Basics
True or false: Dysphagia is a disease
FALSE. It is a SYMPTOM
NOT a feeding (placement of food in mouth) or eating disorder
Definition of Penetration
Above and to the level of the vocal folds
Structures involved in bolus containment
Cheeks, lips, tongue, velum, PES/UES
True or False: before a person can swallow, the the individual must recognize that something edible is present and then transfer that something into the mouth.
TRUE. Cognition and feeding
What phase is mastication in and what happens during?
Oral Phase
- rotary jaw movements break down food (cyclic jaw movements), buccal tension, saliva softens food/starts digestive process
Goal of dysphagia treatment
- Restoration of healthy swallow function?
- Maximize OQL and minimize complications?
- Palliative?
- No intervention?
Definition of dysphagia
“Impairment of emotional, cognitive, sensory, and/or motor acts involved with transferring a substance from the mouth to the stomach, resulting in failure to maintain hydration and nutrition, and posing a risk of choking and aspiration” (Tanner, 2006, p. 16)
Structures involved in bolus preparation/mastication
Cheeks, mandible, salivary glands, teeth, tongue
True or False: A swallow is a positive-pressure driven event
TRUE
Definition of deglutition
The act of swallowing, including 1) oral (preparation and transfer), 2) pharyngeal, 3) esophageal stages
Categories causing dysphagia and an example of each
1. Neurological etiologies
2. Mechanical/structural etiologies
3. Iatrogenic etiologies
4. Behavioral etiologies
Signs/symptoms of dysphagia
- cough, voice change, # of swallows, dysarthria / dysphonia, abnormal/absent gag reflex, nasal regurgitation, CN dysfunction, poor secretion management, oral residue
considerations for a cough: why, voluntary, effective, reliability of
Structures involved in bolus transport
Palate, tongue, soft palate (velum), base of tongue, pharyngeal walls, PES/UES, esophagus
Definition of EFFICIENCT in relation to dysphagia
How fast did the bolus travel? Was anything left behind?
- timely, no material remains
Traditional 3-phase model of swallowing
Voluntary
- Oral - containment on midline of tongue, preparation: mastication, transport: lingual stripping posteriorly against hard palate
Involuntary
- Pharyngeal -
- Esophageal -
Consequences of Dysphagia
Medical: under/malnutrition, dehydration, pulmonary complications, delayed oral intake, feeding tubes, weight loss/muscle wasting, mortality
Clinical: increased healthcare costs, increased length of stay
Psychosocial: loss of personal pleasure, social isolation, financial burden associated with special diet
Components of a CSE, strengths and weakness of
1. Chart review
2. Interview
3. Clinical outcome assessment
4. cognitive/motor speech/language screen
5. OME, CNE
6. PO trials
- strengths: immediacy, no time limit, repeatable, non-invasive, naturalistic, informs management plan
- limitations: cannot ID all airway invasion, tell you WHY signs/symptoms occur, determine presence/amount of pharyngeal residue, allow visualization of entire swallow; patient factors
Structures involved in airway protection
Definition of SAFETY in relation to dysphagia
Where did the bolus go?
- does NOT enter airway
Two bolus holding patterns
Tipper: tongue tip elevated and bolus is between midline of the tongue and the hard palate
Dipper: bolus initially held on floor of mouth in front of the tongue; tongue tip ‘dips’ beneath to collect when ready for transport
Overview of Dysphagia Management
Goal: patient to orally consume safely and efficiently to sustain life and avoid health issues (behavioral for SLPs)
- compensatory (adapt)
- restorative (improve/restore)
Tools/measures to evaluate the swallow
- Hyolaryngeal palpation
- cervical auscultation
- pulse oximetry (gr than or equal to 2% drop from baseline, or below 90)
- spontaneous swallow frequency (under 40/min)
- gag reflex
Cranial nerves involved in swallowing and function
CNV Trigeminal
CNVII Facial
CNIX Glossopharyngeal
CNXII Hypoglossal
How many times do we swallow each day?
500-2,000
18-400 dry swallows per hour
Where is the pharyngeal swallow triggered?
At the anterior faucial pillar, middle of the base of the tongue, and at the valleculae