438 Chapter 5

Front 1

A clinical or bedside examination studies:

Back 1

eating behavior
language
cognition
oromotor function

Front 2

An x-ray study examines

Back 2

oral physiology
phrayngeal physiology

Front 3

Evidence gathered during a screening that identifies aspiration but does not provide physiological information as to why the patient aspirates is called

Back 3

Indirect evidence

Front 4

Screening answers the question

Back 4

Is the patient dysphagic?

Front 5

A diagnostic answers the question

Back 5

What is the nature of the patient's physiology during swallowing?

Front 6

Two characteristics of a good diagnostic procedure:

Back 6

Should correctly identify those individuals who are actually aspirating or having residue (procedural specificity)
Should not generate many false positives or false negatives

Front 7

Abnormal behaviors observed during eating in a child or cognitively impaired adult (that might suggest a swallowing difficulty)

Back 7

rejection of food
food selectivity
gagging
open-mouth posture

Front 8

12 types of information gleaned from the bedside or clinical examination

Back 8

1. medical diagnosis/history, swallowing diagnosis/history
2. medical status (incl. nutritional and respiratory)
3. oral anatomy
4. respiratory function (in relation to swallow)
5. labial control
6. lingual control
7. palatal function
8. pharyngeal wall contraction
9. laryngeal control
10. ability to follow directions, monitor/control behavior
11. reaction to oral stim
12. reactions/symptoms during attempts to swallow

Hint 8

Tx Stat OrAnat Res LLPPL Able ReStim Sym

Front 9

2 main parts of the bedside or clinical examination

Back 9

Preparatory examination (no actual swallows)
Initial swallowing examination

Front 10

Preparatory examination consists of:

Back 10

Review of chart, gaining information on vocal tract control

Front 11

Reviewing the patient's chart should identify:

Back 11

1. current/past medical problems
2. current/recent medications
3. history of swallowing disorder
4. presence/type/duration/method of placement of any airway device
5. presence/type/duration of placement/adequacy/complications of oral/nonoral nutrition

Front 12

Observations made upon entering the patient's room include:

Back 12

1. posture in bed
2. alertness/reactions
3. trach tube and status
4. general awareness/handling of secretions and tube management

Front 13

Observations of respiratory status include:

Back 13

1. rate
2. timing of saliva swallows in relations to phase of respiratory cycle
3. timing of cough in relation to respiration.
4. duration of comfortable breath hold (IF FEASIBLE)
5. rest breathing pattern (oral or nasal?)

Front 14

What comes first, breathing? Swallowing?

Back 14

Uh....

Front 15

Trachs are placed for:

Back 15

1. upper airway obstruction
2. potential upper airway obstruction
3. provision of respiratory care

Front 16

Cuffed trachs are used when

Back 16

1. needed for respiratory treatment (ventilation)
2. potential for aspiration

Front 17

Minimal leak technique

Back 17

Cuff is slightly deflated. This prevents tracheal stenosis, doesn't inhibit relearning to swallow, and places less pressure on the esophagus

Front 18

What test is used to examine aspiration in ventilator-dependent patients?

Back 18

Blue dye test (suction trach immediately after eating)

Front 19

In an Oral-Motor Control Examination, you will check

Back 19

1. ability to open mouth voluntarily
2. ID optimal oral-sensory and bolus types
3. ID and compensate for swallowing apraxia
4. ID and compensate for abnormal oral reflexes
5. collect management information

Front 20

Typical size of trach used in adults

Back 20

8; changed to a smaller size to encourage oral-nasal breathing (4-6)

Front 21

What are fenestrated trach tubes for

Back 21

They allow greater airflow into the upper tract for voicing and for individuals being weaned off a trach.

