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101 Cards in this Set

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What is the order of procedures?
1) Screening Procedures

2)Bedside evaluation:
a)preparatory examination
b)initial swallow examination

3)Modified Barium Swallow:
a)postural techniques,
b)sensory techniques,
c)swallow maneuvers,
d)food consistency/diet changes,
Characteristics that require in-depth evaluation in children and developmentally delayed adults:
1. Rejection of food
2. Food selectivity
3. Gagging
4. Open mouth posture
Explain the Preperatory Examination
no actual swallow, but gathers information about the posture that may result in the best swallowing, the best position for food in the mouth, the potentially best food consistency, and some indication of the nature of the patient’s swallowing disorder
What 9 things do you look at in the prepratory examination?
a. Patient chart review
b. Observation upon entering the patients room
c. Respiratory status
d. Tracheostemy tubes, intubation, and mechanical ventilation
e. History
f. The examination of oral anatomy
g. oral-motor control
h. laryngral function examination
i. pulmonary function testing
Name 5 of the things you look at when examining the oral-motor control
• ability to open mouth voluntarily
• identification of optimal oral-sensory stimuli and bolus types
• identification of and compensation for swallowing apraxia
• identification of and compensation for abnormal oral reflexes
• labial function
• lingual function
• posterior tongue function
• chewing function
• soft palate function and oral reflexes
• oral sensitivity examination
Discuss the initial swallow examination. When should you do it? NOt do it? What is it for?
should look at the risk-benefit ratio in deciding to do it. Should note during feeding the patient’s reaction to food, oral movemens in food manipulation and chewing, any coughing, throat clearing, or struggling behaviors or changes in breathing and their frequency relative to swallowing and their occurrence during meal (beginning, middle, or end), changes in secretion levels throughout the meal, duration of the meal and total intake, and coordination of breathing and swallowing. Prior to initiating swallow, the patient’s preparation is most important. If there are excess secretions, suctioning should be completed both orally and transtracheostomy (and after deflated, do it again orally).
Discuss monitoring the tracheostomy tube in swallowing.
Best to deflate the tracheostomy cuff prior to attempting any swallow. During each swallow, patient should gently occlude his or her tracheostomy tube with a gloved finger or gauze to establish near normal pressure. Advantages to initiating therapy while tube is in place is that the therapist can observe aspiration more directly by examining the expectoration through the tube. Also coughing eliminates aspirated materials more easily.
Of over 2,000 patients with tracheostomy tubes at Northwestern, how many had a swallowing disorder that was related to the tube.
1.
If you have decided to proceed with a beside swallowing evaluation, what 5 things do you have to decide on before evaluation?
a. potentially best posture
b. selection of optimal food position in mouth
c. selection of possible best food consistency
d. selection of optimum swallowing instructions
e. utensils to be used in the initial swallowing evaluation
the modified barium swallow in the lateral plane focuses on what anatomical features?
Focuses on lips anteriorly, hard palate superiorly, posterior pharyngeal wall posteriorly, bifurcation of the wairway and the esophagus inferiorly.
The two purposes of modified barium swallow (viedofluoroscopy)
Two purposes: to define the abnormalities in anatomy and physiology causing the patient’s symptoms and to identify and evaluate treatment strategies that may immediately enable the patient to eat safely and/or effectively.
generally, food is placed on the mouth using a ____, but if the patient has a strong bite reflex use a _____
Generally food is placed on patients mouth in a disposable plastic spoon but if they have a bite reflex a heavier plastic spoon is in order.
4 step Order of therapy
1-postural techniques- 2-increase oral sensation-3- swallowing maneuvers- 4-diet (food consistency)
Inefficient oral transit (reduced posterior propulsion of bolus by tongue). Posture and rationale? sensory stim? Maneuvers?food type?
