Dysphagia (CD 5671)

Signs symptoms of Dysphagia and/or Aspiration (indicators for referral)

Aspiration pneumonia

Clinical signs

coughing during swallowing
fever
congestion
lung infiltrates

Diagnosis

CXR
history

Risk factors (Langmore et al., 1998)

Dependent for feeding
Dependent for oral care
Decayed teeth
Tube feeders
Multiple medical diagnoses
Multiple medications
Smoking
Dysphagia (in the presence of other risk factors)
Intra-operative (not reported in the study)

Other signs of dysphagia

prolonged chewing
prolonged meals
failure to swallow
food left in mouth after swallowing
food falling out of the mouth
food refusal
painful eating

Normal oropharyngeal swallow

Oral phase (usually less than one second with liquids)

preparatory

lip seal
lateral resistance by cheeks
posterior seal by tongue and palate
oral manipulation of the bolus by tongue
jaw movement
mastication
food mixes with saliva

oral

tongue tip elevates and tongue blade pushes bolus posteriorly
triggers pharyngeal swallow

Pharyngeal phase

elevation and retraction of velum
pharyngeal constriction/peristalsis
hyoid moves anteriorly and superiorly
elevation and closure of larynx

epiglottic inversion
false vocal cords
true vocal cords

relaxation of cricopharyngeal sphincter

Esophageal phase

Peristalsis

Forces moving bolus from oral cavity to esophagus

Posterior tongue movement
Pharyngeal peristalsis
Negative pressure in esophagus
Gravity

Age-related changes
Infants

Anatomy

tongue takes up a large portion of the mouth
fatty tissue "sucking pads" in the masseter

help to stabilize cheeks
disappear by 4-6 months

larynx is suspended higher in pharynx

epiglottis touches velum

infants are total nose breathers
jaw, tongue, cheeks, lips work as a single control unit

Function

oral

suck/swallow pattern
rotary jaw motion during chewing develops from 1-3 years
fluid may be collected in valleculae prior to swallow

pharyngeal

reduced laryngeal elevation
epiglottis does not invert until about age 5

Older adults

increased chewing
reduced sense of taste and smell
increased use of dipper bolus hold
longer oral phase
later trigger of pharyngeal swallow
mild increase in oral and pharyngeal residue
reduced laryngeal elevation
increased frequency of penetration
slower and less efficient esophageal clearance

Neurogenic disorders

dysfunction depends on pathways affected. As high as 1/3 of pts referred for neurogenic communication disorders will also have dysphagia
Stroke

UMN (cortex, internal capsule, tracts)

reduced alertness
spastic dysarthria
weakness, reduced coordination

poor oral control
reduced gag reflex
delayed swallow reflex
reduced pharyngeal peristalsis

RH stroke can result in impaired judgement

Brainstem

reduced alertness
can result in flaccid dysarthria
weakness, reduced coordination
reduced laryngeal adduction
impaired cricopharyngeal functioning

Traumatic Brain injury

cognitive problems including attentional deficits, impulsivity, poor reasoning
reduced oral control
delayed or absent swallow reflex
reduced pharyngeal peristalsis
reduced laryngeal sensitivity to penetration
tracheo-esophageal fistula secondary to long-term intubation

Cervical Spinal Cord injury

absent or delayed pharyngeal swallow
reduced pharyngeal peristalsis
reduced base of tongue retraction
reduced laryngeal elevation or closure
UES dysfunction

Tumors

depends on site of lesion

ALS (UMN & LMN disease, progressive)

difficulty with lingual control and oral manipulation of the bolus
nasal regurgitation
delayed initiation of the swallow
reduced pharyngeal peristalsis
reduced laryngeal elevation
UES dysfunction
esophageal reflux
esophageal dysmotility
progressive respiratory insufficiency and weakness of abdominal muscles

Parkinsons (degeneration of substantia nigra, results in tremor, rigidity, and bradykinesia; progressive)

tongue tremor with reduced initiation of lingual movement
repetitive tongue-pumping action
lingual festination (posterior part of the tongue remains elevated, preventing passage of bolus into the pharynx)
reduced swallowing frequency
delayed pharyngeal swallow
reduced pharyngeal peristalsis
inadequate laryngeal elevation and/or closure
reduced laryngeal sensitivity to penetration
repetitive, involuntary reflux from the valleculae and pyriform sinuses into the oral cavity
UES dysfunction
reduced esophageal peristalsis
dementia