Front 22

If a trach tube has been in place more than 6 months:

Back 22

1. scar tissue may have formed, restricting laryngeal elevation
2. reduced vocal fold closure for swallowing and vocalization (subglottic sensory receptors)

Front 23

During swallowing, an inflated cuff

Back 23

Can reduce laryngeal elevation by creating friction against the tracheal wall

Front 24

Swallowing can worsen when on a ventilator because

Back 24

the ventilator controls the respiratory and the patient cannot lengthen the exhalation to allow for the swallow. Any delays can increase the risk of aspiration

Front 25

Intubation can cause

Back 25

reduced ROM of lips, tongue, pharynx, larynx for up to a week

Front 26

Over ____ of patients who aspirate do not cough.

Back 26

50%

Front 27

Patients who are aware that an oropharyngeal swallowing disorder is present are

Back 27

highly reliable in their identification and description of the swallowing disorder

Front 28

Liquids easy to swallow, pastes/thicker materials difficult may suggest

Back 28

difficulty in oral transit because of poor tongue control

Front 29

Thicker consistencies easier than thin liquids may suggest

Back 29

a delayed or absent triggering of the pharyngeal swallow (thicker foods cling to tongue base/valleculae)

Front 30

On the basis of a careful history, the swallowing therapist may have information on

Back 30

1. the localization of the disorder in terms of the oral or phayngeal stage of the swallow (or both)
2. the easiest and most difficult types of material for the patient to swallow
3. the nature of the swallowing disorder

Front 31

Examination of oral anatomy includes.

Back 31

lip/hard palate configuration, soft palate and uvula (VPO), facial arches, tongue, adequacy of mandibular sulci, scarrin in oral cavity or on neck, asymmetries, dentition, secretions.

Front 32

Oral-motor control examination should includ:

Back 32

Range, rate, and accuracy of movement of lips, tongue, soft palate, pharyngeal walls during speech, reflexes, swallowing

Front 33

Therapy for pts who have trouble opening mouth voluntarily

Back 33

oral massage, verbal reinforcement, downward pressure on chin (check bite reflex)

Front 34

Some patients with cognitive impairments produce most oral activity in response to particular combinations of

Back 34

taste, texture, and temperature.

Front 35

A patient with swallowing apraxia usually performs best at the bedside when

Back 35

no directions are given regarding eating or swallowing

Front 36

A patient with swallowing apraxia may perform poorly during an MBS because

Back 36

verbal commands are given bring conscious focus to the act of swallowing.

Front 37

Abnormal oral reflexes exhibited by patients with neurologic impairments include:

Back 37

hyperactive gag, tongue thrust, tonic bite

Front 38

To test labial function, the clinician should have the patient

Back 38

spread lips widely on /i/, round on /u/, then alternate x10; check diadochokinetic rate, lip closure during rest and saliva swallowing, repeat sentence with lots of bilabials, chew while changing posture

Front 39

Lingual function should be assessed

Back 39

both anteriorly and posteriorly

Front 40

Anterior tongue examination includes

Back 40

1. extension and retraction
2. rapid alternation of lateral movements
3. clearing lateral sulci
4. rapid elevation/depression of tip w/ wide open mouth
5. diadochokinetic /ta/
6. tip-alveolar stop heavy sentence repetition

Front 41

Posterior tongue examination includes

Back 41

1. hold back of tongue in /k/ position for several seconds with mouth open
2. diadochokinetic /ka/
3. back velar stop heavy sentence repetition

Front 42

Chewing assessment is most safely done

Back 42

with gauze rather than food, which provides the flexibility of food with none of the risk

Front 43

Function of soft palate is examined by

Back 43

having the patient produce a strong sustained /a/, then rapidly repeat it.

Front 44

What muscle elevates the palate?

Back 44

levator palatini

Front 45

What muscle retracts the palate?

Back 45

palatopharyngeus

Front 46

Platal refelx is the __________ of the oral reflexes

Back 46

least stable

Front 47

What should be observed as the result of stimulating a gag reflex?

Back 47

A strong symmetrical contraction of the entire pharyngeal wall and soft palate (aff IX and poss X; eff X and poss IX; V)

Front 48

Does the presence or absence of a gag reflex in neurologically impaired patients indicate the patient's ability to swallow.

Back 48

Er, no.