If due to reduced to elevation:
1)head back- utilizes gravity to clear oral cavity
2)position food in oral cavity or syringe 5-10 mil of liquid into oralpahrynx and bypass tongue elevatatio
3) supraglottic swallow if worried about premature spillage
4) initially try thicker liquid so you don't have to worry about premature spillage. Later do thinner liquid so its easier for tongue
If due to reduced anterior-posterior movement:
1) tilt head beack for gravity
2)position food posteriorly in oral cavity or synringe 5 to 10 ml of liquid to byass tongue elevation
3) supraglottic swallow if worried about prematured spillage (extended supraglottic)
4) initially thicker liquids, later thinner liquids
If due to disorganized patterns of anterior-posterior tongue movement (such as parkinson's repeated tongue pumping):
same as others. also:
1) alert patient to pumping and ask him to consciously hold the bolus against hard palate with tongue and to initiate the swallow with a single strong swoop back
If due to reduced tongue strength:
same as ohers
If due to swallowing apraxia-searching motion of lack of response to food in place
1)techniques to improve sensory input by changing bolus characteristics, can try thermal tactile stim, have patient feed himself
Delay in triggering the pharyngeal swallow. Posture and rationale? sensory stim? Maneuvers?food type?
1) head down-widens valleculae to prevent aspiration
2) thermal tactile stimulation
3)supraglottic swallow. can also try suck swallow
4) thickened liquid
Reduced tongue base posterior motion-residue. Posture? sensory stim? maneuver? diet change?
1) head down-pushes tongue base backward toward pharyngeal wall
in valleculae
2)Effortful swallow-effort increases posterior tongue base movement
pull-back, yawn, garggle, Masako (Swallow with anterior tongue hold)
3)thin liquids
unilateral laryngeal dysfunction- aspiration during swallow
Posture? sensory stim? maneuver? diet change?
1)head down - places epiglottis in more posterior protective position, narrows laryngeal entrance
-or- Head rotated to damaged side- increase vocal fold closure by applying extrinsic pressure
2)super-supraglottic swallow- tilts arytnoids forward, closing airway entrance before and during swallow,
supraglottic swallow if at level of true folds, effortful breath hold
3)purees and thick liquids including thickened foods and thickened liquids
reduced laryngeal closure aspiration during swallow
Posture? sensory stim? maneuver? diet change?
1)head down-places epiglottis in more posterior position, protects and narrows airway
2)super-supraglottic swallow- tilts arytnoids forward, closing airway entrance before and during swallow
-or-
???if due to laryngeal lifting problem try Mendhelson Maneuver, super-supraglottic with masako, (in therapy try shaker, falsetto)???
3)purees and thickened foods and thickened liquids
reduced pharyngeal contraction (residue spread throughtout pharynx)
Posture? sensory stim? maneuver? diet change?
1) lying down on one side- change direction of gravity on pharyngeal residue
2)Masako Maneuver-the tongue holding technique is designed to exercise the portion of the superior constrictor known as the glossopharyngeus muscle. This muscle is believed to be responsbile for the retraction of the tongue base and anterior bulging of the posterior pharyngeal wall. Needs to be done in conjunction with supraglottic,effortful swallow
follow swallow with repetitive dry swallows
3)thin liquid (also alternating liquid and semisolid so liquids wash smisolids away. limiting diet to liquids or thin paste
unilateral pharyngeal paresis-residue on one side of pharynx
Posture? sensory stim? maneuver? diet change?
same whether it's due to paralysis or scarred pharyngeal wall:
1)head rotated to damaged side of pharynx- twists pharynx and closes pyriform sinus on the affected side and directs food down the normal side; eliminates damaged side from bolus path; if unilateral paresis is in lingual function as well as pharynx, tilt head toward stronger side keeping materials on the stronger side in oral cavity and through the pharynx
2)supraglottic
3) thin liquids (alternate liquids and solids to wash hicker consistencies)
cricohpharyngeal dysfunction- reside in pyriform sinuses
Posture? sensory stim? maneuver? diet change?