Progressive Supranuclear Palsy (affects basal ganglia, cerebellum and brain stem-- results in pseudobulbar palsy, dysarthria, dystonia, severe rigidity of the head and neck producing a back-ward retracted head position)

hyper-extended neck posture
excessive lingual and velar movements
impaired oral anterior-posterior bolus transport
delayed initiation of the pharyngeal swallow

Huntington's disease (characterized by involuntary movements, dementia, and emotional impairment)

neck and trunk hyperextension
involuntary movement of the body, head, and oral motor structures that interfere with oral phase
absent or inefficient mastication
irregular breathing patterns that interrupt the normal reciprocal respiration-deglutition cycle
pharyngeal dysmotility
uncoordinated and asynchronous vocal cord adduction/abduction

Muscular Dystrophy (40 separate Neuromuscular disorders which have in common the progressive and irreversible wasting of muscle tissue. Some of these diseases are known as dystrophies, the wasting of the muscles from within themselves. Others are atrophies, wasting arising from a disorder originating in the nerve system which causes loss of the ability to use muscles. There is no cure for Muscular Dystrophy.--from MDA web-site)

generalized pharyngeal weakness
UES dysfunction
reduced pharyngeal peristalsis

Myasthenia Gravis (characterized by fatigue and exhaustion of the muscular system caused by damage to acetylcholine receptors at the myoneural junction)

overall reduction in oral preparatory phase
reduced lingual motility
nasal regurgitation
reduced pharyngeal peristalsis
slowed esophageal transit
progression of symptoms with continued eating

Post-polio Syndrome

excessive tongue pumping and lingual movements
difficulty with bolus control because of lingual and/or velar weakness
delayed pharyngeal swallow
reduced pharyngeal peristalsis, often asymmetric
reduced laryngeal sensitivity to penetration
UES dysfunction
GER and disordered esophageal dysmotility

AIDS

most problems cause by infections to CNS or local infections of mouth, pharynx, larynx, esophagus, and lungs
odynophagia
dementia

Dementia

Diseases with associated dementia

Parkinsons
MS
Huntingtons
Pick's disease
Cruetzfeldt-Jakob disease

may reduce ability to use compensatory techniques
reduced initiation of oral preparatory lingual and mandibular movements
protracted and nonpurposeful bolus processing
loss of bolus control
prolonged oral transit
delayed pharyngeal swallow
may need assistance with feeding

Psychogenic

anxiety
strained strap musculature

Mechanical disorders

Acute inflammations

Herpes simplex

Palatal and pharyngeal ulcers may cause odynophagia

Ludwig's angina

massive swelling and displacement of the tongue
mouth pain
stiff neck
drooling
dysphagia

Tonsillitis, epiglottitis, pharyngitis
Lateral pharyngeal space infections
Candidiasis (thrush)

fungal infection
odynophagia
poor oral control

Chemical irritants

Pharyngoesophageal diverticulum (Zenkers)

abnormal muscular outpouching that forms either above the CP or below
usually only large tic's are symptomatic

regurgitation of undigested food
foul breath
fullness in the neck
weight loss
nocturnal cough or aspiration

Carcinoma

Apply "50%" rule with caution
Complications arise from loss of structure and loss of sensation
Oral lesions

mastication
formation of bolus
anteroposterior transport
oral seal

Oropharyngeal lesions

tongue, velum, tonsils, BOT, superior or lateral pharynx
nasal regurgitation
decreased bolus transit
aspiration
UES dysfunction

Partial laryngectomy

hemilaryngectomy (unilateral excision of the vocal fold, vestibular fold, ventricle, and superior laryngeal nerve with preservation of the epiglottis)

reduced vocal cord adduction
reduced laryngeal elevation
retention, aspiration

supraglottic laryngectomy (resection of both vestibular and aryepiglottic folds and one or both superior laryngeal nerves, includes epiglottis)

pre-reflex aspiration
reduced peristalsis
UES dysfunction resulting in post-reflex aspiration

total laryngectomy

low risk of aspiration
risk for pharyngeal dysmotility
UES dysfunction, stricture
structural deviations causing pockets
TEF

leakage through or around the prosthesis
aspiration of the prosthesis
pharyngeal or esophageal stenosis
infection
development of secondary fistulas

