Human Communication disorders Exam 6

oral preparation phase (normal swallowing)

Tongue and cheeks move food to the teeth for chewing and to mix with saliva to form a solid bolus

– Tongue cups to hold fluid in a liquid bolus

– The back of the tongue raises to contact the velum and forms a back wall separating the oral and pharyngeal cavities, so the bolus doesn’t spill into the pulmonary airways

oral transport phase (normal swallowing)

The oral transport/transit stage starts once the bolus is formed

– The bolus is moved from the front to the back of the mouth

– The pharyngeal swallow reflex is triggered when the bolus reaches the anterior faucial pillars

– Oral transport typically takes less than 1 second

pharyngeal phase (normal swallowing)

The velum moves up to meet the rear wall of the pharynx to prevent the bolus from going into the nasal cavity

– The base of the tongue and the pharyngeal wall move toward one another to create pressure needed to project the bolus into the pharynx

– The pharynx contracts and squeezes the bolus down

– The hyoid bone rises, bringing the larynx up and forward

– The true and false vocal folds close and the epiglottis is lowered, covering the airway

– The pharyngeal swallowing reflex involves contraction of superior, middle, and inferior constrictor muscles

– The pharyngeal phase is complete when the upper esophageal sphincter opens and the food or liquid moves into the esophagus

– The pharyngeal phase usually takes less than 1 second

oral preparation/oral transport phase (disordered swallowing)

– If the lips do not seal properly, drooling can occur

– Chewing may be impaired because of poor muscle tone or paralysis involving the mouth or because of missing teeth

– Insufficient saliva will impede adequate bolus formation – Food may pocket in the cheek

– The muscles of the tongue might not function purposefully or efficiently enough to move the food to the teeth for chewing and to transport the bolus from the front to the rear of the mouth to prepare for the pharyngeal phase

pharyngeal phase (disordered swallowing)

If the swallow is not triggered or is delayed, material may be aspirated

– If the swallow is inefficient, material can remain in the pharynx after the swallow, increasing risk for aspiration of the retained material after the swallow or during a subsequent swallow

– Failure to close the velopharyngeal port can lead to substances going into and out of the nose

– Poor tongue mobility may result in insufficient pressure in the pharynx, which is needed to drive the bolus into the esophagus

esophageal phase (disordered swallowing)

If peristalsis is slow or absent, the complete bolus might not be transported to the stomach

– Residue on the esophageal walls can result in infection and nutritional problems

– Reflux from retained material in the esophagus may reach the level of the pharynx, increasing risk of aspiration after the swallow

etiologies of pediatric and adult dysphagia

Infants and children with feeding and swallowing disorders may experience

– Malnutrition

– Inadequate growth

– Dehydration

– Ill health

– Prolonged feeding times

– Fatigue

– Difficulty learning

– Poor parent-child relationships

Children with central or peripheral nervous system deficits or immaturity, neuromuscular disease, and craniofacial anomalies are vulnerable to pediatric dysphagia

etiologies of feeding and swallowing disorders

Prematurity

– Cerebral palsy

– Intellectual and developmental disability

– Autism spectrum disorder

– Craniofacial anomalies

– Stroke

– Head and neck cancer

– Parkinson disease

– Traumatic brain injury

– Dementia

lifespan issues in feeding and swallowing disorders

Feeding and swallowing problems may occur at any point in the lifespan

• Newborns may be unable to suckle and/or ingest nutriment

• Infants may refuse food and develop unhealthy food preferences

• Neuromotor problems and structural abnormalities that are congenital or acquired can interfere with feeding and swallowing

• The outcomes of a swallowing disorder include dehydration, malnutrition, poor health, weight loss, fatigue, frustration, respiratory infection, aspiration, and death

evaluation for swallowing

• Not everyone with the etiologies listed will have a swallowing disorder

• Swallowing problems may not be readily apparent

• Patients may not report difficulties, and some may experience silent aspiration

• The first step is to screen individuals at risk for dysphagia

screening for dysphagia

• A primary indication of dysphagia in infants is failure to thrive

• Infants in a neonatal intensive care unit are monitored for weight gain and development

• Full-term infants who are not accepting breast or bottle are signaling feeding problems

• Infants are observed during mealtimes to evaluate breathing and physical coordination, oral-motor functioning, and techniques that enable quantification of nutritive and nonnutritive sucking skill

• Caregivers can be counseled and instrumental evaluation recommended when warranted

yale swallow protocol (YSP)