1)head rotated to weaker side pulls cricoid cartilage away from posterior pharyngeal wall reducing resting pressure in cricopharyngeal sphincter
2) if the problem is reduced laryngeal elevation try Mendhelson Maneuver, super-supraglottic (with masako?), throat clearing(in indirect therapy try shaker and falsetto)
3) thin liquids (so that it can enter esophagus)
postural techniues can eliminate aspiration up to ___% of the time
80%
Sensory techniques include
a. increasing downward pressure of the spoon against the tongue in
presenting food in mouth
b. presentation of a sour bolus (50% lemon juice, 50% barium)
c. presentation of a cold blous
d. presentation of a bolus requiring chewing
e. presentation of a larger volume bolus (3 ml or more)
f. thermal-tactile stimulation
explain thermal tactile stimulation
vertically rubbing the faucial arch (5 times) firmly with laryngeal mirror which has been held in ice, before presenting bolus. Does not trigger the pharyngeal swallow at the time of stimulation but rather hightens the sensitivity for the swallow in the central nervous system and to alert the central nervous system so that when the patient voluntarily attents to swallow, he or she will trigger a pharyngeal response.
explain techniques to improve oral sensory stimulation.
generally used in patients with swallowing apraxia, delayed onset of the oral swallow, or delayed onset of the pharyngeal swallow. Measures of the effectiveness of these procedures to increase oral sensory input include 1-time between command to swallow and initiation of the oral stage-2-oral transit time-3-pharyngeal delay
the supraglottic swallow is designed to?
close the airway at the level of the true folds before and during swallow. Voluntary breath hold usually closes the vocal folds before and during the swallow. The maneuver was designed for reduced or late vocal fold closure. Was also designed for delayed pharyngeal swallow because it closes the vocal folds before and during the delay.
the steps of the supraglottic swallow:
• take deep breath
• keep holding breath and lightly cover tracheostomy tube if present
• keep holding breath as you swallow
• immediately after you swallow, cough
what is the extended supraglottic swallow designed for?
the extended supraglottic swallow technique is for patients who have severly reduced tongue mobility or bulk due to cancer and have little or no transit time so need to use large boluses to use gravity to dump food down with head tilted back. Start with small amounts (1 or 3 ml) of liquid on spoon and observe as patient tosses head back and dumps the liquid in the pharynx to determine whether (1) the pharyngeal swallow triggers on time and (2) airway closure is sufficient to protect the airway
steps of the extended supraglottic swallow:
hold breath tightly
• Put entire 5 to 10 ml of liquid in the mouth
• Continue to hold the breath and toss head back, thus dumping the liquid into the pharynx as a whole
• Swallow two to 3 times or as many times as needed to clear the majority while continuing to hold the breath
• Cough to clear any residue from the pharynx
explain the super supraglottic swallow
designed to close the airway entrance before and during the swallow. Effortful breath hold tilts arytnoid forward, closing airway entrance before and during the swallow. The maneuver was designed for reduced closure of the airway entrance.
What was the effortful swallow designed for?
designed to increase tongue base posterior motion during the pharyngeal swallow and thus improve bolus clearance from the valleculae. The maneuver was designed for reduced posterior movement of the tongue base.
What was the Mendehlson Maneuver designed for?
designed to increase the extent and duration of laryngeal elevation and thereby extend the duration and width of cricopharygeal opening- can also improve the overall coordination of the swallow. Was designed for reduced laryngeal movement to keep UES open longer, but also for a discoordinated swallow because it normalizes the timing of the pharyngeal swallow events.
What should be the last strategy examined?
Generally elimination of certain food consistencies from the diet should be the last strategy examined.
If the report does not include _________, and ______ and ________ it is incomplete.
If the report does not include the anatomic or physiologic reason for the aspiration or residue, and the interventions attempted to reduce or eliminate these symptoms and their effects, or reasons why they could not be attempted it is incomplete.
Clincian should carefully observe the swallowing mechanism by placing outstretched fingers lightly where?
on the patient’s neck, with the forefinger under the tip of the mandible on the soft tissue, second finger on the hyoid, the first lingual movement at the initiation of the posterior propulsion of the bolus (which defines the beginning of the oral transit time) can be felt.
What did asley et al find on Prevention of Barium Aspiration during Videofluroscopic Swallowing Studies
Postural techniques can eliminate aspiration of barium of at least small volumes in most patients.
Recommends changes of posture during MBS procedures.
What did Kahrilis find on Volitional augmentation of upper esophageal sphincter opening during swallowing
the opening of the UES can be modified using volitional techniques such as the Mendelsohn maneuver that affect hyoid and laryngeal elevation
What did Bisch et al find on Pharyngeal Effects of Bolus Volum, Viscosity, and Temperature in Patients with Dysphagia resulting from neurologic Impairment and in normal subjects.