Irradiation

oral and pharyngeal inflammations
diminished volume and thicker consistency of saliva
change in taste, sensation
loss of appetite

Cervical Spine Disease

osteophytic changes may reduce pharyngeal space
interfere with epiglottic inversion

Nasogastric tubes

pharyngeal retention
hypersalivation
depressed cough reflex
laryngopharyngeal injuries
GER
dislodgement of tube into trachea

Artificial Airways

Endotracheal tubes

from mouth or nose through vocal cords to trachea
cannot speak or eat while in place
prolonged intubation may result in

reduced VC closure
reduced sensitivity
laryngeal/pharyngeal scar tissue

Tracheostoma tubes

Features

outer & inner cannula
cuff

air
foam

fenestration
"talking trach"
speaking valve

Effects on swallowing

mechanical interference

reduced laryngeal elevation

loss of subglottal pressure
loss of laryngeal air expulsion
reduced laryngeal and pharyngeal sensitivity
pressure on esophageal wall from cuffed tubes

The Dysphagia Management Team

Speech pathologist, coordinator
Physicians

radiologist
pediatrician
physiatrist
neurologist
ENT
GI

Dietitian

nutrition support team

Nursing
Other

Occupational therapy
Physical therapy
Social work
Psychology

Team Assessment of Dysphagia in Adults

Goals

identification

presence or absence of a problem
occurrence of aspiration

description

nature of the problem
severity of the problem
conditions under which aspiration occurs

etiology
identification of compensatory techniques
"identification of the conditions under which a person may eat safely"

Bedside (clinical) assessment

clinical history

chart review

medical status

reason for admission
PMH

neurological history
hx of H&N Ca

Tumor (T x-4)
Node (N x-1)
Metastasis (M x-1)

previous pneumonias

respiratory difficulties

need for O2
Presence of ET or trach

level of alertness
GI history

nutrition status

current diet
nutrition status

weight
nutrition labs

ALB 3.5 g
Pre-alb <15 mg

calorie/protein intake

medications

psychotropic medications
sedatives

radiology reports

head CT
CXR

infiltrates (RML & RLL)
pleural effusion

increased fluid in pleura, takes up space in lung

barium esophagram
UGI

surgical/procedure reports

ENT reports
Endoscopy reports

reports from other therapies
nursing reports

alertness
difficulty eating

patient interview

nature of problem
onset and duration
progression (gradual vs sudden)
constant vs intermittent
sticking sensation

where
with what

coughing/choking

with what

pain

where
when

liquids easier than solids
heartburn/reflux
nasal reflux
dry mouth
weight loss
appetite change
food preferences (for assessment)
voice change

oral motor examination

structure

facial symmetry
dentition
oral cavity
tongue
velum
oropharynx

function

lips

retraction
protrusion
closure

tongue

protrusion
elevation
lateral extension

velum

gag reflex
phonation

larynx

vocal quality
cough

sensitivity

light touch
hot/cold

swallow assessment

format will depend on functional level of patient

first food trial
currently eating

dry swallow
response to stimulation

pressure to lips and tongue
empty spoon on tongue
lemon swab on lips and tongue
thermal stimulation

response to food consistencies

oral phase

drooling
mastication
bolus formation

tongue movement
salivation

oral clearance

anterior sulcus
lateral sulci
tongue body

reflexes

rooting
bite
oral defensiveness

pharyngeal phase

promptness
laryngeal excursion
vocal quality
cough
cervical auscultation

cessation of breathing
strong "clunk"
clear airway

Materials

dry swallow
non-food stimulated swallow
soft solid/puree
liquid
formable solids
particulate solids

Advantages

natural setting
normal food consistencies
can observe care giver

Disadvantages

limited primarily to oral phase
have to make inferences about pharyngeal, esophageal
cannot detect silent aspiration

