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79 Cards in this Set
- Front
- Back
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Oral Prep Phase
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-voluntary control
-sensory recognition -tongue mixes food w/saliva, manipulates into bolus -sensory feedback to bolus |
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5 Neurological events in the oral prep. phase
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1. lip closure
2. buccal tone 3. tongue action 4. lateral rotary jaw mvmt. 5. downward/forward mvmt. of the jaw |
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Oral Phase
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1-1.5 seconds
-voluntary control -initiated when tongue begins posterior mvmt. of bolus -bolus squeezed against hard palate by midline tongue -need intact: labial seal, lingual mvmt., buccal musculature |
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Pharyngeal Phase
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1 second
-when the leading edge of the bolus passes any point b/t the anterior faucial arches and the point where the tongue base crosses the lower rim of the mandible -involuntary control -soft palate elevates and contracts -tongue base ramps to deliver bolus -bolus tail reaches tongue base, TB retracts to contact the anteriorly bulging posterior pharyngeal wall starting the: -top to bottom contraction of pharyngeal constrictors -elevation and anterior mvmt. of the hyoid and larynx -closure of airway at all 3 spinctors (airway closed approx 2/3 to 1 sec per swallow) 1. epiglottis and aryepiglottic folds 2. arytenoids, base of epiglottis, false folds 3. true vocal folds -cricopharyngeal sphincter opens |
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Esophageal Phase
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8-20 seconds
-involuntary control -bolus enters esophagus to pass into stomach -food pushed by persitatlsis |
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Oral Prep Phase Problems
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reduced lip closure
reduced buccal and tongue tension reduced lateral tongue mvmt reduced tongue mvmt to form cohesive bolus reduced coordination of tongue to hold bolus reduced oral sensitivity reduction in range of jaw mvmt delayed or absent reflex tongue thrust reduced tongue elevation reduced/disorganized anterior and posterior tongue mvmt slippage of food into anterior and lateral sulcus |
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Pharyngeal Phase Problems
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delayed swallow reflex
inadequate velopharyngeal closure nasal and airway penetration of food reduced pharyngeal peristalsis unilateral pharyngeal dysfunction reduced laryngeal elevation cricopharyngeal dysfunction reduced laryngeal closure difficulty propelling bolus through pharynx and into PE segment residue on pharyngeal walls, valleculae aspiration before and after swallow delayed pharyngeal transit time reduced pharyngeal peristalsis (constricting/relaxing mvmts. of pharynx) pharyngeal paralysis reduced mvmt. of base of tongue reduced laryngeal mvmt inadequate closure of airway cricopharyngeal dysfunctions |
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Esophageal Phase Problems
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lax cricopharyngeus muscle
backflow of food from esophagus to pharynx reduced esophagus contractions due to surgery, neuro damage, or radiation therapy formation of diverticulum (pouch that collects food) development of tracheo esophageal fistula esophageal obstruction reduced peristalsis |
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CN #5
Trigeminal Nerve |
jaw movement-bilateral innervation
-sensory-conveys sensory info. from the anterior 2/3 of the tongue, mucosa of the mouth, skin of the lower lip and jaw, mucosa of the nasopharynx, soft and hard palate, gums, upper teeth -motor-innervates the muscles of mastication, responsible for the major mvmts. of the mandible (mouth opening, closing, rotary mvmt.), innervates the muscle of the floor of the mouth and the tensor veli palatine (aids in elevating the palate) |
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CN #7
Facial Nerve |
bilateral upper, contralateral lower
-sensory-convey taste sensation from the anterior 2/3 of the tongue -motor- innervates muscles of facial expression, salivary glands, obicularis oris (lip shapping) and the buccinator muscle (flattens cheeks and holds food in contact w/teeth) damage here can cause food to be caught in the sulci |
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CN #9
Glossopharyngeal |
tongue/pharynx mvmt. info.