Few significant effects of temperature on swallowing disorders or swallow measures (except 1ml cold)
Increase in bolus volume and viscosity decreased pharyngeal delay times in pts with neurologic impairment.
What did leder et al find on the relationship between tracheostomy and aspiration in the acute care setting?
No causal relationship between trachotomy and aspiration status was exhibited.
What did Logemann find on the benefit of head rotation in pharyngoesophogeal dysphagia
Head rotation can improve swallowing in patients with unilateral oropharyngeal dysphagia. Beneficial effects include 1) functional exclusion of the relatively flaccid, weakened pharyngeal wall, and 2) reduced UES tone. (operative mechanism depends on dominant mechanism of dysphagia)
After Clinical Bedside, what do Langmore and Logemman say is next ?
Logemann argues that FEES is necessary because bedside swallow exams fail to detect 38-40% of aspiration and do not allow for observation of the physiology of pharyngeal swallow. Langmore argues that FEES is not always feasible or necessary, and endoscopy is often sufficient. Read the article.
What does Welsch say on changes of pharyngeal dimensions due to chin tuck
Chin tuck procedures causes a posterior shift of the anterior pharyngeal wall and the laryngeal entrance, while widening the angel of the epiglottis to the anterior tracheal wall, improving airway protection. Widening of the valleculae is not uniform.
What does Shannon say about those who benefit from the chind down position for dysphagic patients with delayed swallow or reduced airway closure?
Not all patients who aspirate because of a delayed pharyngeal swallow or reduced airway closure benefit from the chin-down procedure. Those who do not benefit show a significantly loarger increase in the epiglottic angle.
Whar does de Lama Lazara have to say about the impact of thermal tactile stim on the pharyngeal reflex?
The anterior faucial arches are mon of the most sensitive areas for triggering the swallowing reflex. Use of thermal sensitization improved triggering of the swallowing reflex in 23 of 25 neurologically impaired patients. Effects immediate. Longterm effects are unknown. No reflex will be triggered if reflex is absent.
What does Martin have to say about normal laryngeal valving patterns during a normal 3 breathhold maneuver?
Videofluoroscopy allows visualization of the biomechanics of oropharyngeal and cervical esophagus and to determine if patient is able to maintain laryngeal valving. 3 breath-hold maneuvers were easy, inhale hard, inhale/exhale hard. Arytenoid & TVF produced on all maneuvers; FVF and ant arytenoid tilting only during hard holds.
What do Fugi and Logemann say about the effect of a tongue holding maneuver on posterior pharyngeal wall movement
Inhibits triggering of pharyngeal swallow, increases pharyngeal residue, shortens airway closure. Does allow pt to actively change the degree of muscular contraction of the PPW (posterior pharyngeal wall)
What does Logemann say the potential importance to dysphagic patients and normal individuals of preswallow sensory input is?
More research needs to be done on the effects of preswallow sensory input in normal individuals and dysphagics.
Normal swallowers exhibit systematic changes in temporal measures of oropharyngeal swallow as a result of changes in bolus volume and viscosity (effects of taste unknown)
What does Davis say the effect of a a maxillary glossectomy prosthesis on articulation and swallowing is?
Residue in the oral cavity decreased markedly with the prosthesis (25% with, 90% without) t/d and k/g productions were also more normal
if you are interested if te sternocledimastoid muscle is contracting you would use?
electromyography (EMG)- hooked wire if deep
What is the screening test for the presence of aspiration given at the bedside for a tracheostomy patientthat gives measured amounts of foodand suctions the tracheostomy immediately after for the presense?
blue dye test. Note if blue-dyed tinges appear LATER, does not neccessarily mean aspiration occured.
