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118 Cards in this Set

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What is the most prevalent swallowing disorder in patients with closed head trauma?
Delay triggering the pharyngeal swallow
What is the most prevalent swallowing disorder in patients with stroke?
Delay triggering the pharyngeal swallow
How is the length of coma related to the severity of swallowing problems?
The longer the coma, the more severe the swallowing problems (yeah, that one made you feel good, didn’t it?)
Patients with closed head injury have complex swallowing problems due to the combination of _____________, ____________, and ______________.
Closed head injury, damage to other parts of the body, and nature of emergency care.
Neurogenic damage can be caused by what three forces?
Direct head injury, contra-coup injury, and twisting/shearing of the brainstem
Patients with head trauma may experience other injuries including ____________, _____________, and _______________.
Puncture woulds to the neck, laryngeal fracture, and penetration wounds to the chest (affecting the esophagus)
Patients receiving emergency care may be injured by ____________ or _____________.
Tracheostomy - may be placed to high scarring the larynx. Intubation - forceful intubation can also damage the larynx.
What are four oral swallowing disorders seen in those with closed head injury?
Reduced lip closure, reduced tongue ROM (with poor bolus control), abnormal oral reflexes (including bite reflex), and delayed/absent pharyngeal swallow.
What are eight pharyngeal swallowing disorders seen in those with closed head trauma?
Reduced laryngeal elevation, reduced closure of airway entrance, reduced closure of airway throughout, reduced tongue base motion, reduced CP opening (usually related to reduced laryngeal motion), uni/bilateral pharyngeal wall weakness, tracheoesophageal fistula, reduced velopharyngeal closure.
In patients with closed head injuries, reduced airway closure and reduced CP opening (due to poor laryngeal motion) are generally related to ______________ instead of neurologic damage.
Physical damage to the larynx
What are some patient characteristics which affect swallowing in those with closed head injury?
Impulsiveness, tendency to overstuff mouth, cognitive difficulties, reduced sensation.
True or False: The recovery of swallowing after closed head injury is well documented
False: One study showed recovery over time but it was based on bedside evaluation (Gasp! No radiographic study?!)
True or False: Patients of any age will develop complications from aspirating over a short period of time
False: Younger patients can aspirate (especially on liquids) with no apparent consequences for a year or more.
Why is it important to counsel the family regarding swallowing and dietary changes during the acute phase?
Because if you wait until the rehabilitation stage, the patient and family may not comply with your recommendations.
If a patient with closed head injury has cognitive deficits __________________ will be easier to use than _____________.
Postures and sensory heightening will be easier than voluntary maneuvers.
True or False: Most patients with closed head injury will need to use voluntary maneuvers in order to manage their swallowing disorders.
False: Because the most common disorders are delayed pharyngeal swallow and reduced range/coordination of tongue motion and these can be addressed using other methods.
Initial therapy tasks for patients with cognitive deficits include…
sensory heightening strategies, resistance exercises, range of motion exercises.
When working with family members of patients with closed head injuries, it is crucial to explain the _______________.
Goal of each therapy task and compensatory strategy.
True or False: If you determine that a patient has reached a plateau and dismiss them from therapy while on non-oral or limited oral feeding, that patient will not be able to return to a full oral diet.
False: You should re-evaluate the patient every 6 mos. to 1 year. It is possible that the patient will recover swallowing function after a longer period of time.
In patients with cervical spinal cord injuries, swallowing disorders are usually __________ in nature.
Common swallowing disorders in patients with cervical spinal cord injuries include (5):
Delayed triggering of pharyngeal swallow, reduced laryngeal elevation, reduced anterior movement of the larynx (causes reduced UES opening), reduced tongue base motion, and uni/bilateral pharyngeal wall dysfunction.
Damage to CV 4,5, or 6 will often result in…
Poor laryngeal motion leading to poor UES opening
Damage to CV 1 or 2 will result in…
No sensory awareness of swallowing difficulties
True or False: Patients with cervical spinal cord injury may have difficulty closing the airway entrance.