Videofluorographic assessment (xrays using fluorescent screen to visualize motion)

set-up

media

barium liquid, thin consistency
esophatrast, paste
barium pill

food mixtures

juice
puree

pudding
applesauce

solid

cookie
cracker

accessories

cup
spoon
straw
10 cc syringe
basin
radiopaque identification numbers/letters

positioning

upright when possible
habitual feeding position
lateral view
A-P view
chairs

Vess
Hausted

personnel

speech pathologist
radiological technician
radiologist
respiratory therapist
ICU nurse
OT/PT

radiation precautions

lead aprons
radiation indicator badge
lead walls
restrict exposure

Instructions

"hold in your mouth until I tell you to swallow"
may have to present material simultaneously

cognitive deficits
auditory comprehension deficits

Order of materials

least risk
most important

Order of views

lateral identifies aspiration
A/P identifies symmetry

Contra-indications

decreased alertness
decreased cooperation
isolation requirements?

clinical signs

oral phase

mastication

oral retention

bolus formation

premature delivery
oral retention

bolus propulsion

pharyngeal retention
oral retention

bolus clearance

oral retention

pharyngeal phase

velar elevation

nasal reflux

epiglottic inversion

penetration during swallow
vallecular retention

laryngeal elevation

vallecular retention
penetration
pyriform retention

vocal cord adduction

penetration
aspiration during the swallow

peristalsis

pharyngeal retention

esophageal phase

cp dilation

pyriform retention

peristalsis

esophageal retention

structural integrity

stenosis
fistula
diverticulum

Decision-making

interpretation

primary & secondary impairments
primary & secondary disabilities
compensations

advantages

can visualize all phases of swallow
can often identify contributing impairments
can examine effectiveness of compensatory strategies

disadvantages

radiation exposure
unnatural environment
unnatural food consistencies
skilled observations
expensive

Other instrumental techniques

FEES

fiber-endoscopic evaluation of swallowing
Examining swallowing function using nasendoscopy
Advantages

does not require radiation
can use natural food materials (dyed)
can be conducted in speech clinic
good for observing (Langmore & McCullogh, 1997)

airway closure (TVC, FVC)
arytenoid mobility
amount and location of secretions
frequency of spontaneous swallowing
residue build-up
aspiration before and after the swallow
bolus coordination
fatigue over meal
altered anatomy
effectiveness of postural change

Disadvantages

invasive
cannot see larynx during the swallow
requires considerable skill
may not be covered by Medicare?

Ultrasound

Able to observe

tongue activity
bolus transportation
compensatory techniques
hyoid motion
lingual and floor muscles

Advantages

portable
normal postures
normal food materials
multiple plane imaging
less expensive
does not involve radiation

Disadvantages

unable to observe laryngeal functioning
can't see bone
aspiration is not visible

manometry

measures pressure changes
identifies disruption in peristalsis, UES

measures muscle activity
useful in identifying muscle dysfunction

Nuclear scintography

radioactive material is swallowed
later measurements determine where material ended up
assesses bolus movement, not oropharyngeal function

Team Management of Dysphagia in Adults

Post-Assessment Counseling

first step in therapy
results of study (visual aids when available)
recommendations and rationale

Compensatory techniques

Behavioral modifications

posture

trunk & head

upright
reclined
tilted to side; side-lying

head & neck

tilted to strong side
turned to weak side
tilted back

oral propulsion

tilted forward

premature delivery
vallecular retention
delayed swallow reflex

techniques and maneuvers

safe (supraglottic swallow)

hold breath
tip chin down
swallow
cough
swallow again
breathe

super supraglottic

bear down during supraglottic swallow

Mendelsohn

technique

prolong laryngeal elevation

prolong laryngeal protection
prolong UES dilation

Hard swallow

Food placement

between teeth
posteriorly
gavage feedings

thermal stimulation

reduced sensitivity

"common-sense" compensatory strategies

moistening foods
alternating consistencies
small bites and sips
chew well
double swallow
clear throat

Diet modifications

oral diets

bolus characteristics

viscosity
elasticity
particulateness

modifying liquids

materials

commercial thickener

Thicken-Up
Thick-it

corn starch, flour
rice or potato flakes

consistencies

thin
nectar
honey
pudding

modifying solids

regular
ground meats
mechanical soft
puree
particulate

nonoral diets

NG tube
G tube (~ $10,000 per year)

surgery required

percutaneous endoscopic gastrostomy
does not require general anestesia

J tube

jejunostomy
option for people with severe GER

TPN (>$100,000 per year)

total parenteral nutrition
when GI tract is nonfunctional or when intubated
used only for long-term
infection risk is high
formula is expensive