-sensory-transmits info from pharynx. transmits info re:taste sensation from posterior 1/3 of tongue. transmits info re: general sensations of touch, pain, and thermal sensation orm the mucous membrane of the oropharynx, palatine tonsils, the faucial pillars -motor-inncercates the muscle that elevates and dilates the pharynx and the parotid gland which secretes saliva. |
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CN #10
Vagus Nerve |
bilateral
-sensory-conveys general sensation from the larynx, pharynx, and esophagus -motor-innervates the base of the tongue (raises the back of the tongue), soft palate (raise/lower), the pharynx (contraction), and the intrinsic muscles of the larynx (adducts & abducts the VF and the esophagus) |
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CN #11
Spinal Accessory |
-motor-innervates muscles that move the larynx and pharynx, spinal nerves and respiration
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CN #12
Hypoglossal |
tongue muscles
-innervates all intrinsic and most of the extrinsic muscles of the tongue and the muscles that elevate the hyoid bone and the thyroid cartilage |
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Etiologies of Dysphagia
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-strokes resulting in poor motor control of structures involved in swallowing (brain stem & anterior cortical strokes)
-oral and pharyngeal tumors -neurologic diseases-Parkinson's, ALS, MS, myasthenia gravis, muscular dystrophy, and dystonia -TBI, cervical spine disease -side effects of certain Rx drugs -surgical or radiation Tx of oral, pharyngeal, and laryngeal cancer -brain, head, neck, or gastrointestinal surgeries -genetic factors |
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Myasthenia Gravis
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The hallmark of myasthenia gravis is muscle weakness that increases during periods of activity and improves after periods of rest. Certain muscles such as those that control eye and eyelid movement, facial expression, chewing, talking, and swallowing are often, but not always, involved in the disorder. The muscles that control breathing and neck and limb movements may also be affected.Myasthenia gravis is caused by a defect in the transmission of nerve impulses to muscles. It occurs when normal communication between the nerve and muscle is interrupted at the neuromuscular junction
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Oral Phase Problems
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food residue in anterior and lateral sulcus
premature swallow and aspiration before swallow tongue thrust reduced labial, buccal, and tongue tension and strength reduced range of tongue mvmt. and elevation |
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Describe the different phases of swallowing
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Oral Prep-Masticated food is prepared for swallow in the oral prep phase by making a bolus.
Oral Phase- Begins w/the post. tongue action that moves the bolus post.;the phase ends as bolus passes through anterior faucial arches when swallowing reflex is initiated. Pharyngeal Phase- Consists of reflex actions of the swallow; reflexes are triggered by the contact the food makes w/ant. faucial pillars. The pharyngeal phase involves velopharyngeal closure, laryngeal closure by elevated larynx to seal airway, reflexive relaxation of the cricopharyngeal muscle for the bolus to enter, and reflexive contractions of pharyngeal contractors to move the bolus down and into the esophagus Esophageal Phase-Involuntary. Begins when food arrives at orifice of esophagus; food is propelled through the esophagus by peristaltic action and gravity into stomach. Bolus entry into esophagus results in restored breathing & a depressed larynx and soft palate. |
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Assessment/Evaluation Steps
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1. Medical hx/dx
2. doctor's orders 3. dietary notes 4. respiratory status 5. multidisciplinary team notes 6. VFSS 7. neurological consult 8. dietary consult |
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What are the different parts to an oral mech exam?
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examine for oral cavity structural abnormalities
dentition strength, coordination & ROM-jaw, lips, and tongue jaw function labial function lingual function velar function gag reflex voluntary swallow |
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Materials for a bedside swallow evaluation.
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gloves, spoon, cups, straw
ice chips nectar consistency (thick-thin) honey consistency (falls off spoon) pureed consistency (NOT off spoon) solids (ground or chopped) |
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pooling
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occurs BEFORE the swallow is triggered
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residue
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what is left AFTER the swallow
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penetration
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occurs ABOVE the VFs.
Occurs when the bolus enters the laryngeal vestibule but does not go through the true VFs. If you have good sensation, you feel it going down the wrong way and cough. |
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aspiration
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occurs BELOW the VFs.
Occurs when the bolus enters the airway and goes below the true VFs into the trachea and lungs |
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Aspiration BEFORE swallow
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Due to
a)reduced tongue control-bolus falls prematurely before pharyngeal swallow triggers b) delayed swallow reflex-food has been pushed back by the tongue, but the pharyngeal swallow doesn't trigger on time |
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Aspiration DURING swallow
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Reduced laryngeal closure-food gets through all 3 levels
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Aspiration AFTER swallow
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a) residue in the oral cavity, pharynx, or laryngeal cavity can be aspirated
b) reflux-backflow from esophagus and stomach |
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Signs/Symptoms of Dysphagia
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temperature spikes
drooling weight loss coughing pocketing pneumonia dehyrdration reflux |
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Pharyngeal Transit Time (3)
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The time it takes the bolus to move from the point at which the pharyngeal swallow is triggered through the cricopharyngeal juncture into the esophagus (1 sec or less)
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Pharyngeal Delay Time (4)
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When the bolus head reaches the point where the lower edge or the mandible crosses the tongue base-ends when laryngeal elevations begins (0-.2 secs)
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Pharyngeal swallow trigger (1)
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When the leading edge of the bolus passes any point b/t the anterior faucial arches and the point where the tongue base crosses the lower rim of the mandible-pharyngeal swallow is triggered and oral phase is over
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Apneic Period (2)
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The closing off of the airway for a fraction of a second. Swallowing interrupts the exhalatory phase of the respiratory cycle during the pharyngeal phase.