Front 49

What triggers the gag? (Nerves too)

Back 49

Noixious stimulus that needs to get up and out of the pharynx. (X and poss IX)

Front 50

The gag is triggered from ________ whereas the swallow is triggered from _______

Back 50

surface tactile receptors, deep proprioceptive receptors

Front 51

Oral sensitivity exam should include an assessment of____. Why?

Back 51

light touch. impacts placement of food in oral cavity.

Front 52

Food should be placed in the oral cavity at

Back 52

the point of maximum sensitivity

Front 53

Laryngeal Function Examination includes

Back 53

Voice quality, laryngeal diadochokinetic rate, cough, falsetto voice, phonation time (s/z)

Front 54

Gurgle voice has been associated with ______ and warrants _______

Back 54

aspiration, referral for a radiographic exam

Front 55

Inability to change pitch may imply

Back 55

reduced sensitivity within and surrounding larynx (internal superior laryngeal)

Front 56

Information collected from the preparatory examination includes:

Back 56

1. the posture that may result in best swallowing
2. the best position for food in mouth
3. the potentially best food consistency
4. some indication of the nature of the patient's swallowing disorder

Front 57

Should trial swallows at bedside be attempted?
Yes, if the patient

Back 57

1. can follow directions
2. can cough on command
3. has good pulmonary function

Front 58

Should trial swallows at bedside be attempted?
No, if the patient

Back 58

1. is acutely ill
2. has significant pulmonary complications
3. has a weak voluntary cough
4. is over 80 years old
5. cannot follow directions
6. may have a pharyngeal swallowing disorder

Front 59

If the patient is being orally fed, clinician should note

Back 59

1. reaction to food
2. oral movements (food manipulation/chewing)
3. coughing, throat clearing, struggling behaviors, changes in breathing relative to swallowing, and when during meal
4. changes in secretion levels
5. duration of meal and total intake
6. coordination of breathing and swallowing (uh, see 3)

Front 60

_____ can be of great assistance in the management of swallowing disorders

Back 60

Posture! Of course! What did you think it was?

Front 61

Maneuvers to alleviate symptoms of laryngeal malfunction

Back 61

supraglottic and super-supraglottic swallow to increase airway protection.

Front 62

Pulmonary function testing helps the clinician...

Back 62

determine whether the patient can tolerate any amount of aspiration (ordered and interpreted by physician)

Front 63

Lack of awareness of light touch in the pharynx may indicate

Back 63

poor awareneses of any pharyngeal residue remaining after a swallow

Front 64

The patient has difficulty maneuvering the bolus in his mouth. What posture is suggested?

Back 64

Tilt downward as food is introduced, then throw his head back to drain food from mouth.

Front 65

The bolus it trickling over the base of the tongue and into the pharynx before the voluntary swallow is initiated. What posture is suggested?

Back 65

Tilt downward as food is introduced, then throw his head back to drain food from mouth.

Front 66

Tilting the head back is a safe technique if..

Back 66

the patient has normal pharyngeal and laryngeal control

Front 67

Patient has had a hemilaryngectomy. What posture is suggested?

Back 67

Tilt head downward to widen valleculae, narrow airway entrance, and position epiglottis more posteriorly, diverting material away from airway.

Front 68

Patient has a delay in triggering the pharyngeal swallow. What posture is suggested?

Back 68

Tilt head downward to widen valleculae, narrow airway entrance, and position epiglottis more posteriorly, diverting material away from airway.

Front 69

Patient has slightly inadequate laryngeal closure. What posture is suggested?

Back 69

Chin tuck/tilting head downward may result in greater protection of the airway.

Front 70

Patient has a unilateral pharyngeal paralysis resulting from medullary stroke. What posture is suggested?

Back 70

Turning head towards the affected side, directing material down the more functional side.

Front 71

Patient has a lingual hemiparesis in addition to ipsilateral pharyngeal dysfunction. What posture is suggested?

Back 71

Tilting head towards the stronger side will direct material down that side during both the oral and pharyngeal stages of the swallow.