Therapy

exercises

Oral

lip

tongue

cheek

Pharyngeal

Shaker (head/chin lift)

sequence

lie on floor and lift head to look at feet, without lifting shoulders

hold for 60 seconds & then release (3 reps)

complete 30 short repetitions then rest (3 sets)

entire sequence 5 times per day

strengthens laryngeal elevators

Masako maneuver

anterior posturing of tongue

strengthens pharyngeal constrictors

should be done with dry swallows only

Mendelsohn

laryngeal

stimulation

thermal

tactile

taste

lemon ice

ingredients

8 tsp thick-it

3 Tbsp + 1 tsp dry pre-sweetened Lemonade mix

1 tsp sugar

1/8 tsp salt

2 cups water

blend, portion out, freeze

makes 15-20 portions

DPNS

Summary of Physiological Foundations:

the pharyngeal swallow is reflexive

many of the individual muscular component movements can only be elicited reflexively

when higher centers are damaged, brain stem function (reflexive center) may be intact

the solitary tract nucleus in the medulla has close anatomical and physiologic relationships with CN IX, X, and XII, critical for swallowing and other airway protective reflexes

Summary of Rationale for Technique

when patients are unable to volitionally elicit particular muscular contractions and/or movement patterns, these behaviors may be elicited reflexively

it is beneficial to treat impairment level deficits even when volitional control is not available

stimulation of sensory centers during reflex elicitation remediates the impairment of reduced sensation

Summary of Technique

Three specific reflexes are targeted (the combination of which contribute to swallow reflex):

palatal reflex¹ (velopharyngeal closure)

Tongue base retraction reflex² (bolus propulsion, laryngeal elevation)

Pharyngeal constrictor reflex³ (bolus propulsion)

Reflexes are elicited via a modified gag response

Nine elicitation techniques are utilized using frozen lemon glycerine swabs

swab laterally across soft palate¹

swab anterior to posterior on each side and medially of the palate¹

swab laterally across bitter taste buds (posterior tongue)²

swab anterior to posterior from each lateral side of tongue to medial portion of bitter taste buds²

swab posterior to anterior along lingual septum²

swab superior to inferior (or reverse) on each side of posterior pharyngeal wall³

swab anterior to posterior from soft palate down uvula^1,2

swab soft palate from lateral sides to uvula^{(should elicit swallow
response)}

swab applied to nasal spine¹

Reported Efficacy:

Stefanakos reports in her seminar that DPNS is effective for patients with

CVA's

mild/moderate MS or Parkinsons

age related neuromuscular insufficiency

DAT (non-combative) through stage 6

TBI if seizures are controlled

DPNS is contraindicated for:

uncontrolled seizure disorders

abdominal surgery patients

advanced neuromuscular disease

noncompliant DAT

myasthenia gravis

extensively radiated patients

patients on telemetry

patients with significant respiratory compromise

patients with tonic bite reflex

patients with dyskinesias

Questions/Issues of Concern (my own and those raised by others--see Dysphagia Archives)

the gag reflex is an "opposing" reflex to the swallow reflex elicited by noxious stimuli--what are the implications for presentation of pleasant food stimuli and coordination of individual movements for a swallow reflex?

procedures/efficacy data have not been made available for peer review (however nearly all anecdotal reports have been positive)

there are no clear guidelines for which impairments this technique is indicated (e.g., why would cortical strokes require remediation of a brainstem response?)

theoretical foundations need substantiation (as would occur in a peer review process)

"ownership" of techniques (only those attending workshops are considered "certified")

"Heather's Take"

If physiologic foundations are accurate, then using such techniques have the great advantage of directly treating the impairment

Lack of peer review is a SIGNIFICANT concern, in spite of positive anecdotal reports

I use techniques for patients lacking consistent volitional swallow

Non-Compliance

individuals competent for medical decisions

counseling and education
documentation

individuals not competent for medical decisions

may need to consult psych to determine competency
consult ethics committee
documentation

Follow-up

necessary to verify efficacy of recommendations
monitor for progression
monitor for recovery