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118 Cards in this Set
- Front
- Back
- 3rd side (hint)
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What is the most prevalent swallowing disorder in patients with closed head trauma?
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Delay triggering the pharyngeal swallow
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What is the most prevalent swallowing disorder in patients with stroke?
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Delay triggering the pharyngeal swallow
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How is the length of coma related to the severity of swallowing problems?
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The longer the coma, the more severe the swallowing problems (yeah, that one made you feel good, didn’t it?)
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Patients with closed head injury have complex swallowing problems due to the combination of _____________, ____________, and ______________.
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Closed head injury, damage to other parts of the body, and nature of emergency care.
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Neurogenic damage can be caused by what three forces?
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Direct head injury, contra-coup injury, and twisting/shearing of the brainstem
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Patients with head trauma may experience other injuries including ____________, _____________, and _______________.
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Puncture woulds to the neck, laryngeal fracture, and penetration wounds to the chest (affecting the esophagus)
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Patients receiving emergency care may be injured by ____________ or _____________.
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Tracheostomy - may be placed to high scarring the larynx. Intubation - forceful intubation can also damage the larynx.
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What are four oral swallowing disorders seen in those with closed head injury?
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Reduced lip closure, reduced tongue ROM (with poor bolus control), abnormal oral reflexes (including bite reflex), and delayed/absent pharyngeal swallow.
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What are eight pharyngeal swallowing disorders seen in those with closed head trauma?
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Reduced laryngeal elevation, reduced closure of airway entrance, reduced closure of airway throughout, reduced tongue base motion, reduced CP opening (usually related to reduced laryngeal motion), uni/bilateral pharyngeal wall weakness, tracheoesophageal fistula, reduced velopharyngeal closure.
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In patients with closed head injuries, reduced airway closure and reduced CP opening (due to poor laryngeal motion) are generally related to ______________ instead of neurologic damage.
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Physical damage to the larynx
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What are some patient characteristics which affect swallowing in those with closed head injury?
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Impulsiveness, tendency to overstuff mouth, cognitive difficulties, reduced sensation.
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True or False: The recovery of swallowing after closed head injury is well documented
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False: One study showed recovery over time but it was based on bedside evaluation (Gasp! No radiographic study?!)
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True or False: Patients of any age will develop complications from aspirating over a short period of time
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False: Younger patients can aspirate (especially on liquids) with no apparent consequences for a year or more.
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Why is it important to counsel the family regarding swallowing and dietary changes during the acute phase?
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Because if you wait until the rehabilitation stage, the patient and family may not comply with your recommendations.
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If a patient with closed head injury has cognitive deficits __________________ will be easier to use than _____________.
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Postures and sensory heightening will be easier than voluntary maneuvers.
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True or False: Most patients with closed head injury will need to use voluntary maneuvers in order to manage their swallowing disorders.
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False: Because the most common disorders are delayed pharyngeal swallow and reduced range/coordination of tongue motion and these can be addressed using other methods.
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Initial therapy tasks for patients with cognitive deficits include…
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sensory heightening strategies, resistance exercises, range of motion exercises.
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When working with family members of patients with closed head injuries, it is crucial to explain the _______________.
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Goal of each therapy task and compensatory strategy.
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True or False: If you determine that a patient has reached a plateau and dismiss them from therapy while on non-oral or limited oral feeding, that patient will not be able to return to a full oral diet.
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False: You should re-evaluate the patient every 6 mos. to 1 year. It is possible that the patient will recover swallowing function after a longer period of time.
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In patients with cervical spinal cord injuries, swallowing disorders are usually __________ in nature.
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Pharyngeal
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Common swallowing disorders in patients with cervical spinal cord injuries include (5):
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Delayed triggering of pharyngeal swallow, reduced laryngeal elevation, reduced anterior movement of the larynx (causes reduced UES opening), reduced tongue base motion, and uni/bilateral pharyngeal wall dysfunction.
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Damage to CV 4,5, or 6 will often result in…
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Poor laryngeal motion leading to poor UES opening
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Damage to CV 1 or 2 will result in…
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No sensory awareness of swallowing difficulties
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True or False: Patients with cervical spinal cord injury may have difficulty closing the airway entrance.