• Brief cognitive screen

• Oral mechanism examination, and a 3-ounce water challenge

• The patient passes the screening if they drink the entire 3 ounces of water without stopping and without coughing, choking, or other signs of aspiration

• If they fail, it is recommended they undergo instrumental swallow examination

assessment for dysphagia

• Self-assessment checklists may be used to obtain information from the adult patient’s perspective

• When feeding or swallowing difficulties are suspected based on the screening, or the patient is at risk for feeding and/or swallowing difficulties, additional clinical assessment is needed

• Instrumental assessment may be recommended to confirm clinical findings, determine the underlying nature of the swallowing disorder, or when pharyngeal dysphagia is suspected

clinical swallow evaluation (CSE) or bedside swallow evaluation

The clinical swallow evaluation (CSE) or bedside swallow evaluation is an important part of the comprehensive evaluation of dysphagia

• Case history and background information

• Thorough case history is obtained, including the chief complaint, current physical and neurological status, medical conditions, recent surgeries, or medications

• Three concerns that might result in a referral

▪ Difficulties observed related to feeding and ingestion of food or liquid

▪ Client appears at risk for aspirating food or liquid

▪ Client appears to not be receiving adequate nourishment

cognitive-communication functioning in clinical swallow evaluation

• Determine alertness/wakefulness, ability to follow directions, ability to respond to questions, attention and recall, orientation, and general functioning

caregiver and environmental factors in clinical swallow evaluation

Is the caregiver patient and attentive?

• Does feeding take place in a quiet environment?

• What position is the client when eating or drinking?

How does the client express feeding preferences?

• Careful observation and communication will help the SLP assess how best to improve caregiver contributions

• Personal and cultural desires should be respected and accommodated

oral mechanism in clinical swallow evaluation

• Abnormalities of the lips, teeth, tongue, palate, and velum are noted

• Look for facial symmetry and note weakness

• Motor difficulties such as tremor, flaccidity, excessive muscle tone, and poor coordination are noted

• Oral reflexes and sensation are examined

• Checking for a strong, protective cough indirectly assesses laryngeal function

• Poor oral hygiene, which can occur following prolonged illness, is a risk factor for aspiration and aspiration pneumonia

swallow trials in clinical swallow evaluation

• If a client is alert and manages his/her saliva without signs of aspiration or respiratory compromise, swallow trials may be conducted

• The SLP provides various foods or liquids for the patient to try and will look, listen, and feel for indications of difficulty swallowing

• Overt symptoms of aspiration (coughing, throat clearing) are observed

• The SLP will determine if the patient has a protective cough

• Patient readiness for eating and drinking is assessed

• The SLP will watch how well the patient eats with utensils and drinks from a cup

• Observes and feels the movement of the hyoid bone and thyroid cartilage by watching and placing a finger gently on this area

• Records the number of times the client swallows each trial of food or drink

• Multiple swallows may suggest inadequate pharyngeal contraction and pharyngeal residue

• Of importance is which food consistencies appear to cause difficulties and which seem to be swallowed efficiently

managing a tracheotomy tube in clinical swallow evaluation

• Tracheostomized patients are at increased risk of aspiration

• The swallowing evaluation includes all components of the CSE and instrumental swallow examination when pharyngeal dysphagia is suspected

• The tracheostomy cuff should be deflated and a speaking valve placed, if possible, prior to assessment

• Speaking valves can increase swallowing efficiency and decrease aspiration risk by facilitating expiration through the upper airway after swallowing

• This helps expel food or liquid that might be misdirected toward the trachea during swallowing

instrumental swallow evaluation

Although the CSE is useful in identifying the presence or absence of a swallowing problem, it cannot adequately determine the nature or severity of dysphagia of the pharyngeal phase

• Complete, accurate assessment of swallowing requires the use of instrumentation

videofluoroscopic swallowing study

• Videofluoroscopy is also referred to as a modified barium swallow study (MBSS)

• Video X-ray procedure performed in a radiology room and is used when clinical evaluation or screening suggests dysphagia and/or aspiration

• Barium is prepared in different viscosities of liquid and can be added to foods

• SLP determines size, texture, and consistency of the food or beverage to be presented and the head and body position during the study

• A radiologist or X-ray technician use equipment to observe movement of the barium during the swallow

