Swallowing Exam 1

Paramby

Jerri A. Logemann

• Barium cookie test

Jerri A. Logemann

• Barium cookie test

Queen of Dysphagia

1980s

When did swallowing begin to fall under the SLP scope of practice

Begins at lips, ends at Cricopharyngeus muscle (UES)

Borders of swallowing

1. Oral Prep: mastication/holding bolus

2. Oral: tongue moves to move bolus

3. Pharyngeal: begins at faucial pillars

4. Esophageal: begins when bolus enters Cricopharyngeus muscle

Oropharyngeal swallow is a continuum divided into stages

Stages of Swallowing

Interstage transition

Part of the bolus is in the oral cavity and part is in the pharynx

(common with soup that also has solids in it)

Taste

________ is the sensory aspect of swallowing

Doctor - SLP cannot recommend tube feeding, but we can let the doctor know the client needs to be NPO

Whose responsibility is it to recommend tube feeding

• nourishment

• socialization

• spirituality

• medication

• lifestyle treatment

Eating/Drinking affects what aspects of life

Dys: disorder/difficulty

Phagein: To ingest/engulf

Dysphagia: Difficulty in swallowing

Dysphagia meaning

primary medical diagnosis; symptom

(dysphagia cannot occur by itself; it is always caused by something else)

Dysphagia is not a _______ _______ _______; it is always a __________

1. nasal cavity

2. Airway

3. Out of mouth

Misdirection of a swallow

Aspiration

Food or liquid entering airway below vocal folds

Penetration

Food or liquid entering airway, but remaining above vocal folds

Choking

Complete blockage of the airway

Silent Aspiration

Food/liquid enters airway, passes below vocal folds, and no effort is made to eject

1: Normal

2: Normal/Penetration

3-5: Penetration

6-7: Aspiration

8: Silent Aspiration

Penetration Aspiration scale

True

In Arkansas, SLPs can

In some states SLPs cannot scope, only doctors can

There is not adequate intraoral pressure when your mouth is open

Why is it difficult to swallow using the compensatory strategy of tilting your head back?

Stroke

TBI

Dementia

CP

Progressive disorders (Parkinson’s, Huntington’s, ALS)

Neurological Conditions/Causes of Dysphagia

80-90%

What percent of people complain of swallowing issues after surgical spinal fusion?

• Radiation/chemotherapy

• Intubation/tracheostomy

• Post surgical cervical spine fusion

• Post surgical coronary artery bypass grafting

• Medication

Dysphagia is the Iatrogenic (side effects) of what?

Ipsilateral

Cranial nerves are

1. Pharyngeal branch

2. Superior laryngeal branch

3. Recurrent laryngeal branch

   1. L side: travels down to aorta and back up

   2. R side: travels down to subclavian artery and back up

Branches of Vagus nerve

SLP: attitude is to fix it

Swallowing specialist: may know that you cannot fix some problems but can still help them and prevent certain conditions to avoid premature mortality

Traditional SLP vs Swallowing Specialist

• Clinical swallow eval

• MBSS/VFSS

• FEES

• management

• Chest x-ray

• Chest CT

Ways dysphagia is observed

Stroke

#1 neurological cause of dysphagia and the main cause of oropharyngeal dysphagia in adults

Pneumonia

Infection of the lungs

Aspiration Pneumonia

Excess of aspiration combined with other things (bad hygiene, bad health, etc.) can cause pneumonia

Oropharyngeal dysphagia

Main cause of pneumonia is NOT ____________ but it can play a role in it

it affects swallowing

Chewing is only abnormal if

Small: 1-3ml (3 phases)

Large: 10-20ml (simultaneous oropharyngeal activity)

Small vs. large volume swallow

Thinner = faster (less pressure)

Thicker = slower (more pressure)

Viscosity of Liquids

Approx 1 second

Duration of a swallow

1. Epiglottis

2. False vocal folds

3. True vocal folds

3 levels of airway protection

Approx 5-10 seconds

How long does it take the bolus to reach the stomach

• smaller sips

• slow down

• thickened liquids

• chin tuck

Compensatory strategies for swallowing problems

Inhale, swallow, exhale

Inhale, small exhale, swallow, exhale

Breathing for swallowing

• patient was not actually choking

• food stuck in valleculae

• cardiac arrest

reasons heimlich may not work in some cases (based on video)

72%

Percent of adults that are tippers

Tippers: bolus remains on top of tongue until swallow is initiated

Dippers: bolus moves under the tongue into floor of mouth; bolus is then lifted up and swallow is initiated

Tippers vs. dippers

1. Mandible lowers, volume increases in oral cavity; pressure decreases

   Suction

2. Cheek and lip muscles contract to create more energy

3. Velum lowers; tongue raises (lingua-velar seal) and anterior lip seal

Steps of straw drinking

Holding larynx up during swallowing to prevent food/liquid from entering airway

assists in swallowing coordination and UES opening/duration

Mendelsohn Maneuver

Problems

• Difficult to do

• SLPs think they do it correctly but don’t

Solutions

• during instrumental eval, use FEES

• Hook up SEMG (electromyography) to muscles (BEST SOLUTION)

Problems w Mendelsohn Maneuver and how to fix it

Faucial pillars cannot be seen on fluoroscopy, so we look at ramus of mandible (bone) during swallow initiation

Hyoid bone needs to move when bolus passes ramus of mandible (indicating swallow has begun)

• delay in swallow when hyoid does not move

Initiation of pharyngeal swallow on video fluoroscopy - what do we look at?

