Swallowing Final (Paramby)

When did our scope of practice start to include swallowing?

1980s

Where does the SLP’s scope begin and end for swallowing? Why? Is it outside our scope of practice to recommend tube feeding? What does NPO mean?

Our scope of practice begins at the lips and ends at the UES/Crico-pharyngeal muscle

This is our scope because this is where we can do behavior modification. Past the UES, you cannot modify the swallowing.

Yes, it is outside our scope of practice to recommend tube feeding.

NPO is Latin for nothing by mouth

Penetration

food or liquid enters the airway and stays above the vocal folds

Choking

complete blockage of the airway

Aspiration

food or liquid enters the airway and goes below the vocal folds

What does a score of 1, 2, 6, and 8 mean on the Penetration Aspiration Scale (PAS)?

1 = normal

2 = normal but also penetration

6 = aspiration

8 = silent aspiration

What is the normal swallow pattern?

Inhale > Swallow > Exhale

OR

Inhale > small exhale > Swallow > Exhale

T/F: You need adequate intraoral pressure to swallow.

True (mouth open = <pressure so not good for swallowing)

What is the most common cause of oropharyngeal dysphagia in adults?

Stroke

Why are we worried about aspiration?

because it could turn into pneumonia

When dealing with bolus volume, does a small or large bolus go through the phases more linearly?

Small Bolus Volume

When dealing with bolus volume, does a small or large bolus create simultaneous oropharyngeal activity?

Large bolus volume

What 3 things happen during a swallow to close/protect the airway?

1. Epiglottis Inverts

2. Vocal Folds Close

3. False Vocal Folds Close

What is the difference between a tipper and a dipper?

Tipper holds the bolus on top of the tongue before swallowing while a dipper holds the bolus under the tongue before swallowing.

How does Boyle’s Law play into straw drinking?

To create the suction for straw drinking, the soft palate is lowered against the base of the tongue, the muscles in face/cheek contract to create suction this leads to the volume increasing and the pressure decreasing.

Why might we not recommend straw drinking?

If the patient is inappropriately creating suction by doing this during inhalation.

What is the Mendelsohn Maneuver and what is it used for? What is the problem with it?

The UES is being kept open by holding the initial swallow at the peak, so the hyoid bone stays up.

This is used by SLPs for swallowing coordination.

Problem: it’s very difficult to do & SLPs think they do it correctly but are typically wrong (need instrumental eval to really know if doing it right)

What are 3 positives signs for a lower chance of getting aspiration pneumonia?

If they patient is

• physically active

• has good oral hygiene

• can feed themselves

What are the 3 branches of EBP?

• External Scientific Evidence

• Internal Evidence (clinical expertise)

• Patient & Family Preference (client perspective)

Swallowing is a highly synchronized sequence of events with a short duration of ___ and incoordination leads to what?

Short duration of <1 sec

Incoordination leads to Dysphagia

What is the difference between a Barium Swallow Study and a Modified Barium Swallow Study?

Barium is typically past the UES (focus is on esophageal phase and beyond) meaning it is completed by a radiologist.

MBSS has a focus on the oral & pharyngeal phases (it’s done by SLPs)

What is the purpose of biomechanical analysis?

To figure out a cause for aspiration or residue. (no mention of cause is bad clinical practice)

When you are talking about aspiration and residue, you are talking about what?

The barium (you’re essentially treating the barium by thickening liquids, but that should be your last resort)

What are the 4 muscles of mastication?

1. Masseter

2. Temporalis

3. Medial Pterygoid

4. Lateral Pterygoid

Every muscle that ends in -glossus is a tongue muscle except what?

Palatoglossus (it’s innervated by CN X - Vagus)

Which muscles help with the anterior movement of the hyoid bone?

• Mylohyoid

• Geniohyoid

• ABD

For all of these, the mandible is the origin & the hyoid bone is the insertion (b/c hyoid is moving

What muscle helps with superior movement of the hyoid bone?

Hyoglossus

Which muscles pull the hyoid in the posterior direction?

Stylohyoid

PBD

What are the 3 main pharyngeal constrictor muscles?

• Superior pharyngeal constrictor muscle

• Middle pharyngeal constrictor muscle

• Inferior pharyngeal constrictor muscle

These muscles are pushing the bolus down.

What pushes the epiglottis from the vertical to the horizontal position?

the tongue base

What muscle is involved in thyrohyoid shortening?

Thyrohyoid

(thyroid moving to hyoid so hyoid is origin & thyroid is insertion)

What 2 things need to happen for the UES to open?

1. Cricopharyngeal muscle needs to relax

2. Hyoid/Thyroid/Cricoid needs to move superiorly & anteriorly

How does Boyle’s Law work with the Hypopharyngeal Suction Pump?

Cricopharyngeus muscles opens, so the volume increases and the pressure decreases. Below the muscle, the pressure is negative, so it acts like a vacuum sucking the bolus into the esophagus b/c it wants to fix the pressure difference.

What 2 things are encompassed in the phrase “premature spillage”?

1. Oral Containment Impairment

   • majority of bolus in the oral stage but some trickles down to the pharynx

2. Pharyngeal Onset Delay

   • cohesive bolus reaches pharynx before the initiation of the swallow

What can be a possible treatment for pharyngeal onset delay?

Chin Tuck

What is the origin/insertion of the hyoglossus?

It depends upon the action (reversible between tongue and hyoid)

After a Coronary Artery Bypass Grafting (CABG) surgery, there is a chance for dysphagia b/c of vocal fold impairment due to RLN getting hit. Which side of the VF might be weak?

LEFT (b/c the heart is on the left side and CN are ipsilateral)

Does Dr. Paramby consider a the clinical swallow evaluation a screening?