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True: This is usually related to poor laryngeal elevation or anterior movement
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True or False: Patients with cervical spinal injury don't generally have trouble closing the airway at the vocal folds.
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True: This is infrequent in this population. When it does occur, it is generally related to direct laryngeal damage (Intubation, trachostomy placement, prolonged trach)
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When patients have SCI damage at or above C3, they may require _______________.
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Mechanical ventilation
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Name reasons patients with cervical SCI are difficult to assess at bedside
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Patients may require mechanical ventilation (cuffed trach) and when the damage is above C5 the swallowing disorders are generall pharyngeal so you can't observe it at bedside.
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If a patient is wearing a head/neck brace, during X-Ray you may need to _________________.
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Angle the patient 15-30 degrees because the brace may shadow certain parts of the anatomy.
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With cervical SCI patients, what procedures will you use during the radiographic study?
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Postural changes are often not possible, sensory heightening and voluntary maneuvers are the most helpful.
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What are the effects of cervical bracing on the swallow?
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Not yet identified in dysphagic patients, but some studies conducted on individuals with normal swallow. These patients report a worsening of the swallow when wearing a brace but the only significant change is LONGER airway closure.
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Swallowing becomes more difficult when cervical bracing positions the head in what ways?
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If the chin is pulled back / chin or head is retracted on the neck, also if head is extended.
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Following an anterior cervical fusion, patients may suffer from what swallowing issues?
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Swelling of posterior pharyngeal wall, reduced laryngeal elevation/anterior movement (resulting in reduced closure of airway entrance and reduced CP opening), reduced uni/bilateral pharyngeal wall movement, and possible oral stage problems/delayed triggering of pharyngeal swallow.
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Swallowing problems in patients with anterior cervical fusion are caused by…
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Trauma to peripheral nerves, swelling, and reactions to hardware in the neck
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What is the recovery pattern for swallowing in patients with anterior cervical fusion?
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Patients generally recover significantly in 3 months or less. You should determine intervention strategies to allow for oral intake in the meantime.
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What are the most helpful techniques for patients with anterior cervical fusion?
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Generally compensatory techniques are useful because the swallow is likely to recover spontaneously. Most helpful are: Mendelsohn manuever, supraglottic swallow, super supraglottic swallow. (Remember, postures = ouch!)
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Damage to the [part of brainstem] will lead to significant swallowing problems including ____________________.
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Medulla / complete inability to trigger pharyngeal swallow
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Patients with damage to the medulla may benefit from what techniques?
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Sensory heightening because the issue is often a problem triggering the pharyngeal swallow. Try Thermal-Tactile Stim and/or Suck-Swallow technique.
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What is the goal of sensory heightening techniques?
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To lower the threshold of the swallowing center in the central nervous system
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Following removal or acoustic neuroma or other tumor from a cranial nerve, there may be damage to cranial nerves ____, ____, ____, ____, and possibly ____.
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VIII, IX, X, XII and VII
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Symptoms of cranial nerve damage following neurosurgical procedures will be __________ and may include…
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UNILATERAL, facial weakness, pharyngeal wall paresis/paralysis, soft palate weakness, vocal fold adductor paralysis, tongue paresis
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Damage to cranial nerve IX will often result in…
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Delayed triggering of the pharyngeal swallow
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As cranial nerve damage usually results in _________ problems, patients will often benefit from ______________________.
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Unilateral / postures: head rotated to the damaged side or chin down to protect the airway during delay.
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In addition to compensatory strategies, patients with cranial nerve damage benefit from…
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ROM and resistance exercises for lips, oral tongue, tongue base and larynx (Falsetto, effortful swallow, super-supraglottic swallow)
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None
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Patients who are cognitively intact should practice exercises ______ times per day for ______.
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10 / 5 minutes
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Poliomyelitis may lead to disturbances in what stage of the swallow?
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Both Oral and Pharyngeal
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What oral stage swallowing disturbances may result from poliomyelitis (2)?
