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115 Cards in this Set

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What is the frequency of occurrence of oropharyngeal dysphagia in persons with closed head trauma or neurosurgical procedures?
It has not been assessed
What swallowing problem occurs most frequently with strokes and closed head trauma?
DTriPS
There is an apparent relationship between _________ following a head injury and ______
length of coma
severity of swallow
What are three types of neurogenic damage that can result from a head injury?
1. direct head injury
2. contra-coup damage
3. twisting on the brainstem (kind of how your brain feels right now...)
What're are two problems (other than the actual head injury) seen in people that don't wear their seatbelts that can affect swallowing?
laryngeal fracture (dashboard injury)
penetration wounds in the chest that affect the esophagus
Wear your seatbelt
True or False

Intubation, especially long term, can cause laryngeal damage
True
True or False

Emergency tracheostomies are often placed too low, and result in scarring of the esophagus.
Uh, false.

Placed too HIGH and cause scarring in the LARYNX
What sorts of factors, if any, should you take into account when evaluating a patient who has head trauma?
How did they sustain it? Are there any other puncture wounds/fractures/penetration wounds that could conceivably affect swallowing? Were they in a coma? Were they trached? Were they intubated? Who did these things and under what circumstances? Etc.
Name me some oral disorders you might see in a patient with a head injury (4-ish):
Reduced lip closure, reduced lingual ROM with poor bolus control, abnormal oral reflexes (tonic bite), DTriPS/APS
Name me some pharyngeal disorders you might see in a patient with a head injury (8-ish):
FLUB DUVET
Fistula, Larynx, Unilateral/Bilateral, Delay, Ues, Velopharyngeal, Entrance (airway), Tongue base

t/e Fistula
rd Laryngeal elev
rd Ues open
rd Vp clos
U/B pw pys/par
rd awy Entrance clos (or airway closure)
rd Tb movt
If the clinician is first seeing the patient with a head injury ________ or more after the injury, the clinician may have a difficult time _____ that could create the patient's swallowing disorders, but it is _____ that the clinician attempt to do so.
3 months or more
reconstructing the various types of damage
critical
Are there any characteristics in addition to physical swallowing disorders that can make the return to oral intake difficult for individuals with neurogenic damage and if so, what are, say, four of them?

CIST
Cognition, Impulsiveness, Sensation, Too (much)

impulsiveness
tendency to put too much food in the mouth
cognitive difficulties (swallow maneuvers hard to understand)
reduced sensation
In one study based on bedside observations, the frequency of apparent swallowing difficulties ______ from the acute care setting through the initial and final rehabilitation stages, indicating a pattern of ______ in swallowing disorders.
diminished significantly
consecutive improvement
True or False

Compliance with dietary recommendations and swallowing therapy can be a difficult problem in most patients with head injuries, even if they received a good assessment of their swallow during the acute care period.
False

If they received a good assessment early on (during acute care) they are usually compliant. If not, then there's trouble.
True or False

Many young adult patients with head injuries can continue to aspirate with no immediate pulmonary consequences.
True. This is not a good thing.
What sorts of treatment strategies are most useful with patients who have head injuries (think of 2)?
postural changes and enhanced sensory input.
True or False

Patients with head injuries resulting in cognitive deficits are cannot cooperate with resistance and range-of-motion exercises.
False

can also cooperate with such exercises.
When using family members to provide additional therapy, it is critical to give them the _____ for the procedure
goal
Patients with neurologic damage who are severely dysphagic and plateau in their progress should be reassessed every _____ in order to determine whether recovery may have taken place.
6 months to a year.
With a cervical spine injury, if there is no concurrent head injury, the patient's swallowing problems are usually ____ in nature.
pharyngeal
There are four swallowing disorders commonly seen in patients with cervical spine injuries (no attendant head injury). What are they?
1. reduced laryngeal elevation and anterior movement causing reduced cricopharyngeal opening
2. reduced tongue base motion
3. delayed triggering of the pharyngeal swallow
4. uni/bilateral pharyngeal wall dysfunction
With a cervical spinal cord injury, there is a tendency for poor laryngeal movement and consequent reduced UES opening to occur more often when damage occurs at ____
C4, 5, or 6
With cervical spinal cord injury, patients have no sensory awareness of their swallow difficulty when the injury occurs at:
C1 or 2
True or False

