
Risk factors - tobacco, occupation, indoor/outdoor pollution
What are the 6 clinical indicators that significantly predict risk of aspiration?
- abnormal gag reflex
- dysphonia
- dysarthria
- cough after swallow
- voice change after swallow
What postural adjustment recommendation would you make to facilitate airway protection during swallowing where the tongue base is in a more protective position over the larynx close to the pharyngeal wall?
Head/chin down
Where is the "swallow centre" located?
Medulla
What do you call the sensation of something in throat and what might it be associated with?
Globus pharyngeus, often associated with reflux or esophageal motility disorder
What is the most common respiratory pattern with swallowing according to Martin-Harris et al. (2005)
Exhale - swallow - exhale
invasive (radiation exposure), lack of correspondence to real-life eating context, poor visibility of secretions, can't assess sensation or pressure, dependent on image quality
What is the indication for teaching super supraglottic swallow and what are the steps?
Indication: Someone with poor airway protection, designed to close entrance to airway voluntarily
1. hold material in mouth
2. breathe in through nose, then hold breath tightly
3. keeping breath held tight, push hands hard against table/each other
4. keep pushing hands as you swallow
5. release breath with sharp cough, then swallow again
which region of the UADT is known to be most reflexogenic in triggering the swallow?
oropharynx - PPW, LPW, posterior faucial pillar
What is the PAS score for when material enters the airway, contacts the vocal folds, and is ejected from the airway?
PAS = 4
When material enters the lungs and causes inflammation +/- infection this is called:
Pneuomonitis
what are the indications for VFSS over FEES?
to visualize submucosal anatomy, assess oral stage and BOT movement, UES stricture, hypertonicity, to examine movement of multiple structures at the height of the swallow, if laryngectomy
What are the indications for an effortful swallow maneuver vs. Mendelsohn Maneuver?
Effortful Swallow - residue
Medelsohn - UES not opening, residue in pyriform, better airway protection
Which cranial nerve is responsible for the opening of the UES and what 4 things does UES opening depend on?
CN X (RLN)
1. relaxation of cricopharyngeal muscle
2. tissue compliance
3. traction from movement of hyolaryngeal complex
4. intrabolus pressure
What are the clinical symptoms of Zenker's Diverticulum and what is the best course of treatment?
Clinical Symptoms: dysphagia with solids and liquids, regurgitation of undigested foods, coughing/aspiration, halitosis
*Use VFSS for diagnosis
Treatment: diverticulectomy and/or cricopharyngeal myotomy
What are the best independent predictors of aspiration pneumonia?
tube fed
dependent for oral care
dependent for feeding
current smoking
# of meds
# of decayed teeth
multiple medical diagnoses
List some limitations of FEES
vasovagal response (vomit, faint), nosebleed
can't assess oral chamber or esophagus
white-out at height of swallow
penetration/aspiration during swallow is inferred
can't judge degree of BOT retraction, pharyngeal constriction, UES opening, HLE