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Reduced lingual control of bolus, disturbed pattern of bolus propulsion
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What pharyngeal stage swallowing disturbances may result from poliomyelitis (3)?
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Reduced pharyngeal contraction, Unilateral pharyngeal paralysis, Reduced velopharyngeal closure (leading to nasal regurgitation)
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Guillan-Barre is a ____________ causing rapid onset of paresis which may progress to…
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Viral-based disease / complete paralysis requiring tracheostomy and mechanical ventilation.
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Swallowing difficulty is occasionally the first sign of __________ and is soon followed by general weakness and paralysis.
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Guillan-Barre
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What will be observed during radiographic study in patients with Guillan-Barre?
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Generalized weakness in oral and pharyngeal swallow; reduced ROM of oral tongue, tongue base, and larynx.
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Therapy for patients with Guillan-Barre should begin with…
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Gentle resistance and ROM exercises, increasing effort as the patient improves.
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Respiration is originally unstable in patients with Guillan-Barre, so ________________ should be postponed. Later on _____________ are helpful.
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Swallowing therapy or maneuvers that prolong airway closure; Supraglottic swallow or Mendelsohn.
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Patients with cerebral palsy may exhibit (4 characteristics)…
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Inappropriate oral reflexive behaviors; inability to hold cohesive bolus; disorganized lingual movements (bolus not propelled smoothly); pieces of food may spread out during chewing (premature spillage)
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Patients with cerebral palsy may be placed into which three categories of swallowing disorders?
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Moderate to severe oral function problems; oral function problems + delay triggering pharyngeal swallow; oral function problems + delayed PS + neuromuscular abnormalities during PS
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Most children with cerebral palsy fall into the category of swallowing disorders characterized by… This means which consistencies will be challenging?
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Oral function problems + Delayed PS / foods requiring chewing will be a challenge due to oral motor issues while thin liquids will also be difficult due to pharyngeal delay
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What three oral function problems are commonly observed in patients with cerebral palsy?
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Reduced lip closure, tongue thrust, reduced tongue coordination
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Patients with cerebral palsy may exhibit what 3 neuromuscular abnormalities once the pharyngeal swallow is triggered?
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Reduced tongue base retraction; reduced laryngeal elevation; significant residue after swallow leading to aspiration (this group may aspirate on every consistency)
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Management of swallowing disorders in patients with cerebral palsy commonly includes…
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Oral motor therapy; thermal tactile stim; diet change to thickened liquids and purees (LAST OPTION)
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TRUE or FALSE: Cricopharyngeal dysfunction is rarely a problem in patients with cerebral palsy
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TRUE: Myotomy should not be attempted unless other options have been exhausted. As the child grows the larynx will also drop and this may improve opening of the UES.
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Do patients with cerebral palsy generally suffer from aspiration DURING the swallow?
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No, generally laryngeal closure is adequate
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When does aspiration generally occur in patients with cerebral palsy? What causes it?
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BEFORE the swallow: reduced tongue control and delayed pharyngeal swallow / AFTER the swallow: residue left due to poor tongue base action and reduced laryngeal elevation.
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Dysautonomia is also known as ____________ and is a ____________ disease with widespread effects including…
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Riley-Day Syndrome / Inherited / autonomic inbalance, sensory deficits, motor incoordination, certain episodic phenomena
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Patients with Riley-Day syndrome suffer from what type of swallowing problems?
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Milder problems - reduction of oral tongue control and reduced tongue base and pharyngeal wall motion. More severe problems - oral involvement and delayed triggering of pharyngeal swallow.
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Patients with Riley-Day syndrome may require a G-tube because…
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1) Delayed PS - patient may not handle thin liquids and G-tube will be needed for hydration. 2) Dysfunctional LES places the patient at risk for reflux. A G-tube decreases this risk.
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Swallowing therapy for patients with Riley-Day syndrome may include…
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Oral motor therapy to improve tongue function, thermal-tactile stim to help with triggering of pharyngeal swallow.