Problems with closure at the vocal folds occur frequently in patients with cervical spinal injury.
False

They are infrequent, unless related to direct laryngeal damage due to trauma of the injury, emergency airway management, or prolonged tracheostomy.
If mechanical ventilation is present, a ____ is frequently also present to facilitate operation of the ventilator, because many ventilators operate on ____
cuffed tracheostomy tube (cuff inflated)
positive pressure principles
True or False

An inflated tracheostomy cuff can exacerbate vocal cord closure problems (in the long term) as well as restricting laryngeal movement.
True
Why might the presence of a mechanical ventilator and/or a tracheostomy tube make an accurate bedside assessment more difficult? (Name 2)
1. difficulty feeling laryngeal elevation during swallow
2. high incidence of pharyngeal stage swallowing problems in patients w/ damage at C5 or above (unable to assess pharyngeal disorders bedside)
What are some of the problems faced when positioning a patient with a cervical spinal cord injury for an MBS?
1. may not be able to be elevated to a vertical position
2. may only be able to be elevated when a neck or chin brace is present.
Let's not even mention trying postures or swallow maneuvers....
If the patient is unable to be elevated during the radiographic study, the study should be completed with the patient _____. This may be at ______ from horizontal.
in the position she/he is usually fed
30 to 60 degrees
True or False

Even though parts of the oral cavity or pharynx may be shadowed or covered by a neck or chin brace, it is essential that a straight lateral study be accomplished so the oropharyngeal swallow physiology may can be examined properly.
False.

angle the chair or cart 15 to 30 degrees can usually move the shadows of the brace off of critical anatomic elements of the pharynx.
True or False

Many patients report a worsening of their swallow when they have been placed in a SOMI or head brace.
True
In a 1992 study only ___ measures of swallowing changed when a brace was worn (by a normal swallower). Those were ___, which were ____.
one (Yeah, the plural was a trick)
That was duration of airway closure, which was prolonged
The percentage of patients who receive anterior or posterior cervical fusion who have some degree of postoperative dysphagia is:
not known
What are three reasons swallowing disorders might occur in a patient with a cervical spinal fusion?
SHaWN
Swelling, HArdWare, Nerve trauma

1. post-operative swelling
2. trauma to peripheral nerves
3. reaction to hardware in the neck
True or false

Patients who have had cervical spinal fusions may exhibit oral stage problems as well as a delay in triggering the pharyngeal swallow, uni- or bilateral pharyngeal wall weakness, and reduced laryngeal elevation and anterior movement.
True
Reduced laryngeal elevation and anterior movement often results in ____ (other than aspiration, b/c you could still have fairly affective closure...)
reduced UES opening
Patients with cervical spinal fusions experience significant recovery of their swallow within _____ post-operatively. An ___ can define the nature of and intervention strategies for the patient's swallowing disorder
3 months
MBS, of course!
True or False

It is not safe to use swallowing maneuvers with patients who have had cervical spinal fusion.
False

They are most frequently helpful, especially the MM, SG, and SSG.
Neurosurgical procedures affecting the _____ often result in significant swallowing problems; sometimes a complete inability to trigger a pharyngeal swallow. The patient may exhibit ___, ___, and ___ struggling but not true pharyngeal swallow
medulla
OT, TB, and Lg
In cases where no true pharyngeal swallow is seen, what two procedures can be utilized to heighten stimulation to the CNS thus lowering the threshold of the swallowing center?
thermal-tactile stim
suck-swallow
After surgical removal of an acoustic neuroma, the patient may exhibit unilateral damage to cranial nerves __, __, __, __ and possibly __
IX, X, XII, VIII, VII

