746 Exam II

What is a Zenker's Diverticulum

A pouch in the wall of the puyniform sinus

How is a Zenker's diverticulum formed

by the pressure from the bolus and the UES not opening

How do you find a Zenker's Diverticulum and how is it treated

Video fluroscopy and surgically

How does an anterior cerbical spine surgery impact swallowing

The larynx is displaced to access the posterior pharyngeal wall. The pharynx is then cut open to access the spinal cord

How does the tissure respond during the anteriro cerbical spine surgery

the muscle becomes inflammed the impacts only last about 4 days

what are complications with an anterior cervical spine srugery

age posteriro fusion Cervical spondylosis/other degenerative spinal diseases Combined anterior/posterior procedures

What are neoplasms

tumors

How do tumors impact swallowing

Distort swallowing Obstruct swallow Reduce swallowing movement Impair motor and sensory functions

Location of the swallowing valves that can be imapcted by tumors and cause dysphagia

Lip seal anterior tongue posterior tongue palate velopharyngeal region larynx UES

What are post surgical complications assocated with head and neck cancers

malnutrition dehydration aspriation and pneumonia

What are possible surgical locations for head and neck tumors

lip surgery floor of mouth surgery lingual surgery palate surgery mandibular surgery oropharyngeal surgery hypopharyngeal surgery laryngeal surgery

what is a tracheotomy

surgical incision into the trachea to establish an airway

how it a trach different than a stoma

trach is temporary

what are the reasons for a trach

tumor trauma edema they need ventilator support but they cannot stay on it forever management of pulmonary hygiene

what % of people on trachs aspirate

43-83%

what issues to trachs cause

exposure to unfiltered air impaired cough loss of postive end of aspiration presssure impacts to swallowing

What is a speaking Valves (Passi Mirror Valve)

allows air into the trach but does not let air out -the exhaled air must travel around the trach tube and through the VF out the mouth of the nose

How do you know if you can put a speaking valve on?

If they can exhale air around the deflated cuff

Can you put a valve on someone that has an inflated cuff

NO the cuff must be deflated

Can you voice with a passi mirror valave?

yes you have an improved cough and it restores subglottic air pressure

Team members on a dysphagia team

SLP dietitian radiologist pulmonogist neurologist RN

Tyoes of swallowing evaluations

Dysphagia screeners (nuring) swallowing self-assessments bedside/clinical swallow eval video fluroscopic swallowing/modified barium swallow fiber optic endoscopic evaluation (FEES)

what 5 things are evaluated in a clinical swallow eval

Identify current swallowing functions identify presence of potential cause of dysphagia (what stage) identify strategies to ensure immediate swallow safety Develop a plan for swallowing management Determine the impact on quality of life

Clinical swallow examination advantages

quick immediate results cost efficient repeatable

Clinical swallow examination disadvantages

not standardized wide variation for interpretation very limited visualization inadequate for a complex case

When would you do a bedside eval only?

When they are too critical to be transported

When would you do a bedside swallow eval and then an assessment?

When you cannot confidently say they swallow safely or they 100% swallow incorrectly

When would you skip the bedside eval and go right to the instrumental examination?

o Someone that is a known silent aspirator and aspirator o Brainstem stroke in the medulla o Someone that uses suction to control their secretions (because they are not swallowing)

What are the two types of instrumental swallowing assessments

Fiber Optic Endoscopic Evaluation Swallow (FEES) Videofluroscopic Swallow Study (Video swallow/VFSS) or modified barium swallow study (MBS)

What to instrumental swallowing assessments assess

-anatomy and physiology -determine presence cause and severity of dysphagia -determine the presence of silent aspiration

FEES

Helpful to see pre and post swallowing skills not good to see actual swallow as the camera turns white when the epiglottis flips over and it refelct the light *give pt dyed liquid trials

Videofluroscopic swallow study (VFSS)

real time imagery of oral pharyngeal esophageal swallowing stages to determine dysphagia

what can you see from VFSS

pharyngeal stripping wave pharyngeal contraction pharyngeal UES opening tongue base retraction pharyngeal residue esophageal clearnece in upright position