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Pharyngeal Activity
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1. soft palate elevates and contracts
2. tongue base ramps to deliver bolus 3. bolus tail reaches tongue base-tongue base retracts to contact the ant. bulging post. pharyngeal wall 4. top to bottom contraction of pharyngeal constrictors 5. elevation and ant. mvmt. of the hyoid and larynx 6. closure of airway @ all 3 sphincters (airway closed approx. 2/3 to 1 sec per swallow) epiglottis and aryepiglottic folds-arytenoids, base of epiglottis, false folds-true VFs 7. cricopharyngeal sphincter opens as the bolus passes, the UES returns to tonic state |
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What are red flags in a chart review for Dysphagia?
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temp spikes
vocal quality pocketing reflux drooling, secretion mngmt. coughing, throat clears, eye watering weight loss oxygen sats dehydration |
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Compensatory Strategies for Dysphagia
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posture
chin down head rotation to damaged side backward/side head tilt tilt head to intact side sour bolus food placement external pressure to cheek labial closure support chin support smaller bites thin liquid from spoon alternate solids and liquids swallow twice after each bite to clear residue increase food cohesiveness |
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Exercises for Dysphagia
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supraglottic swallow-breath, hold, bite, swallow, cough, re-swallow
effortful swallow -could this damage the VFs? mendelsohn maneuver-swallow and hold larynx up |
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What is the purpose of the salivary glands in the oral cavity?
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To maintain moisture, reduce tooth decay, neutralize stomach acid
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anatomy & physiology of swallowing center
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The swallowing center is located in the brainstem. It is bilateral in nature; located in the reticular formation of the medulla @ the level of the facial nerve; all of the CN involved in swallowing either originate or end in the medulla.
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Best predictors found in a bedside story:
best hx measure- best oral motor measure- best voice measure- |
best hx measure-pneumonia
best oral motor measure- jaw strength best voice measure- wet and dysphonia |
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Clinical items that are independent predictors of dysphagia.
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-older than 70 y/o
-male -disabling stroke -palatal weakness and asymmetry -incomplete oral clearance -impaired pharyngeal response (cough/gurgle) |
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Clinical predictors of aspiration
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Delayed oral transit time
Incomplete oral clearance |
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What to look for in a medical chart review
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face sheet
physician orders progress notes nurses notes & graphs dietary notes respiratory notes therapy section lab results consults misc. temp. x-ray reports medications |
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Red flags of chart review and bedside eval.
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coughing/choking/gagging
drooling increased temp pneumonia dehydration gurgly or wet voice increase need for breathing tx after meals pocketing decreased appetite/self imposed changes in diet weight loss |
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Bedside Evaluations
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trachs & speaking valves
Blue Dye Test 3 oz. Water Swallow Test Cervical Auscultation Pulse Oximetry |
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3 oz. Water Swallow Test
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stroke patients
abnormal response during or for one minutes after, or wet-hoarse vocal quality. Cough reflex as sole indicator not vocal quality. |
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Timed Test of Swallow
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Uses speed of swallow as an index of abnormality. Give water and ask them to drink, measure speed. Even the authors reported this could be "hazardous"
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Cervical Auscultation
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Use a stethoscope to listen to the sounds of swallowing, place stethoscope over "lateral border of the trachea immediately inferior to cricoid cartilage" Growing clinical use, few studies. How do dysphagic swallow sounds differ from normal swallow sounds? not known.
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Things to report after bedside...
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-Do you need to:
rec. other asmt. rec. an istrumental exam refer to other medical specialties -is the pt safe to eat by mouth? -can they maintain adequate nutrition and hydration (dietary consult required?) -combo. of tube feed and po? (Note-Medicare will not pay for therapy if you are rec. "pleasure feeds"-need to have goals that indicate pt can progress) -who can/should safely feed the pt? -what family training is needed? -how should meds be given? -how should pts be positioned? -need for oral care? |
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What are the benefits of an oral peripheral exam?
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diff dx and med hx
precursor of what to assess/observe in swallow eval diet rec cog. linguistic screening: following directions, apraxia, attn. to task determine goal and direction of therapy |
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What are 3 reasons for doing an oral peripheral exam?
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1. Description of current problem
2. onset of dysphagia 3. current diet and problem foods |
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What are 3 things to assess in a neuromotor eval?
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1. sensori-neuromotor mechanisms
2. cranial nerves related to speech (artic components) 3. phonatory mechanisms |
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What are the relevant Cranial Nerves to Swallowing?