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None
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Techniques to design to improve SPECIFIC swallowing disorders include (7):
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Surgical reduction of osteophytes; vocal fold medialization; injection of material into the vocal fold to include closure; laryngeal suspension; dilation of scar tissue in CP area; cricopharyngeal myotomy; botox injection into spastic CP
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Cervical osteophytes may cause swallowing disorders due to…
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1) Displacement of posterior pharyngeal wall which may interrupt bolus flow, 2) pressing on nerves which creates a sense of dysphagia.
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Cervical osteophytes may be surgically removed but there are two possible disadvantages
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1) Scar tissue will be created, 2) Possilbe surgical trauma to nerves innervating swallowing structures
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After a patient with insufficient airway protection attempts exercises, a surgical option to protect the airway is…
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To inject the damaged fold with material to improve closure / Vocal fold medialization surgery
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_____ % of aspiration is caused by poor vocal fold closure
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10% or less
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Laryngeal suspension is used for patients with [swallowing disorder]. It is sometimes used in patients with [medical diagnosis] but rarely in _________ patients.
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Reduced laryngeal elevation; Head and neck cancer patients; Neurologic patients
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__________ are mercury-filled soft rubber tubes used to dilate scar tissue in the CP region.
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Bougies
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The effects of scar-tissue dilation are ________, lasting __________.
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Temporary / 1-3 months
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Dilation of the CP region is generally NOT effective when the cause of the CP dysfunction is…
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Neurologic damage
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Describe the surgical procedure for a CP myotomy
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External incision made through the neck (usually left side); CP fibers are slit from top to bottom usually at posterior midline; May extend upward to inferior constrictor and downward into the upper esophageal musculature.
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Improvement of the swallow following a CP myotomy is reported in _______% of cases.
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60-78%
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None
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What is the criteria for candidates for CP myotomy?
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1) CP dysfunction must be the predominant problem; 2) Patient must be able to move material through the oral and pharyngeal stages of the swallow; 3) Patient must be able to voluntarily close airway during the swallow.
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What effect does a CP myotomy have if performed as a preventative measure at the time of oncologic procedure?
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Study found no difference in post-operative swallowing for patients who did/did not receive a preventative myotomy.
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When a CP myotomy alone does not fix the swallowing problem, what can be used?
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Head-rotation to the unoperated side (helps with opening UES and directs food to more "open" side). Also, Mendelsohn Maneuver can be used to prolong lanrygeal elevation.
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CP Myotomy is counterindicated for patients with…
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Multiple dysfunctions of the vocal tract - reduced lingual control, delayed pharyngeal swallow, reduced pharyngeal contraction - on top of CP dysfunction.
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Complications of a CP myotomy include…
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Hemorrhage, recurrent laryngeal nerve damage, complications from surgically opening the neck.
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What are two disadvantages of Botulinum Toxin injection for relaxation of the CP?
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1) Difficult to accurately place the injection - CP is hidden behind cricoid cartilage, 2) Inaccurate injection can paralyze other muscles in the area worsening the dysphagia.
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List six procedures used to control unremitting aspiration
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Epiglottic pull-down, suturing vocal folds together, suturing false vocal folds together, laryngeal bypass / tracheoesophageal diversion, tracheostomy, total laryngectomy
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What is an advantage and disadvantage to epiglottic pull-down?
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AD: It is potentially reversible; DIS: The epiglottis commonly pulls away, making the procedure unsuccessful
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What is the procedure and disadvantages for suturing the vocal folds together?
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The epethelium is stripped and the vocal folds are sewn shut. They often tear apart making the procedure unsuccessful. Also, it is usually irreversible.
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What are some advantages to suturing the false vocal folds together to control unremitting aspiration?
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The false folds are less likely to tear apart than the true vocal folds. Also, this procesure is usually reversible.
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For a tracheoesophageal diversion, the cut is generally made at ________ and this is a ___________ procedure.
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3rd-4th tracheal ring / relatively permanent
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A total laryngectomy is only used to control aspiration when…
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There is no other solution for aspiration - it is a permanent procedure.
