• Overview of Dysphagia
• Definitions
• What is dysphagia?
• difficulty swallowing
• symptom vs. sign
• Why do we care?
• Health risk
• aspiration
• malnutrition
• dehydration
• Quality of life
• 580 swallows/day
• Feeding vs swallowing
• feeding: getting the food into the mouth, manipulation of the bolus, and oral stage
• common issues
• cognitive status
• limb strength &/or control
• swallowing: oral, pharyngeal & esophageal stages, including swallowing reflex & airway protection
• common issues
• coughing/choking
• "sticking"
• Oral & pharyngeal vs esophageal
• Oral & pharyngeal
• non-instrumental and instrumental observations
• SLP most common "expert"
• may be addressed by behavioral modifications
• esophageal
• limited to instrumental observations
• radiologist, GI, ENT most common experts
• medical/surgical management
• Dysphagia in Speech Pathology
• Head/neck anatomy & physiology
• Etiological Parallels
• head & neck cancer
• neurologic disorders
• developmental disorders
• "Rehab" focus
• ASHA position statement
• More about aspiration
• 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)
• Normal oropharyngeal swallow
• Anatomy (Logemann Ch 2, Groher Ch 1)
• Oral structures
• hard tissues
• mandible
• maxilla
• dentition
• soft tissues
• lips
• cheeks
• velum
• uvula
• faucial arches
• muscles
• tongue
• intrinsic
• vertical: widens and flattens tongue tip
• transverse: elongates, narrow and thickens tongue
• inferior longitudinal: creates convex shape, depresses tongue tip
• superior longitudinal: raises tongue tip and edges
• extrinsic
• styloglossus: draws tongue upwards and backwards
• genioglossus: protrudes tongue, depresses tongue/elevates hyoid
• hyoglossus: depresses tongue
• mastication
• temporalis: closes and retracts mandible
• masseter: closes mandible
• medial pterygoid: closes mandible
• lateral pterygoid: opens, protrudes mandible, allows side-to-side movement
• face
• orbicularis oris: closes, opens, protrudes, inverts, twists lips
• zygomaticus major: moves UL upward and outward
• zygomaticus minor: elevates UL
• levator labii superioris: elevates and retracts lips
• levator anguli oris: pulls down corners of lips
• depressor anguli oris: depresses LL, draws angle of mouth down and inward
• depressor labii inferioris: depresses LL
• mentalis: pushes up LL, raises chin
• risorius: draws angle of mouth outward, causes dimples
• buccinator: flattens cheek, holds food in contact with teeth
• palate
• levator veli palatini: elevates velum
• tensor veli palatine: stretches velum
• palatoglossus: raises back of tongue
• palatopharyngeus: closes nasopharyngeal port
• uvular: shortens and raises uvula
• landmarks
• lateral sulci
• anterior sulcus
• Taste sensation
• sensitive to:
• salt
• sweet
• sour
• bitter
• location
• tongue
• oral mucosa
• epiglottis
• Pharyngeal structures
• hard tissues
• cervical vertebrae
• hyoid bone
• laryngeal cartilages
• cricoid
• thyroid
• arytenoids
• epiglottis
• soft tissues
• posterior pharyngeal wall
• base of tongue
• false vocal cords
• true vocal cords
• muscles
• suprahyoid
• mylohyoid: elevates tongue and floor of mouth/depresses jaw when hyoid fixed
• digastric (anterior belly): raises hyoid when jaw is fixed/depresses jaw if hyoid fixed
• geniohyoid: draws hyoid forward, depresses mandible if hyoid fixed
• stylohyoid: elevates hyoid and tongue base
• hyoglossus: depresses tongue
• genioglossus: depresses and protrudes tongue
• styloglossus: elevates and retracts tongue
• palatoglossus: narrows fauces and elevates posterior tongue
• pharynx
• palatopharyngeus: narrows oropharynx, elevates pharynx
• stylopharyngeus: raises and dilates pharynx
• salpingopharyngeus: raises nasopharynx, draws lateral pharyngeal walls up
• cervical esophagus
• cricopharyngeus: relaxes to allow passage of bolus into esophagus
• laryngeal
• cricothyroid: tightens vocal cords
• posterior cricoarytenoid: abducts VFs
• lateral cricoarytenoid: adducts VFs
• transverse arytenoid: adducts VFs
• oblique arytenoid: adducts VF & aryepiglottic fold
• thyorarytenoid & vocalis: relaxes VF
• landmarks
• velar port
• vallecular sinuses
• pyriform sinuses
• laryngeal vestibule
• upper esophageal sphincter
• trachea
• Innervation
• Cranial nerves
• Afferent control
• trigeminal: general sensation (anterior 2/3 of tongue)
• facial: taste (anterior 2/3 of tongue)
• glossopharyngeal: taste and general sensation (posterior 1/3 of tongue)
• internal branch of SLN (vagus): mucosa of valleculae
• pharyngeal branch of vagus: tonsils, pharynx, soft palate
• glossopharyngeal, vagus: pharynx, larynx, viscera
• Efferent control
• oral
• trigeminal: masticators, floor of mouth
• facial: lip sphincter, buccinator
• hypoglossal: tongue
• pharyngeal
• glossopharyngeal: constrictors and stylopharyngeus
• vagus: palate, pharynx, larynx
• esophageal
• vagus: esophagus
• Higher centers
• brain stem nuclei / medullary reticular formation
• cerebellum
• cortical centers
• Function (Logemann Ch 2, Groher Ch 1)
• 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
• Swallowing Disorders in Adults I (Logemann Ch 3)
• Patient description of symptoms
• Can't get swallow started
• Coughing
• Choking
• Sticking
• Comes back up
• Oral dysfunctions
• Oral preparatory
• Impairments
• reduced labial closure
• reduced buccal tension
• reduced tongue strength, mobility, or control
• reduced oral sensitivity
• xerostomia
• Signs
• drooling
• prolonged oral preparation
• oral retention
• poor bolus control
• premature delivery
• Mastication
• Impairments
• reduced tongue movement
• lateral
• vertical
• buccal weakness
• reduced mandibular movement
• mandibular/maxillary allignment
• poor/absent dentition
• Signs
• incomplete mastication
• prolonged oral preparation
• oral retention
• pharyngeal retention
• Oral
• Impairments
• tongue thrust
• reduced tongue elevation
• reduced A->P movement of tongue
• reduced buccal tension
• Signs
• oral retention
• pharyngeal retention
• Pharyngeal
• Impairments
• delayed swallowing reflex
• absent swallowing reflex
• inadequate velopharyngeal closure
• reduced pharyngeal peristalsis
• unilateral pharyngeal paralysis
• cervical osteophytes
• scar tissue
• pharyngeal wall
• base of tongue
• pharyngeal structures
• cricopharyngeal dysfunction
• reduced laryngeal elevation
• reduced epiglottic inversion
• reduced vocal cord adduction
• reduced sensitivity
• Signs
• nasal regurgitation
• retention
• penetration
• aspiration
• Esophageal
• Impairments
• cricopharyngeal dysfunction
• reduced peristalsis
• diverticulum
• obstruction/stenosis
• fistula
• tracheo-esophageal
• esophago-cutaneous
• Signs
• retention
• reflux
• aspiration
• Swallowing Disorders in Adults II