• The views are digitally recorded for later analysis by the physician and SLP

fiberoptic endoscopic evaluation of swallowing

• Involves insertion of a flexible fiberoptic laryngoscopy by the SLP through the patient’s nose and into the pharynx

• The patient may be asked to cough or hold their breath to evaluate anatomy and physiology and swallow foods of different textures and thicknesses that have been dyed

• It may reveal bolus spilling into the pharynx before swallowing, and residue may be seen after the swallow

• Oral and esophageal phases are not visible with FEES

• FEES can provide information about body and head posture, preferred food types, and aspiration

• FEES may be preferred for head and neck cancer patients and for those with anatomical changes following surgery, trauma, or cranial nerve damage

compensatory strategies (treatment of swallowing disorders)

temporary measures to maintain client safety with oral intake of food or liquids

do not involve changes to swallowing physiology

• Support safe and adequate nutrition and hydration

• Minimize the risk of respiratory complications

• Maximize quality of life

direct rehabilitation strategies (treatment of swallowing disorders)

accomplished during swallow

aim to change swallowing physiology by accelerating recover of swallowing function

help maintain swallowing function in progressive diseases or develop skills needed for feeding and swallowing effectiveness and efficiency for pediatric disorders

indirect rehabilitation strategies (treatment of swallowing disorders)

exercises that theoretically improve swallowing without the patient having to swallow

aim to change swallowing physiology by accelerating recover of swallowing function

help maintain swallowing function in progressive diseases or develop skills needed for feeding and swallowing effectiveness and efficiency for pediatric disorders

feeding environment

• Modifying the environment to ensure that it is conducive to success during meals is important

• Visual and auditory distractions should be minimized

• Eating area should not contain irrelevant items

• Lighting should be comfortable and noise reduced

• Caregiver should be relaxed and tuned in to the client regarding feeding speed, food preferences, and quantity

• Attention and focus to the person being fed and reinforcement of healthy, effective eating behaviors are important

• When possible, the goal is the development of self-feeding skill

utensil modification (feeding environment)

• Utensils for feeding need to be appropriate

• For infants, a slow-flow nipple may be helpful

• A Teflon or latex-covered spoon may be used for children with immature oral reflexes who may bite hard on any object placed in the mouth

• Children and adults with motor coordination difficulties may benefit from using a shallow bowled spoon

• Special cutout cups may help improve tongue positioning when drinking

• Eliminating the use of a straw may be helpful in managing amount of liquid ingested

modification of foods and liquids

Certain foods that are hard to chew, small or slick when wet, or are thick and sticky may need to be eliminated

• Elimination of certain unsafe or difficult to swallow items may be sufficient to eliminate risk of aspiration

• For others, a range of food consistency requirements might be recommended

• Modifications to food consistency may improve chewing, increasing efficiency and safety during meals

• Increasing liquid thickness can improve control over liquids by slowing the flow of liquid through the pharynx and reduce risk of aspiration and penetration of liquids into the airway

internal dysphagia diet standardization initiative (IDDSI)

an international, standardized, culturally sensitive system to describe modifications to foods and liquids that improve the safety and efficiency of swallowing

• was developed to improve consistency of terminology across health care settings around the world and standardized measurement procedures to ensure correct food identification and liquid viscosity

nonoral feeding

• Clients who require more than 10 seconds to swallow a liquid or food bolus or who aspirate more than 10% of either will likely require at least some nonoral feeding

nasogastric tube (NG) feeding

• A tube is placed through the nose that passes through the pharynx and esophagus, and finally into the stomach

• Liquefied food and water are inserted through this tube

• Usually temporary

percutaneous endoscopic gastrostomy (PEG, G-tube)

• A hole is surgically made from the abdomen to the stomach

• A soft tube is placed through this hole

• Blended regular food can be inserted into the tube

• May be a permanent means for nutrition and hydration

jejunostomy tube (J-tube)

• Like a G-tube but is inserted into the jejunum, or middle part of the small intestine

total parenteral nutrition (TPN)

• Bypasses the gastrointestinal tract and administers a specialized solution of nutrition through a vein

• All nonoral feeding methods are managed by physicians, such as a gastroenterologist, in consultation with a registered dietician

body and head positioning

• Body posture and stability have a strong influence on oral-pharyngeal movements

• An upright, symmetrical position with a 90-degree hip angle and sufficient postural support is optimal

• The head and neck must be positioned and prevented from making extraneous movement, as able

• Infants with severe respiratory and swallowing difficulties might feed better when placed on their sides