True: This is usually related to poor laryngeal elevation or anterior movement
True or False: Patients with cervical spinal injury don't generally have trouble closing the airway at the vocal folds.
True: This is infrequent in this population. When it does occur, it is generally related to direct laryngeal damage (Intubation, trachostomy placement, prolonged trach)
When patients have SCI damage at or above C3, they may require _______________.
Mechanical ventilation
Name reasons patients with cervical SCI are difficult to assess at bedside
Patients may require mechanical ventilation (cuffed trach) and when the damage is above C5 the swallowing disorders are generall pharyngeal so you can't observe it at bedside.
If a patient is wearing a head/neck brace, during X-Ray you may need to _________________.
Angle the patient 15-30 degrees because the brace may shadow certain parts of the anatomy.
With cervical SCI patients, what procedures will you use during the radiographic study?
Postural changes are often not possible, sensory heightening and voluntary maneuvers are the most helpful.
What are the effects of cervical bracing on the swallow?
Not yet identified in dysphagic patients, but some studies conducted on individuals with normal swallow. These patients report a worsening of the swallow when wearing a brace but the only significant change is LONGER airway closure.
Swallowing becomes more difficult when cervical bracing positions the head in what ways?
If the chin is pulled back / chin or head is retracted on the neck, also if head is extended.
Following an anterior cervical fusion, patients may suffer from what swallowing issues?
Swelling of posterior pharyngeal wall, reduced laryngeal elevation/anterior movement (resulting in reduced closure of airway entrance and reduced CP opening), reduced uni/bilateral pharyngeal wall movement, and possible oral stage problems/delayed triggering of pharyngeal swallow.
Swallowing problems in patients with anterior cervical fusion are caused by…
Trauma to peripheral nerves, swelling, and reactions to hardware in the neck
What is the recovery pattern for swallowing in patients with anterior cervical fusion?
Patients generally recover significantly in 3 months or less. You should determine intervention strategies to allow for oral intake in the meantime.
What are the most helpful techniques for patients with anterior cervical fusion?
Generally compensatory techniques are useful because the swallow is likely to recover spontaneously. Most helpful are: Mendelsohn manuever, supraglottic swallow, super supraglottic swallow. (Remember, postures = ouch!)
Damage to the [part of brainstem] will lead to significant swallowing problems including ____________________.
Medulla / complete inability to trigger pharyngeal swallow
Patients with damage to the medulla may benefit from what techniques?
Sensory heightening because the issue is often a problem triggering the pharyngeal swallow. Try Thermal-Tactile Stim and/or Suck-Swallow technique.
What is the goal of sensory heightening techniques?
To lower the threshold of the swallowing center in the central nervous system
Following removal or acoustic neuroma or other tumor from a cranial nerve, there may be damage to cranial nerves ____, ____, ____, ____, and possibly ____.
Symptoms of cranial nerve damage following neurosurgical procedures will be __________ and may include…
UNILATERAL, facial weakness, pharyngeal wall paresis/paralysis, soft palate weakness, vocal fold adductor paralysis, tongue paresis
Damage to cranial nerve IX will often result in…
Delayed triggering of the pharyngeal swallow
As cranial nerve damage usually results in _________ problems, patients will often benefit from ______________________.
Unilateral / postures: head rotated to the damaged side or chin down to protect the airway during delay.
In addition to compensatory strategies, patients with cranial nerve damage benefit from…
ROM and resistance exercises for lips, oral tongue, tongue base and larynx (Falsetto, effortful swallow, super-supraglottic swallow)
Patients who are cognitively intact should practice exercises ______ times per day for ______.
10 / 5 minutes
Poliomyelitis may lead to disturbances in what stage of the swallow?
Both Oral and Pharyngeal
What oral stage swallowing disturbances may result from poliomyelitis (2)?
Reduced lingual control of bolus, disturbed pattern of bolus propulsion
What pharyngeal stage swallowing disturbances may result from poliomyelitis (3)?