• 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
• EMG
• 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
• why
• 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
• PEG
• 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'm going to try the techniques
• 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
• Facilitating Quality Outcomes -- Program management
• Identification
• Sources
• Referral base
• Screening of at-risk individuals
• Monitors
• timeliness
• sensitivity
• Follow-up
• within stay
• across stays
• across facilities
• Quality outcomes
• Data collection
• Data display
• Caseload considerations
• Danger of overload
• Dysphagia clinics
• Mealtime programs
• Dysphagia aides

Arvedson, J. C & Brodsky, L. (1993). Pediatric swallowing and feeding. San Diego: Singular.

Groher, M. E. (1997). Dysphagia: diagnosis and management. 3^rd Edition. Boston: Butterworth-Heinemann

Logemann, J. A. (1998). Evaluation and Treatment of Swallowing Disorders (2^nd Edition). Austin: Pro-Ed.

Logemann, J. A. (1993). Manual for the videofluoroscopic study of swallowing (2^nd Edition). Austin: Pro-Ed.

Miller, A. J. (1999). The Neuroscientific principles of swallowing and dysphagia. San Diego: Singular.

Perlman, A. L. (1997). Deglutition and its disorders. San Diego: Singular.

Stefanakos. K. (1998). Deep pharyngeal neuromuscular stimulation. Workshop presented in Hickory, NC. December 5-6.

Wolf, L. S., & Glass, R. P. (1992). Feeding and swallowing disorders in infancy. San Antonio: Therapy Skill Builders.

Yorkston, K. M., Miller, R. M., & Strand, E. A. (1995). Management of Speech and Swallowing Disorders in Degenerative Diseases. Tuscon: Communication Skill Builders.