• For some adults with pharyngeal weakness on one side, laying on their side with the stronger pharyngeal side in the down position allows gravity to assist in bolus transport

compensatory positioning strategies

• Additional compensatory techniques

• Chin tuck posture

• Head-back position

• Head tilt

• Head rotation

• Compensatory positioning strategies require patient compliance, adequate intellectual abilities, and the physical capability to complete maneuvers and manage swallowing disorders effectively

exercise-based therapy

direct and indirect rehabilitative swallowing treatments

• Goal is to increase muscle strength and coordination to improve swallowing function

• Tongue exercise programs that aim to increase tongue strength through progressive resistance training may indirectly result in swallowing-related changes such as improved bolus propulsion, clearance, and timing

• Tongue exercise protocols may be paired with swallow practice

• Exercise maintenance programs are needed

• Principles of exercise science guide the development of successful direct and indirect exercise programs that may improve swallowing physiology, including

▪ Task specificity

▪ Muscle load

▪ Resistance

▪ intensity

swallowing-specific excersis

direct and indirect rehabilitative swallowing treatments

swallow-specific

supraglottic and super-supraglottic swallow exercise

effortful swallow exercise

Direct and Indirect Rehabilitative Swallowing Treatments

▪ The person is instructed to swallow while squeezing their muscles

▪ Improves retraction of the base of the tongue toward the posterior pharyngeal wall, helping with bolus propulsion

supraglottic and super-supraglottic swallow exercises

Direct and Indirect Rehabilitative Swallowing Treatments

▪ Teach voluntary closure of the glottal area via effortful breath-holding, with the additional instruction to bear down for the super-supraglottic swallow

Mendelsohn maneuver

Direct and Indirect Rehabilitative Swallowing Treatments

swallowing -specific exercises

direct and indirect rehabilitative treatment

▪ The patient is taught to hold the larynx manually at its highest point during the swallow

▪ Useful for clients who do not have adequate laryngeal elevation to protect the airway

surface electromyography (sEMG)

Direct and Indirect Rehabilitative Swallowing Treatments

• sEMG can provide real-time information about muscle activation during swallowing

• The SLP can teach patients various exercises, such as the effortful swallow exercise, and watch the patient’s pattern of muscle activation on the sEMG monitor

• is used as a biofeedback tool for the patient as they can watch their muscle movements on the monitor and adjust to match the sEMG signal provided by the SLP

neuromuscular electrical stimulation (NMES)

• NMES is widely used despite the lack of large, randomized clinical studies to establish its efficacy

• NMES works by applying electrical stimulation to the neck area via surface electrodes, and eliciting contractions of the targeted muscles for swallowing

• It is hypothesized that swallowing muscles will be strengthened, and sensory pathways for swallowing enhanced

• NMES combined with swallowing-specific exercises results in better outcomes for post-stroke patients

protheses and surgical procedures

Direct and Indirect Rehabilitative Swallowing Treatments

• Patients who lack an intact swallowing mechanism because of malformation, surgery, or another cause may benefit from using a prosthetic device

• Individuals who had oral cancer and have had a significant portion of the soft palate excised may have a palatal obturator

• Patients requiring a partial or complete glossectomy due to oral cancer may be fitted with a tongue prosthesis

• Treatment strategies are needed to optimize the use of a tongue prosthetic device

• If less invasive approaches have been unsuccessful, surgery to improve swallowing and prevent aspiration is sometimes needed

• If a patient has bony growths on the cervical vertebrae that displace the rear pharyngeal wall, these may be reduced surgically

• Other surgical procedures are used to increase the dimensions of the vocal folds or elevate the larynx

treatment effectiveness and outcomes for swallowing disorders

• Objectives are to improve the intake of food and drink and to prevent aspiration

• Potential success is determined by the cause, severity of aspiration, and onset of treatment

• Early identification and successful intervention reduces risk of aspiration and death, shortens the length of time patients need to stay in the hospital, and improves quality of life

• SLPs are successful in preventing dysphagia in some cases

• Caregivers of youngsters who are at risk are instructed in feeding techniques soon after the child’s birth

• Among older adults, swallowing disorders are sometimes related to poor dentition, which might be corrected by appropriate dental care

• SLPs can also provide education and training to caregivers who assist elderly individuals with feeding to prevent malnutrition and dehydration

• Overly restrictive diets can lead to poor oral intake and reduced quality of life • More liberal diets that are still safe are recommended for older adults