Reduced pharyngeal contraction, Unilateral pharyngeal paralysis, Reduced velopharyngeal closure (leading to nasal regurgitation)
Guillan-Barre is a ____________ causing rapid onset of paresis which may progress to…
Viral-based disease / complete paralysis requiring tracheostomy and mechanical ventilation.
Swallowing difficulty is occasionally the first sign of __________ and is soon followed by general weakness and paralysis.
What will be observed during radiographic study in patients with Guillan-Barre?
Generalized weakness in oral and pharyngeal swallow; reduced ROM of oral tongue, tongue base, and larynx.
Therapy for patients with Guillan-Barre should begin with…
Gentle resistance and ROM exercises, increasing effort as the patient improves.
Respiration is originally unstable in patients with Guillan-Barre, so ________________ should be postponed. Later on _____________ are helpful.
Swallowing therapy or maneuvers that prolong airway closure; Supraglottic swallow or Mendelsohn.
Patients with cerebral palsy may exhibit (4 characteristics)…
Inappropriate oral reflexive behaviors; inability to hold cohesive bolus; disorganized lingual movements (bolus not propelled smoothly); pieces of food may spread out during chewing (premature spillage)
Patients with cerebral palsy may be placed into which three categories of swallowing disorders?
Moderate to severe oral function problems; oral function problems + delay triggering pharyngeal swallow; oral function problems + delayed PS + neuromuscular abnormalities during PS
Most children with cerebral palsy fall into the category of swallowing disorders characterized by… This means which consistencies will be challenging?
Oral function problems + Delayed PS / foods requiring chewing will be a challenge due to oral motor issues while thin liquids will also be difficult due to pharyngeal delay
What three oral function problems are commonly observed in patients with cerebral palsy?
Reduced lip closure, tongue thrust, reduced tongue coordination
Patients with cerebral palsy may exhibit what 3 neuromuscular abnormalities once the pharyngeal swallow is triggered?
Reduced tongue base retraction; reduced laryngeal elevation; significant residue after swallow leading to aspiration (this group may aspirate on every consistency)
Management of swallowing disorders in patients with cerebral palsy commonly includes…
Oral motor therapy; thermal tactile stim; diet change to thickened liquids and purees (LAST OPTION)
TRUE or FALSE: Cricopharyngeal dysfunction is rarely a problem in patients with cerebral palsy
TRUE: Myotomy should not be attempted unless other options have been exhausted. As the child grows the larynx will also drop and this may improve opening of the UES.
Do patients with cerebral palsy generally suffer from aspiration DURING the swallow?
No, generally laryngeal closure is adequate
When does aspiration generally occur in patients with cerebral palsy? What causes it?
BEFORE the swallow: reduced tongue control and delayed pharyngeal swallow / AFTER the swallow: residue left due to poor tongue base action and reduced laryngeal elevation.
Dysautonomia is also known as ____________ and is a ____________ disease with widespread effects including…
Riley-Day Syndrome / Inherited / autonomic inbalance, sensory deficits, motor incoordination, certain episodic phenomena
Patients with Riley-Day syndrome suffer from what type of swallowing problems?
Milder problems - reduction of oral tongue control and reduced tongue base and pharyngeal wall motion. More severe problems - oral involvement and delayed triggering of pharyngeal swallow.
Patients with Riley-Day syndrome may require a G-tube because…
1) Delayed PS - patient may not handle thin liquids and G-tube will be needed for hydration. 2) Dysfunctional LES places the patient at risk for reflux. A G-tube decreases this risk.
Swallowing therapy for patients with Riley-Day syndrome may include…
Oral motor therapy to improve tongue function, thermal-tactile stim to help with triggering of pharyngeal swallow.
