Cranial Nerves
Cranial Nerve V, VII, IX, X, XII
nerves involved in the swallow
any perceptible change in bodily function that a patient notice
symptom
Cortical, Diffuse neurological deficits
•Affects behavioral control • Prevalence 60 – 90% •Both oral and pharyngeal deficits
•Recovery of function is good
• Severity is strong predictor of recovery in the next 3-4 months
•High PNA rate
TBI
surgery
radiation therapy (RT)
chemotherapy
a vertical incision is made between the second and third tracheal rings so that the tube is below the level of the VF to allow the team to access the lungs for suctioning.
Tracheostomy Tube
●Education of case management member, family, and client
●Improving the quality of life
● Special food prep, diet restriction, supervision, posture, and mealtime environment change
●Feeding tubes do not promote quality of life, compassion, or significant benefit to most patients with aphasia
Treatment for Dementia
direct view of upper airway structures, including vocal cords
done at bedside
can see in all directions while scoping
immediate results: can patient eat safely or not?
easy to repeat often
no exposure to radiation
FEES Strengths
total oral diet with multiple consistencies but requiring special preparation/compensation
Level 5
(1) Thicken liquids result in less aspiration among patients (2) thicker liquids have a physiologic effect on swallow mechanism (3) delay onset of swallowing and impaired oral control of thin liquids
Why do we thicken liquids
Contrast enter the airway, contacts the VFs, and is not ejected from the airway
Score 5
If damaged loss of sensation, inability to move mandible (lower jaw)
damage Trigeminal Nerve (5)
malnutrition, failure to thrive, fatigue, aspiration, death
symptoms
Oral stage
- Lingual Tremors
- Repetitive tongue pumping
Pharyngeal stage
- Vallecular retention
- Aspiration
Sensory Deficits
Pharyngoesophageal segment dysfunction
Parkinson
removal of <50% of stricture the patient will not have permanent significant swallowing problems
50% rule
a short-term - long plastic, flexible tubes that are inserted through the mouth, through the vocal folds, and into the trachea to aid the patient in respiratory distress. Designed to be connected to a respirator to help the patient breathe
ET
Throat clear, chin tuck, head turn, head tilt found effective at reducing penetration and/or aspiration in 79% of ALS patients
-Other strategies: liquid wash, double swallow, effortful swallow
Longer mealtime duration- Take smaller, more frequent meals throughout the day, add high-calorie snacks
Difficulty chewing- moisten foods with gravies and/or sauces, smaller bite sizes, downgrade to a softer consistency
Treatment/management for ALS
exposure to radiation (minimal)
patient size may be an issue
transport to radiology
cost (more expensive than FEES)
barium (taste)
secretion management (hard to see)
interrater reliability
variability clinician to clinician
patient medical status may be an issue
MBS Weaknesses
FOIS
Functional Oral Intake Scale
IDDSI
International Dysphagia Diet Standardization Initiative
Constrast enters the airway, remains above, the VFs, and it not ejected from the airway (is seen in airway after swallow)
Score 3
Controls sensation of the larynx, base/back of tongue, pharynx, palate, and muscles
Vagus nerve (10)
what is objective, measured, or observed;
dysphonia, dysarthria, abnormal gag reflex, cough after the swallow
signs
●Unexplained weight loss
●Oral-stage dysfunction (oral prep and oral phase)
●Pharyngeal-stage dysfunction (slowed or delayed)
●Major and minor aspiration
●Feeding limitations
Dementia
swelling of mouth, throat, difficulty breathing, difficulty with mastication, difficulty with swallowing, facial disfigurement, numbness face, neck, throat, decreased mobility in the neck and/or shoulders, decreased function of the thyroid
side effects of surgery
has holes in tubing
Fenestrated
Effortful swallow- increased base of tongue retraction,
reduced pharyngeal residue
Chin tuck- improved airway protection, reduced penetration aspiration
Expiratory muscle strength training- forcefully exhaling into a small portable handheld device set to a specific resistance level. -improves cough and airway protection
-taking smaller meals throughout the day to help with fatigue, adding supplemental nutrition Ensure/Boost
Lee Silverman Voice Treatment
Treatment for Parkinson
Pt cooperation for scoping procedure
facial trauma, difficult airway
whiteout at exact moment swallow occurs
must rely on pre and post swallow info to speculate why dysphagia present (cannot see pharyngeal function)