The book kind of plays down damage to VIII and VII, but let's spend a moment reminding ourselves where an acoustic neuroma occurs. Could it, uh, have something to do with oh, I don't know, CNVIII?!?
With damage to CN IX, there is often:
DTripS
Because damage resulting from cranial nerve resection is _____, these patients often benefit from ____. Name two.
unilateral
postural strategies
head rotation & chin down
Patients who have damage to cranial nerves usually benefit from aggressive (2) ____ for (4):
ROM & Resistance exercises
lips, OT, TB, and Lx
What are some exercises for patients after neurosurgical procedures affecting the brainstem and/or cranial nerves?
falsetto exercise for laryngeal elevation
effortful swallow
super-supraglottic swallow or breath hold
Patients who are cognitively intact should practice exercises ____ times a day for ___ each time to improve range of motion.
10
5 minutes
During the oral stage of the swallow, poliomyelitis patients often display ___ and ___.
reduced lingual control of the bolus
disturbed pattern of lingual bolus propulsion
Pharyngeal symptoms of poliomyelitis patients include (3):
1. reduced VP closure (nasal regurgitation)
2. reduced pharyngeal contraction
3. unilateral pharyngeal paralysis
Guillan-Barré is a viral-based disease causing ____ which may lead to ____, requiring ___ and ___.
rapid onset of paresis
complete paralysis
tracheostomy
mechanical ventilation
In Guillan-Barré, the general weakness and paralysis usually begin within a day or two after _____ is noticed.
the swallowing problem
In Guillan-Barré, radiographic studies of swallowing usually reveal what, resulting in what?
generalized weakness in OS & PS.
reduced ROM of the OT, TB, and LX.
True or False

The progressive paralysis in Guillan-Barré is rapid and recovery can take several days.
False

Recovery can take months or years
True or False

If respiration is unstable, as in Guillan-Barré, use of airway closure exercises such as swallow maneuvers can help stabilize respiratory control.
False

Should be used carefully or not at all until respiratory control has been stabilized.
Swallowing therapy for Guillain-Barré often includes:
gentle ROM and Res exercises
swallowing maneuvers (SS, MM) only when respiratory control has improved.
True or False

The degree of oral musculature involvement in cerebral palsy varies widely from one child to the next.
True
Why would the pharyngeal swallow not trigger when small amounts of food fall into the airway while a patient is chewing (say, one with cerebral palsy)?
The voluntary oral stage of swallow has not been initiated.
What three oral symptoms might you see in a child with cerebral palsy?
1. inappropriate oral reflexive behaviors
2. inability to hold cohesive bolus
3. disorganized lingual movements
Examples of moderate to severe oral problems in a child with cerebral palsy include (3):
reduced lip closure
tongue thrust
reduced tongue coordination
Name three categories of swallowing disorders in a child with cerebral palsy:
Which group aspirates on every consistency?
Which is most common?
1. Moderate to Severe Oral Problems
2. M-SOP + Delay in Triggering the Pharyngeal Swallow
3. M-SOP + DTriPS + neuromuscular abnormalities in pharyngeal swallow (Reduced Tongue Base Retraction, Reduced Laryngeal Elevation)
Most in 3 aspirate consistently
Most kids with CP are in group 2.
Why not treat a child with CP and swallowing difficulties with a cricopharyngeal myotomy?
Child grows, larynx lowers, and the UES problem resolves.
Better managed with therapy and growth effects.
Children with CP in category 2 (M-SOP + DTriPS) have swallowing difficulty with both foods and liquids, but for different reasons. What are they?
Foods because of oromotor difficulty
Liquids because of delay (esp. when given large amounts at one time)
What management strategies can be used with a child with CP in category 2 (M-SOP + DTriPS)? There are three named in the book...
oromotor therapy
thermal-tactile stim (TTS)
diet change (thickened liquids and purees), if nothing else works (use last)
Evidence indicates that some individuals with severe developmental delay and cerebral palsy may need ____ to maintain their swallowing function.
Chronic therapy
(strategies should be taught to caregivers and monitored at regular intervals)
True or False