The afferent impluses for the gag reflex are carried mainly by what nerve?
cranial nerve X but IX may be involved
What is difference between gag and swallow?
gag reflex is triggered by a noxious stimulus such as vomit or reflux and the motor response is designed to squeeze the material up and out of the pharynx. Swllow is organized set of motor actions designed to take food safely to esophogus.
how to elicit palatal reflex? how to elicit gag reflex? how to do thermal tactile stim?
palatal-juncture of hard and soft palate; the less table of the reflexes, often requires two strokes
gag- contact with base of tongue or posterior pharyngeal wall
thermal tactile stim- anterior faucial arch
The afferent impluses(nerves that carry impulses from the outer body toward the brain or spinal cord)for the palatal reflux are carried by what nerve? what about the efferent (directing outward from brain or spinal cord)portion?
glossopharyngeus and possibly the vagus; where the efferent part is carried through the vagus and possibly the glossopharyngeus nerve. The trigeminal nerve which also innervates the part of the palate may also be involved.
three questions that need to be answered after evaluation of the patient with an oropharyngeal swallowing problem
1) what type of nutritional management is necessary, 2) should therapy be initiated and what type (compensatory or exercises, direct or indirect) 3) what specific therapy strategies should be used.
The clinician should consider what 8 things in deciding whether to initiate swallowing therapy with a dysphagic patient and what ype of therapy
1) diagnosis
2) prognosis
3) reaction to compensatory strategies
4) severity of patient's dysphagia
5) ability to follow directions
6) respiratory function
7) avaliability of caregiver support
8) patient motivation and interest
Reduced Labial Closure
Range of motion lip exercises include stretching the lips in the /i/ position as far as possible and holding in extreme extension for 1 second; puckering the lips as tightly as possible and holding for 1 second bringing the lips together and holding for 1 second. Gradual increase in time once lip closure is obtained. Also add pressure (tongue blade) or clinician trying to manually part the lips.
Reduced Range of tongue movement laterally during mastication
Lateral ROM exercises (indirect therapy) Temporary, use tongue to mash food on roof of mouth if elevation is there or position food on most mobile side and tilt head.
Reduced Buccal tension or buccal scarring
Facial exercises (indirect therapy)“oh” face, “ee” face rapidly alternate between the two; pull lips as far to one side as possible, then the other side
Reduced range of mandibular movement laterally
Mandibular ROM exercises (indirect therapy)Opening jaw as widely as possible and holding open for 1 second—particularly important post op oral cancer paitnents and patients undergoing oral radiation, should be continued through radiotherapy and 6-8 weeks after
Reduced range of tongue movement vertically
More in indirect…. If patient has not achieved tongue-palate contact after several months of repeating these excercises daily at rgular intervals, a palate reshaping prosthesis may be given- lowers palatal arch (designed by SLP and maxillofacial prosthodontist together) may be compromise between speech needs and swallowing needs
Reduced tongue movement to form bolus
More in indirect…. Temporarily may tilt head slightly forward to keep food in anterior part of the mouth until the patient is ready to initiate the swallow, thus preventing him or her from losing the bolus in one of the lateral sulci, with the start of the swallow the patient may then change head posture
Reduced range and coordination of tongue movement to hold bolus
More in indirect…. Temporary (interim) measure, clinician may suggest that the patient not attempt to manipulate the bolus once it is in the mouth but to hold the material securely against the front if the roof of the mouth and to initiate the swallow immiediately
Reduced ability to hold bolus in normal position
Given a bolus of thick paste consistency (about 1/3 teaspoon) and asked to hold it consciously against the anterior to mid-portion of the palate with the tongue. This exercise requires the tongue tip and lateral margins of tongue be contacting the alveolar ridge immediately posterior to the teeth—then bolus can be made thinner and thinner in consistency
Reduced oral sensation
Should position food on more sensitive side of mouth, use of cold material may help patient localize, use of mild spices or tastes may help localize
Tongue thrust (when due to neurologic impairment)
Heightening awareness of thrust pattern and asking them to consciously position tongue on the alveolar ride and begin the swallow with an upward-backward push often reduces the thrusting. Applying downward pressure to the middle of the tongue may also reduce the thrust and should be done during feeding. As a compensatory measure the patient may be taught to position food posteriorly on the tongue and thus avoid the thrusting pattern. Titlting the head backward or tiltiing body backward 60 degrees (wheelchair) may also be helpful in keeping food in
Reduced tongue elevation
More in indirect…. Interim: position food posteriorly in oral cavity or syringe 5 to 10 ml of liquid into oral pharynx and bypass tongue elevation; tilt head back for gravity; if concerned about aspiration can teach supraglottic swallow;
Reduced anterior-posterior tongue movement
More in indirect…. Frequently this disorder is in conjunction with reduced tongue elevation. Again, in the interim: position food posteriorly in oral cavity or syringe 5 to 10 ml of liquid into oral pharynx and bypass tongue elevation; tilt head back for gravity; if concerned about aspiration can teach supraglottic swallow;
Disorganized patterns of anterior-posterior tongue movement
Such as parkinson’s rapidly repeating tongue movements- alert patient to pumping and ask him to consciously hold the bolus against the palate with the tongue and to initiate the swallow with a single strong backward movement of the tongue.