• For liquid, initiation of swallow should occur when bolus reaches ramus of mandible

• For solid, initiation of swallow should begin when bolus reaches valleculae or pyriform sinus

Initiation of swallow for solid and liquid

Presbyphagia

Natural changes in swallow due to older age

synchronized sequence of events

Swallowing is a highly …

Dysphagia

Incoordination of swallowing leads to

Barium: focus on esophageal phase or beyond cricopharyngeus muscle (Radiologist)

Modified Barium/Video fluoroscopy: Focus on oropharyngeal swallow (SLP)

Barium swallow study vs modified barium swallow study

1. External Evidence (journal articles)

2. Internal Evidence (clinical expertise)

3. Patient & Family Preference

You can educate & recommend but ultimately patient/fam members decide

Evidence Based Practice

• Oral Hygiene

• Functional Status (self feeding)

• Medical status (stroke/other health conditions)

• Physical activity

Article 1 - Risk factors for aspiration pneumonia

cause

It is bad clinical practice if you mention aspiration/residue but not the ________

Not only Evaluation but also

• Diagnostic & Interventional procedure

VFSS - videofluoroscopy swallow study is used for

Patient should be treated first (small sips, take a breath, chin tuck) before treating the barium (diet modification)

Treating patient vs. treating barium

• Masseter

• Temporalis

• Medial Pterygoid

• Lateral Pterygoid

Muscles of Mastication

Mandible

Soft palate

Tongue

Hyolaryngeal (hyoid and larynx) complex

UES

Structures active during entire oropharyngeal swallow

• Mandible

• Hyoid Bone

• Skull base

Anchoring attachment for the tongue

1. Hyoglossus

2. Mylohyoid

3. Geniohyoid

4. ABD: anterior belly of digastric

Muscles that move hyoid anterior and superiorly

Palatoglossus

Innervated by XI (accessory) and X (vagus)

Only tongue muscle NOT innervated by CN XII (hypoglossus)

1. Superior pharyngeal constrictor

2. Middle pharyngeal constrictor

3. Inferior pharyngeal constrictor

all 3 muscles add pressure to push the bolus down - may be residue if any of the muscles are not functioning properly

3 main muscles in pharyngeal wall

Tongue and Velum

Pressure increases in oral cavity

no seal = bolus may fall into pyriform sinus, valleculae, or airway

Linguavelar seal

needs to close so that bolus doesn’t get into nasopharynx

Importance of velopharyngeal closure

• Tongue base touches epiglottis and minimally assists in movement

• Hyolaryngeal excursion/elevation

• Pressure of bolus allows epiglottis to invert

  Lack of anterior hyoid movement or lack of bolus pressure = absent epiglottic inversion or residue

3 factors of epiglottic inversion [ESSAY QUESTION?]

suprahyoid muscles move hyoid/larynx anteriorly and superiorly

• Contributor for epiglottic inversion and contributes to UES opening

• orients airway away from oncoming bolus

Hyolaryngeal excursion

Cricopharyngeus muscle is always contracted and opens when bolus comes through

Cricoid cartilage moves anterior/superior when larynx is elevated therefore opening the cricopharyngeus muscle (volume increases, pressure decreases)

Hypopharyngeal suction: sucks the bolus into esophagus (due to negative pressure below cricopharyngeus muscle)

Cricopharyngeus muscle during Hyolaryngeal Excursion (HLE)

RLN of vagus sends signal to relax the cricopharyngeus muscle

once it is relaxed, it is easier to be pulled open during HLE

Which cranial nerve tells the UES to open

• Posterior suprahyoid muscles:

  • stylohyoid

  • PBD (posterior belly of digastric)

• Anterior suprahyoid muscles

  • Mylohyoid

  • Geniohyoid

  • ABD

• Superior suprahyoid muscle

  • Hyoglossus

Suprahyoid muscles

Cause

1. Poor HLE

2. UES not relaxing

Treatment

1. strengthening of hyoid muscles (SLPs)

2. Myotomy (cutting muscle) (refer)

Cause and Treatment for UES not opening

If one or both happen, premature spillage occurs

Pharyngeal onset delay: cohesive bolus reaches valleculae, pyriform sinus, etc. before swallow is initiated (Treatment: chin tuck)

Oral containment impairment: majority of bolus remains in mouth but small amount trickles down into pharynx

Pharyngeal onset delay vs. oral containment impairment

• Not usually purchased outside US

• Shortage in last 10 years

• Expensive

Barium Info