No, he considers it a valid assessment to initiate therapy with

Screening

• minimally invasive

• quick

What can a dysphagia screening tells us?

• Obvious info (npo or risk for dysphagia)

• A known history of dysphagia

• Medical diagnosis that frequently involves swallowing impairment

• Reduced level of consciousness

• Overt signs of spiration (ex: coughing)

• Overt signs or complaints of difficulty swallowing

Sensitivity

correctly identifying dysphagia in people who DO have dysphagia

Specificity

correctly identifying no dysphagia for people with NO dysphagia

Yale Swallow Protocol

aka 3 oz water protocol

patient drinks 3 oz of water consecutively and if there is no cough/throat clear within 1 min, they pass

What are 3 good swallow screening tools?

1. The Massachusetts General Hospital-Swallow Screening Tool (MGH-SST)

2. Yale Swallow Study (aka 3oz water protocol)

3. The Toronto Bedside Swallow Screening Test (TOR-BSST)

What is the difference between signs and symptoms?

Signs = what we observe (objective)

Symptoms = patient reported (subjective)

What is the safest way to evaluate swallowing?

saliva swallow

What does IDDSI stand for?

International Dysphagia Diet Standardization Initiative

List some compensatory strategies

• Hard Swallow

• Alternate thin & solid (drink after each bite)

• Chin Tuck

• Heat Turn

What treatments do we know of that is not modifying diet?

• Postural changes

• Chin Tuck (aka chin down)

  • do if patient has an oral containment issue

  • do NOT do if patient is aspirating after a swallow

• Mendelsohn Maneuver

• Effortful Swallow

  • use if there is oral or pharyngeal residue

  • this increases muscle activity

  • you can use this for almost anyone with swallow issues (try this first?)

• Head Tilt

  • use if pocketing in oral cavity or one side of face is weak

• Head Rotation

  • use if pharyngeal residue or vocal fold paralysis (rotate to the side with issue ex: R paralysis means rotate to the right)

• Head Extension

  • use for people whose tongue can’t move the bolus very well

In summary, when is CSE helpful and not helpful?

CSE helps:

• SLP know about the oral phase

• predictions with aspiration/penetration (75% accurate)

• voluntary cough (80% accurate)

CSE not helpful:'

• Silent Aspiration

• delayed swallow initiation

• any durational measures

• pharyngeal characteristics of swallow

• UES opening and duration

When should you do an instrumental eval?

Definite indication:

• comprehensive CSE fails to thoroughly address the clinical questions posed by patient or problem

• dysphagia characteristics are vague and require confirmation or better delineation

• nutritional or respiratory issues indicate suspicion of dysphagia

• safety or efficiency of swallowing is a concern

• direction for swallowing rehab is needed

• help is needed to assist in underlying medical problems that contribute to dysphagia symptoms

Possible indication:

• medical condition that has a high risk for dysphagia

  • ex: stroke, ALS, CP, COPD, etc.

• swallow function demonstrates an overt change

• the patient is unable to cooperate for a CSE

NOT an indication:

• no dysphagia complaints

• too medically compromised

• uncooperative

• patient too large for machine

• exam would not alter clinical course or management

Rationale for VFSS

1. To identify normal and abnormal anatomy and physiology of the swallow

2. To evaluate integrity of airway protection before, during, and after swallowing

   • During is difficult with FEES b/c of whiteout

3. To evaluate the effectiveness of postures, maneuvers, bolus modifications, and sensory enhancements in improving swallowing safety and efficiency.

4. To provide recommendations regarding the optimum delivery of nutrition and hydration (e.g., oral versus non-oral, method of delivery, positioning, therapeutic interventions).

5. To determine appropriate therapeutic techniques for oral, pharyngeal, and/or laryngeal disorders.

6. To obtain information in order to collaborate with and educate other team members, referral sources, caregivers, and patients regarding recommendations for optimum swallow safety and efficiency.

Do you need to have a protocol when doing a CSE?

YES

What does FEES stand for? What about FEEST? VFSS?

Fiberoptic Endoscopic Evaluation of Swallowing (FEES)

Fiberoptic Endoscopic Evaluation of Swallowing with Sensory Testing (FEEST)

Video Fluoroscopic Swallow Study (VFSS)

What are the 5 main components of FEES?

1. Assessment of pharynx/larynx

2. Movement and sensation of structures

3. Assessment of structures

4. Direct evaluation of swallowing

5. Evaluation of compensatory strategies

What are some strengths/weaknesses of FEES?

Strengths:

• Portability

• No Radiation

• Biofeedback Tool

• Longer Eval Time (b/c no radiation)

• Can test diff foods

Weaknesses:

• Discomfort

• Limited view (pharynx)

• White Out

• Possible nosebleed

• Possible vasovagal response (passing out)

Can you treat every patient the same?

NO! Every patient is unique

Breath Hold vs Supraglottic Swallow vs Super-Supraglottic Swallow

Breath Hold

• large breath > hold > sip > swallow > large exhale (forced exhale)

Supraglottic Swallow

• same but add a cough at the end

Super-Supraglottic Swallow

• same but more forced

• “Inhale and hold your breath very tightly, bearing down. Keep holding your breath and bearing down as you swallow. Gentle cough when you finish”

Shaker Exercise is what? What can do the same thing?

Shaker = lay flat and lift head up to look at toes for 30 secs

• This targets suprahyoid muscles (muscles above hyoid)

New exercise that does the same thing:

• Chin tuck against resistance (or WADA)

The best way to rehabilitate swallowing is to have patients…

swallow

CN Name, Number, and Function

Duffy Textbook Download from A&P