Reduced tongue strength
Resistance exercises include wither a tongue blade or other flat object to push vertically down on the tongue, asking the patient to resist it if possible. Then the tongue blade can be turned vertically and pushed laterally against one side of the tongue with patient resisting. Then can be put down vertically in front of mouth and used to push back against tongue tip with patient applying resistance
Swallowing apraxia- searching motions or lack of response to food placed in mouth
Techniques to improve sensory input by changing bolus characteristics, thermal-tactile stimulation (indirect)
Scarred tongue contour
Cannot be improved with exercise, can be compensated for by positioning food posterior to the scarring, and to tilt head backward to use gravity to assist in oral transit. Actual treatment involved surgical release of scar- head and neck surgeon.
Delayed or absent triggering of the pharyngeal swallow
Thermal tactile stimulation repeated 3 to 4 times a day for 5 to 10 minutes each time, suck-swalow, or using a bolus with a particular sensory characteristic (sour or cold or a particular volume). Compensatory technique- tilt head forward.
Bilateral reduction in pharyngeal contraction
Masako Maneuver- No direct therapy technique improves pharyngeal contraction at all levels. The tongue holding techinique is called the Masako maneuver and is designed to exercise the portion of the superior constrictor known as the glossopharyngeus muscle. This muscle is believed to be responsible for the retraction of the tongue base and anterior bulging of the posterior pharyngeal wall at tongue base. The maneuver involves holding the tongue between the teeth with the tip extended out ¼ inch. It pulls pharyngeal wall forward while doing the tongue holding. Difficult if there is a pharyngeal delay. Compensatory techniques include:
1. alternating liquid and semisolid or solids so the liquids wash the thicker consistencies
2. limiting the diet to liquids or thin paste
3. following each swallow of food or liquid wih several repetitive dry swallows to clear pharynx
Unilateral pharyngeal paralysis
No exercise improves pharyngeal paralysis but compensatory strategies:
1. turn head toward the affected side thus closing the pyriform sinus on the affected side and directing food down normal side
2. if unilateral paralysis in lingual function as well as pharynx- tilt head toward stronger side, keeping material on the stronger side in oral cavity and through pharynx
3. supraglottic swallow
4. alternate liquid and solid to wash thicker consistencies
Scarred pharyngeal wall
No exercise improves scarring, but there are compensatory strategies. Mainly, the supraglottics swallow may help eliminate residue that is in scar on wall. Also:
5. turn head toward the affected side thus closing the pyriform sinus on the affected side and directing food down normal side
6. if unilateral paralysis in lingual function as well as pharynx- tilt head toward stronger side, keeping material on the stronger side in oral cavity and through pharynx
7. supraglottic swallow
8. alternate liquid and solid to wash thicker consistencies
Cervical osteophyte
A cervical osteophyte or bony overgrowth of one of the cervical vertebrae may be surgically reduced, or the patient may acclimate to it by thinning out the consistency of material swallowed. Changing head posture, particularly to one side or the other may be helpful.
Pseudoepiglottis at the base of tongue in total laryngectomees
Surgically removed, adjust by only swallowing liquids and thin paste, sometimes head rotation will keep the fold out of the bolus path
Cricopharyngeal dysfunction
If problem is truly the muscle’s inability to relax, cricopharyngeal myotomy should be considered (after 5 to 6 months of time to recover spontaneously). If it is a laryngeal elevation problem, try mendehlson maneuver, if they can follow directions. These patients tend to be cervical spine injury, cervical anterior or posterior fusion, stroke, radiation therapy, surgery to the pharynx. If bolus pressure is the problem, that means pharyngeal pressure is lacking, so do excercises to improve tongue base. Combo of mendehlson and head rotation to weaker side may be most helpful.
