acquired dysphagia

Name a few symptoms of dysphagia

Difficulty putting food in the mouth

Inability to control food or saliva

Coughing before, during, or after swallowing

Coughing at the end/shortly after a meal

Recurring pneumonia

Gurgly voice quality

Feeling of "something stuck in throat."

Food refusal or change in diet

Weight loss, dehydration, malnutrition

Dysphagia

Difficulty or discomfort in swallowing.

Aspiration

Bolus enters below the true vocal folds

Penetration

Bolus enters the airway above the vocal folds

Residue

Food or liquid remains inappropriately

Backflow/Reflux

Bolus returns to pharynx/esophagus (not visible on FEES)

What triggers the swallowing mechanism?

The medulla triggers swallow based on sensory/motor patterns.

What initiates the swallow process?

Feedback from tongue movements initiates the swallow.

Which parts of the brain coordinate swallowing?

The cerebral cortex and cerebellum coordinate timing and motor movements.

V - Trigeminal

Sensory: jaw, teeth, lips, cheeks, tongue, hard palate; Motor: chewing

VII - Facial

Sensory: soft palate, taste anterior ⅔ tongue; Motor: facial muscles, stylohyoid

IX - Glossopharyngeal

Sensory: tonsils, pharynx, soft palate, posterior ⅓ tongue; Motor: pharyngeal elevators, Salivation, gag reflex

X - Vagus

Sensory: larynx, pharynx, trachea, esophagus; Motor: larynx, palate, pharynx, Key to swallowing

XI - Accessory

Motor: pharynx, extrinsic larynx, uvula, Key to swallowing

XII - Hypoglossal

Motor: tongue muscles, strap muscles of the neck, Tongue movement

Partial Recovery

Stroke, operable brain tumor, surgical recovery, TBI

Progressive

Dementia, ALS, MS, Parkinson's, post-polio, myasthenia gravis, muscular dystrophy, rheumatoid arthritis (vocal fold closure), COPD, non-operable brain tumors

etiology structurally

Head & neck cancer

Cricopharyngeal hypertrophy

Zenker's diverticulum

Cervical neck disease (osteophytes)

Iatrogenic (Treatment-Induced)

Tracheostomy/ventilator

Drug-induced: decreased sensation, taste, and oral moisture

Post-surgical: thyroid surgery, Graves' disease

Always review patient medications

Psychiatric/Behavioral

Globus pharyngeus, delirium, mania, and alcohol-related issues

Systemic

Myositis, HIV/AIDS, oral/pharyngeal/esophageal lesions, Candida (thrush), GERD

What is the first stage of digestion?

Oral Stage

What happens during the Oral Preparatory phase?

Jaw and lips are closed, and the tongue positions food.

What is mastication?

Rotary chewing of food.

What role does saliva play in the oral stage?

It moistens and breaks down food.

What is bolus formation?

The tongue presses food against the hard palate.

What prevents spillage during chewing?

Labial and buccal muscles.

Voluntary

Choosing food

Jaw

Opens for bolus

Lips

Labial seal

Teeth

Biting/chewing

Mandible

Rotary chew

Buccal muscles

Prevent lateral spillage

Saliva

Moisture & breakdown

Bolus formation

Process of forming a bolus

Velum-tongue contact

Contact between velum and tongue

Labial seal

Final check

Oral Transit Stage

The tongue moves the bolus back to the anterior faucial pillars

What happens to the soft palate during the pharyngeal stage of swallowing?

The soft palate elevates.

What action does the base of the tongue perform during swallowing?

The base of the tongue pushes the bolus.

How do the pharyngeal muscles contract during swallowing?

Pharyngeal muscles contract top-to-bottom.

What causes the UES to open during swallowing?

UES opens due to hyoid elevation, bolus weight, and negative esophageal pressure.

What mechanisms protect the airway during swallowing?

Hyoid/larynx elevate, epiglottis invert, vocal folds close.

What begins the esophageal stage of swallowing?

UES opening

What marks the end of the esophageal stage?

When the bolus enters the stomach

What two factors move the bolus during the esophageal stage?

Peristalsis and gravity

What happens to the larynx during the esophageal stage?

The larynx lowers

What contracts to prevent reflux during the esophageal stage?

PE (pharyngoesophageal sphincter)

What is the duration of the esophageal stage?

3-20 seconds, slower with age

Silent aspiration

Occurs with loss of airway sensation

Screening

Less than 15 minutes to identify need for further assessment

Observations in screening

Medical history, recurrent pneumonia, respiratory status, vocal quality, cough, swallowing frequency, chest secretions, eating behavior

Bedside/Clinical Evaluation

Includes pre-feeding exam, oral-motor exam, and feeding/swallow exam

Pre-feeding exam

Assesses mental status, dentition, oral mucosa, respiratory status

Oral-motor exam

Evaluates facial symmetry, mandibular/labial/lingual/velum function

Feeding/swallow exam

Examines positioning, food consistencies, oral stage function (lip seal, mastication, tongue manipulation, oral residue)

Instrumental Assessment

Includes FEES and VFS

FEES

Fiberoptic Endoscopic Evaluation of Swallow

Pros of FEES

No radiation, superior pharyngeal anatomy view, bedside possible

Cons of FEES

Invasive, nasal bleeding risk, no oral stage view

Indications for FEES

Fatigue, hypernasality, biofeedback, pharyngeal dysphagia monitoring

VFS

Video Fluoroscopic Swallow Study (Modified Barium Swallow)

Pros of VFS

Defines the cause of aspiration, evaluates compensatory strategies

Cons of VFS

Radiation exposure, must participate, size limits

Observations in VFS

Tongue movement, spillage, residue, laryngeal elevation, epiglottis, UES opening, pharyngeal peristalsis

What is dysphagia therapy?

A treatment approach focused on improving swallowing function and ensuring adequate nutrition and hydration for individuals with swallowing difficulties.

What are the key components of dysphagia treatment planning?

Assessing nutrition and hydration, evaluating patient candidacy for treatment, and determining treatment prognosis.

What are compensatory postures in dysphagia therapy?

Techniques that involve positioning the body to facilitate safer swallowing and reduce the risk of aspiration.

What is bolus modification?

The process of changing the size, texture, or consistency of food or liquid to make swallowing easier and safer.

What is adaptive equipment in dysphagia therapy?

Tools and devices designed to assist individuals with swallowing difficulties, such as specialized utensils or cups.

What are physiotherapeutic exercises?

Exercises aimed at strengthening the muscles involved in swallowing and improving coordination.

What is sensory augmentation?

Techniques used to enhance sensory input to improve swallowing function, such as using flavors or temperature variations.

What is biofeedback in dysphagia therapy?

A technique that uses monitoring devices to provide feedback to patients about their swallowing performance, helping them improve their technique.

What are postural techniques?

Specific body positions used during swallowing to enhance safety and efficiency.

What are swallowing maneuvers?

Specific techniques that patients can use to improve their swallowing function, such as the Mendelsohn maneuver.

What is voluntary control in dysphagia therapy?

The ability of a patient to consciously control the swallowing process to enhance safety and effectiveness.

What are additional considerations in dysphagia management?

Factors such as prosthetic management for cancer patients, surgical or medical interventions, non-oral feeding options, and counseling or education for patients and families.