8-point penetration-aspiration scale

a way to describe swallowing

oral hygiene

is very important for health. If you are going to aspirate do it with a clean mouth

what are the two main types of swallowing intervention

compensatory and rehabilitative

what is compensatory swallowing therapy

the focus is on improving swallowing safety not improving the physiology of swallow

what can you do to treat swallowing using compensatory strategies

swallowing maeuvers swallowing postures thermal/tactile oral stim

various swallowing maneuvers (5)

Supraglottic swallow super-supraglottic swallow effortful swallow mendelson meneuver tongue hold meneuver

what is the supraglottic swallow maneuver and the purpose

breathing in before swallow swallow and then cough after -helps to close the VF before during and after swallow

super-supraglottic swallow and purpose

same as SS but "bear-down" during the swallow to increase VG adduction (especially posterior portion of the glottis)

What is effortful swallow and purpose

"swallow while squeezing all your muscles as tightly as you can" to increase tongue base movement and pharyngeal pressure

What is the mendelsohn maneuver and purpose

pt catches the swallow at the apex of the laryngeal elevation. Hold it for several seconds. Helps to extend the duraiton of the UES opening

Tongue hold maneuver (Masako maneuver)

Hold tongue between the front teeth and swallow. Used to incrase time and pressure of tongue base against pharyngeal wall

swallowing postures

head back chin down head rotation head tilt

Head back posture and purpose

Head tilt back and swallow uses gravity to help with the oral transport of bolus (not the best)

Chin down posture and purpose

Put chin down. Protects airway by repositioning the tongue base and epiglottis which narrows the supraglottic region. Needs to keep chin tucked until swallow is completed.

Head rotation posture and purpose

rotate head to the weak side to "crush" it so the bolus goes down the stronger side

head tilt

tilting head to the stronger side to help gravity send the bolus into the neurologically intact side

Rehabilitative swallowing therapy

To improve long-term swallow

types of oral motor exercises

lip tongue jaw and larngeal exercises

Lip exercises

/u/ and /i/ to increase lip production hold different objects between your lips

tongue exercises

tongue tip elevation use /t/ and /d/ and /k/ and /g/ for tongue movement

jaw exercises

trismus-inability to open jaw tongue depressors stacked to open jaw

laryngeal exercises and purpose

sustained phonation increase loudness of the voice

Shaker exercise and purpose

Lay flat on back shoulders maintain contact with surface. Hold head up for one minute while looking at your feet. Then relax for a minute and repeat

Chin tuck against resistance and purpose

place small ball under chin and compress by tucking chin. To improve UES opening

Expiratory muscles strenght training and purpose

One-way valve used to prevent expiration until sufficient expiratory pressure is produced. Used to strenghten respiratory muscles

Neuroplastic principles

Use it or lose it Use it and improve it Specificity: your therapy should be very close to at home expectations Transference: therapy should support other skills

Factors that contribute to the prevention of aspiration pneumonia

prior history of aspiration mobility age state of conscriousness respiration status

Neuromuscular Electrical Stimulaiton (NMES)

Surface level placement of electrodes on neck for the potential benefit of laryngeal elevation -pt must have intact LMN system (peripheral nervous system) -does not speed up the swallow

Pharyngeal Electrical (sensory) stimulaiton

Tells CN IX "wake up" Sensory input not motor Sensation will lead to a motor response

high viscocity

thick great resistance to flow

Low viscosity

thin flows easily

problematic foods

Crumbly and non-cohesive foods (carrots) Mixed consistencies (vegetable soup) Sicky foods (bread)

Frazier Water Protocol (free water protocol)

gives individuals access to water. Need to have a clean oral cavity

Presbyphagia

age related swallowing functions in healthy individuals that may include slower and weaker swallows

Changes associated with aging

cognition, cortical changes, oral changes, pharyngeal stage, esophageal changes

Dementia challenges

loss of food recognition
loss of appetite
difficulty coordinating feeding
declining communication abilities