Reduced laryngeal elevation
Mendhelson Maneuver. Compensatory: sperglottics, super supraglottic, throat clearing, falsetto excercise
Reduced laryngeal closure at airway entrance
Super supraglottic swallow
Reduced laryngeal closure at vocal folds
More in indirect….. Supraglottic swallow
Therapy for Esophageal Swallowing disorders:
Normal handled with medication and surgery
3. Patients with oral cancer did not include a particular food consistency in their diet unless combined oral and pharyngeal transit times were approximately ___ seconds or less.
10 seconds
compensatory treatment procedures include:
postural techniques, stimulation, changes in viscocity/amount of bolus, changes in type of bolus, prosthesis
There are three types of oral prosthetics that may improve swallowing:
a palatal lift prosthetic, reshaping prosthetic, palatal obturator
Five swallowing maneuvers include:
Mendhelson, Supraglottic, super supraglottic, effortful swallow. Also Masako- lingual control
When to use Scintigraphy?
• Scintigraphy- camera takes pictures and calculates AMOUNT of residue of aspiration. Only procedure which actually measures amount of aspiration. Used often to look at children and reflux. Nuclear medicine test.
The parts of the tracheostomy tube are:
the inner cannula, outer cannula, and obturator
The difference between the supraglottic swallow and the super-supraglottic swallow
is the super supraglottic is an effortful breathhold (bearing down) closes airway entrance and true folds as opposed to just the vocal folds (supraglottic).
The difference between the effortful swallow and the super-supraglottic swallow
the effortful swallow is a HARD swallow being aware of the backward tongue propulsion and s used to improve tongue base retraction as opposed to the super-supraglottic swallow which is an effortful breathhold and is for closing the airway entrance and has you cough after.
why use the minimal leak technique?
so no tracheal ischemia which leads to stenosis instead of being fully inflated
hole in tube for speech, usually not in cuffed tracheostomy because defeats the point of the cuff
Fenestrate tube
**** why aren't exercises included in the xray?
Exercises are NOT in the x-ray because they don’t have imemediate effects. • Whichever they respond to best should be used in therapy
• When to use supraglottic as opposed to super supraglottic?
1) use superglottic when the problem is vocal fold adduction; premature spillage or delayed pharyngeal swallow
Child with cricopharyngeal problem-
• Child with cricopharyngeal problem- SHAKER!! Also try mendehlson maneuver—but child doesn’t have as far to rise, head rotation to UES, and falsetto
three therapies you should not use:
• Don’t use electrical vital stimulation, DPNS, or myofacial release (myofacial release comes from PT and supposedly massages and breaks up facia where tight)
When to use manometry?
• Manometry- way to measure pressure during swallow, one kind in esophagus- water manometry little tube 3 mm in diameter has holes all along it, you wouldn’t want to do it in pharynx but when esophagus contracts it shows as pressure goes up. Pharynx- solid state manometry, line for every sensor- generally in pharynx there are 3-5 sensors, one is at the upper sphincter one is at base of tongue, and one is at the esophagus. If what you want to see is pressure, you need manometry, some disagreement about whether you need xray with it.
When to use surface EMG
• Surface EMG- not really diagnostic procedure because all it shows is electrical activity when muscle contracts, you can use for biofeedback or twaching some clinicians to use it for the mendhelson maneuver.
When to use ultra sound?
• Ultrasound- high-frequency soundwaves- look up through mandible @ tongue. Lots of little dots you can connect- white blob is hyoid bone, biofeedback for tongue motion- Not invasive and not clearest picture, not good for phaynx.
When to use endoscopy
• Endoscopy- Endoscopy shows the anatomy the best. the difference between oral and nasal endoscopy is the placement and quality of picture. You would use nasal endoscopy to see if someone could do a supraglottic swallow. Oral endoscopy is good for seeing effortful breathhold.