Dysphagia

=Dysphagia= aka Deglutition disorder Standards: III-B, III-D, III-G

([|if you need a more thorough review of anatomy and physiology related to swallowing check out this site] ) Normal Swallowing Oral Preparatory Phase Oral Phase Pharyngeal Phase Esophageal Phase (not within SLP scope of practice--leave it to the gastroenterologists)
 * Salivation
 * Food enters oral cavity
 * Tongue moves food to teeth
 * Mastication
 * tongue collects/forms bolus
 * (back of tongue is high and velum is bunched downward to keep bolus within oral cavity)
 * bolus moved to back of tongue
 * when bolus passes the point where the mandible crosses the tongue base (as seen radiographically) the pharyngeal swallow should be triggered
 * velopharyngeal port closes
 * larynx moves up and forward (and true and false vocal folds close) to protect airway--breathing stops momentarily
 * epiglottis inverts
 * bolus passes through pharynx (pyriform sinuses)
 * bolus enters UES--upper esophageal sphincter
 * bolus travels down esophagus by peristalsis
 * bolus passes through LES and into stomach

See examples of normal and disordered swallows during VFSS [|here]

**Assessment**
 * Case History** (important info in addition to typical case history)
 * medications
 * xerostomia (dry mouth)
 * dyskinesia--antipsychotics
 * numb oral cavity--liquid form antiseizure
 * change taste in mouth--steroids metallic taste
 * current diet--consistencies, avoided foods, physician ordered diet?, allergies, sociocultural (Jewish, Muslim), what did you eat today?)
 * psychosocial--who prepares food, eats with them, living arrangements
 * have patient describe symptoms in own words
 * when, how long, what
 * (cough, gurgle, choking, pain, stuck--point to where)
 * activity level (low--higher risk for aspiration pneumonia)
 * Bedside Swallow Exam**
 * Full Oral Mech Exam
 * besides structural/function info, you can observe
 * oral hygiene (bad--higher risk for aspiration pneumonia)
 * ability to follow directions
 * cognitive status
 * voice quality and cough quality
 * Observe patient eating
 * Considerations of whether or not to do this
 * have they been eating all along, or not eating for several days
 * hx of pulmonary problems
 * weak cough/throat clear
 * frail
 * difficulty following directions
 * NPO per physician
 * Observe (don't be chatty)
 * hand to mouth
 * rate (ask if it's typical)
 * size of bite
 * voice quality
 * coughing/throat clearing
 * unusual things--compensatory strategies

A FEES study is designed to evaluate the swallowing mechanism, and is performed by an otolaryngologist in conjunction with a speech language pathologist (SLP). The study requires the passage of a flexible fiberoptic endoscope into the throat in order to visualize the actual swallow in progress. While the endoscope is in place, the patient is fed foods of varying consistencies colored with food dye. This test allows the examiners to directly observe the movement of the food from the back of the mouth through the throat, and into the esophagus.
 * FEES** (Flexible Endoscopic Evaluation of Swallowing)

Symptoms to look for ORAL PREPARATORY PHASE ORAL TRANSITION PHARYNGEAL ESOPHAGEAL Look for penetration (up to level of vocal folds) and aspiration (into trachea) before, during, and after the swallow
 * VFSS** (Videofloroscopic Swallow Study) aka Modified Barium Swallow Study
 * See examples of normal and disordered swallows during VFSS [|here]
 * lip closure
 * saliva production
 * weak jaw muscles
 * weak buccal muscles (food falls into lateral sulci)
 * tongue problems
 * large tongue/small oral cavity
 * weakness
 * decreased sensitivity
 * coordination
 * dentition
 * premature spillage
 * tongue thrust
 * velar elevation
 * delayed initiation
 * epiglottis inversion
 * laryngeal elevation
 * vocal fold adduction
 * base of tongue to posterior pharyngeal wall
 * residue
 * osteophytes--bony growths that protrude from cervical vertebrae
 * UES doesn't open or spasms
 * not our scope of practice (well maybe if related to decreased laryngeal elevation)

Tx Options 1) Parenteral feeding, NG-short term, PEG-long term 2) Dietary changes 3) Positioning 4) Swallowing Maneuvers 5) Adaptive strategies 6) Adaptive Utensils, plates, cups, etc (See your OT friends) 7) NMES Neuromuscular electronic stimulation (vital-stim, e-stim) EBP questionable 8) Thermal Stimulation--cold rubbed on faucial arches to increase briskness of swallow EBP questionable 9) Advanced Directive/Informed Consent---quality of life vs. quantity
 * consistency of food (pureed, mechanical soft, regular, perhaps avoid mixed consistencies)
 * consistency of liquid (pudding thick, honey-like, nectar-like, thin)
 * [|free water protocol] (click for more info)
 * Body tilt
 * Chin Tuck
 * Rotate head to weak side
 * Supraglottic swallow--take breath (hold, eat, swallow, cough)
 * Mendelsohn maneuver
 * these can be effective, but require good cognitive abilities
 * finger or tongue sweep into sulci
 * alternate liquids and solids
 * bite size
 * slow rate

__Additional Information for Pediatric Patients__ Much of the information on Dx and Tx are similar so... What's different???

for children, tx positioning/maneuvers may take more stimulation--toys on the side you want the child to turn head etc reflexes are more apparent bottle vs breast fed, latching on newborn, tongue fills the oral cavity, oral cavity is proportionately smaller to the skull posterior tongue descends into the pharynx by 9 years of age fat pad reduces over time 1st year, halves of madible fuse epiglottis is in direct contact with the velum pyriform sinuses are elevated and smaller in infants larynx descents from C3 to C7 in adulthood Positioning--infant can lie flat to swallow until roughly 9 mo, able to suck and swallow at the same time... incline after 9 mo development of other skills are dependent upon feeding milestones--communication, sensory processing and development, socialization, motor coordination, speech Nutrition and fat needed for brain develpment feeding=bonding more likely to wean a tube feeding with children texture aversion and preference (often for crunchy)

References http://radiographics.rsnajnls.org/cgi/content/full/e22/DC1 http://dysphagia.com/swallowing http://www.med.nyu.edu/voicecenter/services/swallowing/fees.html http://www.universityotolaryngology.com/flexibleendoscopicevaluationofswallowingwithsensorytesting1f.nxg

American Speech-Language-Hearing Association. (2002). Knowledge and Skills Needed by Speech-Language Pathologists Providing Services to Individuals With Swallowing and/or Feeding Disorders [Knowledge and Skills]. Available from www.asha.org/policy. Ginsberg, S. (2008). Lecture notes from SPSI 625: Dysphagia, Eastern Michigan University. Hegde, M.N. (2001). __Introduction to Communicative Disorders, 3rd Edition__. Austin, TX: Pro-Ed Inc. Logemann, J.A. (1998). Evaluation and Treatment of Swallowing Disorders, 2nd Edition. Austin, TX: Pro-Ed. Morris, T. (2009). Lecture notes from pediatric dysphagia presentation, Eastern Michigan University.