Children with Dysautonomia (Riley-Day Syndrome) can exhibit minimal problems with swallowing or they can be so severe (affecting the LES) that they require gastrostomy for liquid intake.
True
OT discord, DTriPS, UES difficulty, Abn Esophageal motility, and LES dysfunction has been seen in severe cases of:
Riley-Day Syndrome (Familial Dysautonomia)
What are different medical procedures that manage swallowing disorders designed to do (4)?
PIMA
Provide, Improve, Meds, Aspiration

1. improve specific anatomic/physiologic components
2. eliminate or control unremitting, prolonged aspiration
3. provide non-oral nutrition/hydration
4. medications
Why is surgical management of osteophytes to improve dysphagia risky (2)?
creation of scar tissue, damage to nerves involved in swallowing
Osteophytes can affect swallowing in two ways. What are they?
1. large mass of bone diminishes pharyngeal space preventing the passage of a large or thick bolus
2. pressure on cranial nerve roots produces sense of dysphagia
______ of aspiration is caused by inadequate VF closure.
10% or less
True or False

Injection of a temporary or permanent substance into an inert VF can help with adduction during swallowing, provided that the problem is at the airway entrance.
False.

If the problem is at the airway entrance, or results from reduced lingual control, DTriPS, Absent PS, RTBM, adding bulk to the adductor mechanism will not improve the swallow or reduce aspiration.
True or False

Laryngeal suspension, where the larynx is raised and tilted under the tongue base is used occasionally in head and neck CA pts but rarely in neurologic pts.
True
____ are used to dilate scar tissue in the CP region. What are they?
Bougies. They're mercury-filled soft rubber tubes of increasing diameters used to dilate scar tissue in the cricopharyngeal region.
Dilation will generally (help)/(not help) a patient with cricopharyngeal dysfunction related to neurologic damage.
not help
Effects of dilation of the UES are often ___, lasting approximately ____
temporary
1-3 months
The patient can frequently begin to eat within _____ after a CP myotomy.
1 week
Swallowing improvement rates with a CP myotomy are _____
60-78%
Assuming that cricopharyngeal muscle dysfunction is the predominant problem, is a CP myotomy the correct procedure?
Not unless the patient is able to (1) move material through the OSS and PSS to the UES and (2) is able to voluntarily close the airway during the swallow.
In general, a CP myotomy should not be performed when a patient suffers a stroke, head injury, or spinal cord injury. Why?
spontaneous recovery.
True or False

While not recommended universally, CP myotomy can improve postoperative swallowing in patients who receive a supraglottic laryngectomy or a tonsil/BoT resection.
False.

No difference has been found with CP myotomy.
If the pharyngeal swallow does not trigger, the _____ stands open and will receive any material that drains over the BoT into the pharynx.
larynx
What compensatory procedures might help a person with a myotomy?
Postures such as head turn
MM
or both
Why is botox injection of the CP difficult? Why is this procedure no longer used widely?
the CP is hidden behind the cricoid cartilage.
Affects are temporary and inconsistent.
No surgical procedure should be attempted to control unremitting aspiration until:
an adequate trial of swallowing has been attempted (6 months)
What are 6 surgical procedures used to improve or control unremitting aspiration?
1. epiglottic pull-down
2. suturing the TVF
3. suturing the FVF
4. laryngeal bypass/tracheoesophageal diversion
5. tracheostomy
6. total laryngectomy
Which surgical procedures used to improve or control unremitting aspiration are potentially reversible?
1. epiglottic pull-down
2. suturing the FVF
3. tracheostomy
All nonoral feeding procedures have a higher rate of ____ than oral feeding.
GERD
True or False