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CN 5-Trigeminal
CN 7- Facial CN 9-Glossopharyngeal CN 10-Vagus CN 11- Spinal Accessory CN 12-Hypoglossal |
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What to assess the lips for....
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symmetry
tremors/involuntary mvmt drooling groping tone vs. flaccidity |
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What to do during a lip asmt
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closure
protrusion retraction tension diadokinetics |
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What to do during a lingual asmt.
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protrusion
lateralization elevation depression coordination tongue tip elevation strength tongue base retraction "unguh" diadokinetics "tu-ku" |
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Assess the palate/uvula for...
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Asymmetry
Elevation Malformation |
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Assess the laryngeal for...
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vocal quality
intensity strength in volitional cough hyper/hyponasality |
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Larynx asmt.
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cough/throat clear
max. phonation time :"ahh" (norm. 12-15s) pitch variance laryngeal elevation/anterior excursion |
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Assess dentition for...
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natural
edentulous-no teeth partials or complete denture oral hygiene malocclusion |
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Assess face for....
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asymmetry
tremors/involuntary mvmts drooling masked facies eye drooping tone vs. flaccidity nasal emissions (velopharyngeal elevation) |
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Face asmt.
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wrinkle forehead
close eyes tightly wrinkle nose blow cheeks up with air, move air from cheek to cheek suck cheeks in and hold: fish face |
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Assess jaw for...
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deviation
clenching popping strength inability to open |
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Jaw asmt.
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Mandibular depression/elevation: open and close: with and w/o resistance
Protrusion/retraction: push jaw out and pull jaw in Rotary/lateral mvmt-chewing |
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Assess Lingual for...
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atrophy
fasciculation tremor deviation/asymmetry coordination tone vs. flaccidity |
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Anatomy of Upper Airway
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nose-filters dust and dirt
nasopharynx-filters air, warms or cools air, humidifies air oral pharynx-air passes through larynx-vocal folds open, allowing air to pass trachea-approx. 10-14cm long, joins larynx @ 6th cerv. vert. bifurcates at carina. constructed of 15-20 c-shaped cartilaginous rings vocal folds |
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Anatomy of Lower Airway
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trachea
carina-pt. @ which the bronchi bifurcate left/right bronchus secondary bronchi bronchioles capillary alveolus-where exchange of oxygen and carbon dioxide take place |
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Why would someone need a tracheostomy?
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-to assure pt airway (laryngeal edema, head/neck injury)
-to protect lungs from potential threats -to easily remove secretions from the trachea and lower airway (prevent pneumonia, or aspiration of gastric contents) -to permit long-term vent. support (CNS dysfunct., neuromuscular dysfunct., musculoskeletal d/o) |
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How is trach placed?
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-usually performed @ bedside in ICU-sometime OR
-small incision made through the 2,3, or 4th trach. ring -inserted below the level of the vocal folds |
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What are the parts of a trach?
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cuff
outer cannula inner cannula pilot line pilot balloon obturator |
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What is the purpose of a fenestrated trach?
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Allows air flow upward past the vocal folds
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What are the disadvantages to a foam cuff?
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tend to leak
can become rigid cannot completely deflate |
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What are some diff. trach attachments?
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T-bar-allows for in-line suctioning
Trach collar-allows for large amounts of oxygen HME (heat moisture exchange) PMV (passy-muir valve)-one way speaking valve Red Cap-last step before decannulation |
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Hallmarks of PMV
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one-way closed position speaking valve
no leak design small, lightweight and fits the universal 15mm tub of any sized trach tube |
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What are the clinical benefits of the PMV?
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communication
improves swallow may reduce aspiration vent. application facilitates secretion mngmt. improves oxygenation improves olfaction expedites weaning and decannulation restores positive airway pressure interchangability b/t vent and trach usage facilitates infection control |
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Who is a candidate for the PMV?
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vent. dependent pt
neuromuscular dz. head trauma quadriplegia/paraplegia CVA Chronic Pulmonary Dz. Brochopulmonary Dysplasia Sleep apnea Mild trachea/laryngeal stenosis |
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What are the contraindications of PMV?
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inflated cuff of the trach tube
foam-filled cuff severe airway obstruction unconscious or reduced cogn. unmngbl. secretions severe risk of aspiration laryngectomee bilateral vocal fold paralysis do not use while pt is sleeping |
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Bedside Eval for PMV includes...
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asmt. of baseline signs
positioning suctioning cuff deflation PMV attachment assess for adequate exhalation and phonation length of time pt can tolerate PMV placement remove PMV and reinflate cuff if appropriate educate pt/family/caregiver on usage/POC |
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D/C trach tube
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ventilator
t-bar trach collar PMV red cap decannulation |