Front 72

Patient has a unilateral reduction of oral and pharyngeal function. What posture is suggested?

Back 72

Tilting head towards the stronger side will direct material down that side during both the oral and pharyngeal stages of the swallow.

Front 73

Postural decisions should be made ______ attempting swallows at bedside, and should be based on _____________.

Back 73

Prior to. the information collected in the preswallowing evaluation including history taking and chart review.

Front 74

Liquid must be placed posteriorly in the oral cavity. How? Thicker foods?

Back 74

Use a straw as a pipette, or a syringe. Use a tongue blade.

Front 75

Patients with poor oral control do best with what food consistency?

Back 75

Thickened liquids first, then moving toward thinner consistencies.

Front 76

Patients with a delayed oral swallow do best with what food consistency?

Back 76

Thicker (applesause, mashed potatos)

Front 77

Patients with reduced tongue base or pharyngeal wall contraction do best with what food consistency?

Back 77

Thin liquids.

Front 78

Patients with reduced laryngeal elevation do best with what food consistency?

Back 78

Liquids

Front 79

Patients with reduced closure of the laryngeal entrance do best with what food consistency?

Back 79

Thicker

Front 80

Patients with reduced UES opening do best with what food consistency?

Back 80

Liquids

Front 81

A patient with both a disturbance in oral function and a delayed pharyngeal swallow may do best with what food consistency? Why?

Back 81

Something between a liquid and paste: gravity assists oral propulsion during oral phase, but material will cling to valleculae and epiglottis.

Front 82

Selection of food texture to use during trial swallow depends on

Back 82

1. history
2. oral control
3. pharyngeal and laryngeal control

Front 83

Utensils used in an initial swallowing evaluation include:

Back 83

1. 0 or 00 laryngeal mirror
2. tongue blade
3. cup
4. spoon
5. straw
5. syringe

Front 84

If a patient is exhibiting any excess secretions, before initiating swallows what should happen?

Back 84

Suctioning orally and transtracheostomy (if necessary)

Front 85

Before deflating the cuff (yeah, don't forget to do that) and attempting any swallows, the clinician should

Back 85

check with the patient's physician regarding advisability of deflation and patient's tolerance of aspiration.

Front 86

Immediately after deflating the cuff

Back 86

suction well to clear away any secretions sitting on the cuff.

Front 87

During each swallow, a trached patient should

Back 87

occlude the trach tube

Front 88

Advantages of initiating swallowing therapy with trach in place

Back 88

able to observe aspirations more directly (expectorations through the tube) and can eliminate aspirated material easily by coughing and suction.

Front 89

Swallow problems arising related to trachs.

Back 89

1. restriction of upward laryngeal movement (trachea is anchored to strap muscles and skin by scar tissue)
2. compression of the esophagus.
3. change in intratracheal pressure

Front 90

Can swallowing problems be directly attributed to tracheostomies?

Back 90

Very rarely.

Front 91

Prior to asking the patient to swallow, the clinician should:

Back 91

1. review and write down directions
2. give pt opportunity to practice several dry swallows
3. give adequate time to review and absorb instructions with clinician

Front 92

It is usually advisable to assure the patient that the amount he or she will be given to swallow will be _______

Back 92

minimal

Front 93

When attempting to swallow, the patient should be encouraged to ______ whenever necessary

Back 93

cough

Front 94

When checking the patient's swallow, the clinician should use approximately _____ for both the liquid and thicker consistencies. Why?

Back 94

1/3 teaspoon. Will not block airway and will cause minimal difficulty if aspirated.

Front 95

The clinician places her hand under the patient's chin during the patient's swallow. Where? Why?

Back 95

Index finger behind the mandible (suprahyoid muscles), middle finger at the hyoid, third finger on top of thyroid cartilage, fourth finger at the bottom. To asses submandibular, hyoid, and laryngeal movement, assess initiation of tongue movement, rough estimates of oral transit time and pharyngeal delay time.