Some nonoral feeding procedures can be permanent and should only be used as a last resort.
False

All are temporary and can be removed at any time.
Each feeding via a nasogastric tube is followed by at least ____ to cleanse the feeding tube and provide proper hydration.
120-240 cc of water
With nasogastric feeding, pts should generally ____ after a meal to reduce the risk of GERD.
be kept upright for 1 hour
If a patient remains dysphagic for more than ____, nasogastric feeding is generally replaced by a more permanent solution.
3-4 months
What are 4 nonoral feeding methods more useful in the long term than a nasogastric tube?
Pharyngostomy
Esophagostomy
Gastrostomy
Jejunostomy
What procedure is sometimes done in children and adults with a history of reflux to reduce the risk of reflux of non-oral feedings?
Fundoplication.
Any patient who is aspirating more than ____ of all food consistencies and/or is taking longer than ___ to swallow foods of all consistencies is a candidate for non-oral feeding.
10%
10 seconds
If swallowing rehabilitation is anticipated to take more than ___, a PEG may be more appropriate nasogastric feeding.
1 month
True or False

A number of medications designed to improve esophageal disorders may improve oral or pharyngeal swallowing problems as well.
False

no medications at this time will improve specific oral or pharyngeal swallowing problems, though some pts. with Parkinson's, MyG, or MS gain improved swallowing when put on medications for their disease.
What is the most common reason for dysphagia of previously unknown etiology?
neurologic disease
In a multidisciplinary approach, the SLP does what?
initial intake and evaluation
In a multidisciplinary approach, the SLP and radiologist do what?
MBS
In a multidisciplinary approach, the gastroenterologist does what?
esophageal assessments
In a multidisciplinary approach, the neurologist does what?
CN nerves related to swallowing, symptomatology for neurologic diseases
In a multidisciplinary approach, the otolaryngologist does what?
structural evaluation and sensorimotor evaluation of head and neck (larynx and pharynx)
In a multidisciplinary approach, the pulmonologist does what?
evaluates recent pulmonary (lung) problems
In a multidisciplinary approach in a rehab setting, the physiatrist does what?
fits the dysphagia rehabilitation plan into the pts overall rehab schedule
In a multidisciplinary approach, the gerontologist does what?
helps set realistic goals for aging clients and checks whether they are taking any meds that might contribute to dysphagia
In a multidisciplinary approach, the maxillofacial prosthodontist does what?
prosthetic intervention for impaired tongue function/obturation
In a multidisciplinary approach, the dentist does what?
uh, dentures. You know, chewing.
In a multidisciplinary approach, the pharmacist does what?
drug interactions
In a multidisciplinary approach, the OT does what (2)?
provides assistive devices for eating, direct therapy for arm and hand control to place food in mouth
In a multidisciplinary approach, the PT does what?
optimial patient positioning for meals
In a multidisciplinary approach, the dietitian does what?
blood chemistries, weight monitoring, calorie counts
Together, the ___, ___, and ___ determine when the patient can safely take adequate intake orally so that nonoral intake can be discontinued completely
attending physician, dietitian, and swallowing therapist
_____ should be provided to respiratory therapists and nursing staff to teach ____.
in service education
signs and symptoms of dysphagia
The swallowing therapist should provide in-service training to the feeding staff regarding what (3)?
CRI
Complexity, Range, Individualization

complexity of normal swallowing phsyiology
range of swallowing disorders
need for individualized feeding plans for each patient
What three pieces of information should the swallowing therapist be able to provide regarding MBS for in-service education?
What, Why & How

What: the radiographic procedure
Why: rationale for all aspects of the procedure
How: the way it differs from a TBS or UGI
Pharyngeal disorders resulting from poliomyelitis include ___, ___, and ___.
reduced VP closure (nasal regurgitation)
reduced Ph contraction
unilateral Ph paralysis