safety issues: vasovagal response (fainting)
complications (blood)
FEES Weaknesses
tube dependant with minimal attempts of food/liquid
Level 2
For: reduced laryngeal elevation plus reduced UES opening plus timing How: Swallow normal, feel larynx lift to height of swallow; push tongue forcefully against roof of the mouth, feel and hold larynx up after it lifts, finish swallow (longer elevation of larynx normalizes timing of pharyngeal swallow)
mendelsohn maneuver
Constrast enters the airway, remains above the VFs, and is ejected from the airway (not seen in the airway at the end of the swallow)
Score 2
Transmits sensation to the tongue, pharynx and soft palate provides a sensation of taste to back 1/3 of tongue, related to dry mouth
Interview/medical chart, oral mech exam/physical inspection, the trial of food/liquids, subjective with valid measures
Components of CBSE
reduced ability to initiate a saliva swallow delayed triggering of pharyngeal swallow, incoordination of oral movement, increased pharyngeal transit time, reduced pharyngeal constriction, aspiration, impairment lower esophageal sphincter relaxation
*HINT: these happen after what occurs
AFTER a hemisphere stroke
acute toxicity, late effects, late toxicity, mucositis (painful), Xerostomia (dry mouth), sensory change (taste/smell), fibrosis (tight), trismus (hard to open), neuropathy, stricture (narrowing), loss of appetite, edema, fungal infection, dental change
Side effects of RT
solid tubing without cuff
Non Fenesrated
short term, adjust not change, maintain status quo
compensation
gold standard
-evaluating effectiveness of swallowing postures/maneuvers
-view of oral, pharyngeal, upper esophageal phase
-evaluates the integrity of airway protection before, during, and after the swallow
-best at detecting micro-aspiration (laryngeal closure)
best at determining why a patient is having dysphagia
MBS Strengths
total oral diet with multiple consistencies without special preparation, but with specific food limitations
Level 6
For: Reduced BOT retraction and pressure in pharyngeal phase, anterior/superior hypolarnygeal movement Food residue in valleculae How: Swallow hard w tongue pushed up on roof of mouth increases BOT movement to clear bolus from valleculae
Effortful swallow
Contrast enters the airway, crosses the plane of the VFs, and is not ejected from the airway
Score 6
If damaged paralysis of facial muscles. Poor lip strength. Dry mouth. No taste from 2/3 of tongue
Facial nerve (7)
To define the potential cause, to establish a working hypothesis to define the disorder, to develop a tentative tx plan, to develop a potential list of ?’s for further study, to establish the readiness of the patient to cooperate with any further testing.
Reasons to complete a bedside swallow
Oral Stage: Leakage, mastication, bolus formation, bolus transport, residual pooling
Pharyngeal State: nasopharyngeal regurgitation, valleculae pooling, piriform sinus pooling, airway spillage, ineffective airway clearance, shortness of breath
oropharyngeal swallowing deficits ALS
air cannot get to VF aspiration is less likely
cuff inflated
safety (aspiration)
adequate (nutrition)
expand (consistencies)
prevent
socialization
QOL
recurrence (cancer)
limit functional deterioration
facilitate recovery
objectives of treatment
standardized barium (contrast)
thin (mix with water)
nectar
honey
pudding
cracker (use pudding past)
total oral diet with single consistency
Level 4
No contrast enters the airway
Score 1
If damaged inability to position food for chewing resulting in food getting pocketed in cheeks
damage to hypoglossal nerve (12)
drooling, wet vocal quality, weight loss, abnormal cough
signs and symptoms
allows more air leakage around trach, may get some voicing, decreased airway protection
cuff deflated
Rehabilitation
nothing by mouth
Level 1
Contrast enters the airway crosses the plane of the VFs, is not ejected from the airway and there is no response to apsiration.
Score 8
Barnes Jewish Hospital Stroke Dysphagia Screen
Modified Mann Assessment of Swallowing Ability (MMASA)
Toronto Bedside Swallowing Screening Test (TOR-BSST)
Emergency Physician Swallowing Screening (not us)
Water Test
screenings to detect aspiration
swallowing postures compensatory strategies
normal no restrictions
Level 7
Contrast enters the airway, crosses the plane of the VFs, and is not ejected from the airway despite the effort
Score 7
Swallowing maneuvers compensatory strategies
1.Supraglottic Swallow
2.Super-supraglottic Swallow
3.Effortful Swallow
4.Mendelsohn Maneuver
5.Tongue Hold Maneuver
Aspiration occurs
6, 7, 8