Front 96

What is one way to check a perceived a possible pharyngeal delay during a trial swallow?

Back 96

A second swallow using thermal-tactile stim (to compare to first swallow without it)

Front 97

What can the clinician do bedside after a trial swallow to assess aspiration.

Back 97

1. phonate ah immediately after (gargling sound)
2. pant for several seconds to loosen material in pharyngeal recesses.
3. phonate again to check for garglin
4. turn head to side and phonate, (pressuring pyriform sinus).
5. lift chin up and hold then vocalize (clearing valleculae).

Front 98

The purposes of the MBS

Back 98

1. to define the abnormalities in the anatomy and physiology causing the patient's symptoms
2. identify and evaluate treatment strategies that may immediately enable the patient to eat safely and/or efficiently

Front 99

The MBS is designed to asses not only _____ the patient is aspirating, but also ___, so appropriate and efficient treatment can be initiated.

Back 99

whether, why

Front 100

During the MBS, liquid volumes are increased..

Back 100

..unless or until the patient aspirates

Front 101

How does the MBS differ from the traditional barium swallow?

Back 101

TBS designed to diagnose structural lesions and anatomic deformities in the esophagus; the goal is to fill the esophagus with material (MBS uses very small amounts of liquid to minimize risks of aspiration)

Front 102

_________ is less likely from aspiration of liquids than of thicker foods.

Back 102

Pneumonia

Front 103

The most difficult and time-consuming part of the MBS is

Back 103

positioning the patient

Front 104

The fluoroscopy tube should focus on

Back 104

the lips anteriorly, the hard palate superiorly, the posterior pharyngeal wall posteriorly and the bifurcation of the airway and esophagus inferiorly

Front 105

It is important to get the patient's _______ as low as possible so the pharynx is not shadowed or covered.

Back 105

shoulders

Front 106

The lateral view (MBS) permits visualization of:

Back 106

1. oral and pharyngeal transit times
2. identification of bolus location
3. analysis of lingual movement patterns
4. gross estimate of residue and aspiration amounts
5. timing of aspiration relative to pharyngeal swallow

Front 107

The P-A view (MBS) permits visualization of:

Back 107

1. bolus pathway (one or both sides)
2. placement of bolus and residue in valleculae and pyriform sinuses
3. asymmetries in function of pharyngeal walls and vocal folds

Front 108

Approximately ____ of normal swallowers swallow down only one side.

Back 108

20%

Front 109

Prior to MBS, after patient is positioned, the clinician should tell/show the patient:

Back 109

1. explain what will happen (swallowing different kinds of foods)
2. explain only small amounts at first
3. shown the material to be swallowed on spoon
4. feel free to cough!
5. try your best!

Front 110

If aspiration occurs during MBS, then

Back 110

therapeutic strategies should be introduced to stop the aspiration

Front 111

On the last two swallows (Lorna Doone!), the instructions are different. How?

Back 111

The patient is asked to chew the material well and initiate the swallow when ready. With the liquid and paste, the patient is asked to wait until commanded to swallow.

Front 112

If the patient does well with the various foods presented using interventions or not, the clinician should also..

Back 112

observe self-feeding radiographically to assure they follow the same procedure and is equally successful

Front 113

Can the MBS be used with patients with dementia or severe cognitive problems?

Back 113

Yup.

Front 114

Compensatory strategies introduced during the MBS include (in typical order of introduction)

Back 114

1. postural techniques
2. techniques to increase oral sensation
3. swallowing maneuvers
4. diet (food consistency) changes

Front 115

Who should be referred for videofluroscopy?

Back 115

1. any patient suspected of aspirating
2. any patient with a swallowing disorder of suspected pharyngeal origin
3. any patient with a pharyngeal component to the disorder

Front 116

Therapy planning and implementation for pharyngeal dysphagia cannot be done without_________. Because

Back 116

a radiographic study/MBS/videofluoroscopy. the anatomic/physiologic cause of pharyngeal dysphagia cannot be ID'd at bedside.