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All non-oral feeding types place the patient at higher risk for _______________.
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Gastroesophageal Reflux
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In patients with NG tubes, each feeding is usually followed by…
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120-240 cc of water to cleanse the tube and ensure adequate hydration
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What is the name for a smaller-diameter NG tube that can be used to help prevent irritation and reflux?
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A Dobhoff tube
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Disadvantages of NG tubes include:
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1) Physical presence of the tube is irritating; 2) Potential for reflux; and 3) Feedings usually prepared = expensive
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True or False: Data indicates that the presence of an NG tube changes the physiology of the swallow.
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FALSE
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An NG tube is generally temporary, replaced by a more permanent solution in _____ months if the patient can't transition back to oral feeding.
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3-4 months
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List six options for non-oral feeding:
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NG tube, pharyngostomy, esophagostomy, gastrostomy, jejunostomy, and fundoplication
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What are the advantages and disadvantages of pharyngostomy / esophagostomy?
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AD: No tube through the nose - less irritating and more socially acceptable. DIS: Creation of scar tissue
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What are the advantages and disadvantages of gastrostomy?
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AD: Patient can take blender-prepped foods through the tube. This is a long-term solution to severe swallowing problems. DIS: Stoma site can leak, become infected/sore.
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What are the advantages and disadvantages of jejunostomy?
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AD: It reduces the risk of reflux. DIS: Requires prepared feedings which is more expensive.
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Children with gastrostomy or jejunostomy require an additional procedure to reinforce the LES by wrapping the top of the stomach around it. What is this procedure called?
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Fundoplication
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A patient needs non-oral feeding if they aspirate more than ______ of all food consistencies or take longer than ______ seconds to swallow a single bolus of all food types despite therapeutic intervention.
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10% / 10
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The most common etiology of dysphagia of unknown origin is…
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Neurologic disease
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Which patients are most at risk for a combination of oropharyngeal and esophageal disorders?
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Those over 60 and children with congenital neurologic impairment.
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Who is responsible for esophageal assessment?
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Gastroenterologist
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The neurologic evalaluation will focus on ______________________.
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Cranial nerves innervating muscles of swallowing and symptoms of neurologic disease which may lead to dysphagia.
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Who is responsible for a structural evaluation of the head and neck as well as sensorimotor assessment ofpharynx and larynx?
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Otolaryngologist
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What team member will be enlisted if a patient has a history of recurrent or recent pneumonia?
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Pulmonologist
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Which team member is crucial for patients in rehab centers? What does this person do?
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Physiatrist - helps fit the dysphagia rehabilitation plan into the patient's overall rehab schedule.
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The Gerontologist is responsible for…
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Determining REALISTIC goals for the patient as well as monitoring whether combinations of medications are contributing to the dysphagia.
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Who makes prosthetic devices?
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The Maxillofacial Prosthodontist
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The physical therapist assists with…
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Optimal positioning of the patient during meals
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The occupational therapist can assist with…
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Providing assistive devices for eating
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What are the responsibilities of the dietician?
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Monitoring blood chemistry, weight, and ensuring adequate nutrition.
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Which team member decides when to transition the patient back to oral feeding?
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Swallowing therapist + Dietician + Attending Physician
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Provide an inservice for the respiratory and nursing staff to educate them on _________________.
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Signs and symptoms of dysphagia
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Provide an inservice for staff members responsible for feeding the patient to educate them on ___________________________.
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Complexity of normal swallowing physiology, range of swallowing disorders, and the need for INDIVIDUALIZED feeding plans.
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When establishing the radiographic procedure, be prepared to explain what three things?
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1) The necessary radiographic procedure; 2) The rationale for all aspects of the procedure; 3) The ways it differs from a standard barium swallow/upper GI exam.
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There are generally three fees to factor into the cost of the radiographic procedure. They are…
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The room fee, the radiologist's fee, and the swallowing therapist's fee
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What have studies shown about the cost and efficiency of dysphagia care using a multidisciplinary approach?
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There is not a lot of data in terms of cost OR reduced rates of pneumonia, improved nutrition, and hydration.
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