Front 117

Which compensatory treatment strategies introduced during MBS can easily be used by a wide range of people? Why?

Back 117

Postural techniques and increasing oral sensation. Clinician controlled and do not require active cooperation

Front 118

Why are swallowing maneuvers more difficult than other compensatory treatment strategies?

Back 118

They require
1. the ability to follow directions
2. the ability to voluntarily manipulate the ongoing oropharyngeal swallow
3. increased work/muscular effort and increase potential for fatigue

Front 119

Some patients cannot swallow successfuly without _____

Back 119

swallow maneuvers

Front 120

The best measure of postural effectiveness is:

Back 120

amount of aspiration with and without the posture; OTT and PTT may also show improvement

Front 121

What imaging procedure could be used to accurately measure effects of postural changes on residue and aspiration

Back 121

Scintigraphy

Front 122

Oral sensory techniques include:

Back 122

1. increasing downward pressure of the spoon against the tongue in presenting food in the mouth
2. sour bolus
3. cold bolus
4. chewy bolus
5. larger volume bolus (>3ml)
6. thermal-tactile stimulation

Front 123

Thermal-tactile stimulation has been shown to

Back 123

facilitate faster triggering of the pharyngeal swallow and reducing the delay for several swallows after

Front 124

How do you measure the effectiveness of oral sensory input procedures?

Back 124

1. duration of time from command to swallow until initiation of the oral stage of swallow
2. OTT
3. Pharyngeal delay

Front 125

Swallow maneuvers are designed to:

Back 125

place specific aspects of pharyngeal swallow physiology under voluntary control

Front 126

The swallow maneuvers are

Back 126

1. supraglottic swallow
2. super-supraglottic swallow
3. effortful swallow
4. mendelsohn maneuver

Front 127

The supraglottic swallow is designed to

Back 127

close the airway at the level of the true vocal folds

Front 128

Which swallow maneuver closes the airway at the level of the true vocal folds?

Back 128

The supraglottic swallow

Front 129

The super-supraglottic swallow is designed to

Back 129

close the airway entrance before and during the swallow

Front 130

Which swallow maneuver closes the airway entrance before and during the swallow?

Back 130

The super-supraglottic swallow

Front 131

The effortful swallow is designed to

Back 131

increase tongue base posterior motion during the pharyngeal swallow, thus improving bolus clearance from the valleculae.

Front 132

Which swallow maneuver increases tongue base posterior motion during the pharyngeal swallow, thus improving bolus clearance from the valleculae?

Back 132

The effortful swallow

Front 133

The Mendelsohn maneuver is designed to

Back 133

increase the extent and duration of laryngeal elevation, thereby increasing duration and width of UES opening.

Front 134

Which swallow maneuver increases the extent and duration of laryngeal elevation, thereby increasing duration and width of the cricopharyngeal opening?

Back 134

The Mendelsohn maneuver

Front 135

Which swallowing maneuver can improve overall coordination of the swallow?

Back 135

The Mendelsohn maneuver.

Front 136

Which compensatory treatment strategy should be examined last?

Back 136

Food consistency (diet) changes, natch.

Front 137

Not all therapy procedures can be introduced into the diagnostic setting, because..

Back 137

..not all therapy procedures result in immediate effects (e.g. ROM exercises)

Front 138

What goes into the videofluoroscopic study report?

Back 138

1. OTTs and oral problems
2. Pharyngeal delay and variation with bolus volume/viscosity
3. PTTs and problems
4. Aspiration and its etiology
5. approx amounts of residue
6. intervention strategies and results

Front 139

Recommendations given in a videofluoroscopic study report include

Back 139

1. management of nutritional intake (oral/nonoral)
2. results of interventions and therapy attempted
3. procedures for swallowing
4. reevaluation

Front 140

If the videofluoroscopic study report does not include _____ and ______, the study is incomplete

Back 140

1. anatomic/physiologic reason for aspiration or residue
2. interventions attempted to reduce/eliminated symptoms and their effects or why they were not introduced