Techniques to design to improve SPECIFIC swallowing disorders include (7):
Surgical reduction of osteophytes; vocal fold medialization; injection of material into the vocal fold to include closure; laryngeal suspension; dilation of scar tissue in CP area; cricopharyngeal myotomy; botox injection into spastic CP
Cervical osteophytes may cause swallowing disorders due to…
1) Displacement of posterior pharyngeal wall which may interrupt bolus flow, 2) pressing on nerves which creates a sense of dysphagia.
Cervical osteophytes may be surgically removed but there are two possible disadvantages
1) Scar tissue will be created, 2) Possilbe surgical trauma to nerves innervating swallowing structures
After a patient with insufficient airway protection attempts exercises, a surgical option to protect the airway is…
To inject the damaged fold with material to improve closure / Vocal fold medialization surgery
_____ % of aspiration is caused by poor vocal fold closure
10% or less
Laryngeal suspension is used for patients with [swallowing disorder]. It is sometimes used in patients with [medical diagnosis] but rarely in _________ patients.
Reduced laryngeal elevation; Head and neck cancer patients; Neurologic patients
__________ are mercury-filled soft rubber tubes used to dilate scar tissue in the CP region.
The effects of scar-tissue dilation are ________, lasting __________.
Temporary / 1-3 months
Dilation of the CP region is generally NOT effective when the cause of the CP dysfunction is…
Neurologic damage
Describe the surgical procedure for a CP myotomy
External incision made through the neck (usually left side); CP fibers are slit from top to bottom usually at posterior midline; May extend upward to inferior constrictor and downward into the upper esophageal musculature.
Improvement of the swallow following a CP myotomy is reported in _______% of cases.
What is the criteria for candidates for CP myotomy?
1) CP dysfunction must be the predominant problem; 2) Patient must be able to move material through the oral and pharyngeal stages of the swallow; 3) Patient must be able to voluntarily close airway during the swallow.
What effect does a CP myotomy have if performed as a preventative measure at the time of oncologic procedure?
Study found no difference in post-operative swallowing for patients who did/did not receive a preventative myotomy.
When a CP myotomy alone does not fix the swallowing problem, what can be used?
Head-rotation to the unoperated side (helps with opening UES and directs food to more "open" side). Also, Mendelsohn Maneuver can be used to prolong lanrygeal elevation.
CP Myotomy is counterindicated for patients with…
Multiple dysfunctions of the vocal tract - reduced lingual control, delayed pharyngeal swallow, reduced pharyngeal contraction - on top of CP dysfunction.
Complications of a CP myotomy include…
Hemorrhage, recurrent laryngeal nerve damage, complications from surgically opening the neck.
What are two disadvantages of Botulinum Toxin injection for relaxation of the CP?
1) Difficult to accurately place the injection - CP is hidden behind cricoid cartilage, 2) Inaccurate injection can paralyze other muscles in the area worsening the dysphagia.
List six procedures used to control unremitting aspiration
Epiglottic pull-down, suturing vocal folds together, suturing false vocal folds together, laryngeal bypass / tracheoesophageal diversion, tracheostomy, total laryngectomy
What is an advantage and disadvantage to epiglottic pull-down?
AD: It is potentially reversible; DIS: The epiglottis commonly pulls away, making the procedure unsuccessful
What is the procedure and disadvantages for suturing the vocal folds together?
The epethelium is stripped and the vocal folds are sewn shut. They often tear apart making the procedure unsuccessful. Also, it is usually irreversible.
What are some advantages to suturing the false vocal folds together to control unremitting aspiration?
The false folds are less likely to tear apart than the true vocal folds. Also, this procesure is usually reversible.
For a tracheoesophageal diversion, the cut is generally made at ________ and this is a ___________ procedure.
3rd-4th tracheal ring / relatively permanent
A total laryngectomy is only used to control aspiration when…
There is no other solution for aspiration - it is a permanent procedure.
All non-oral feeding types place the patient at higher risk for _______________.
Gastroesophageal Reflux
In patients with NG tubes, each feeding is usually followed by…
120-240 cc of water to cleanse the tube and ensure adequate hydration
What is the name for a smaller-diameter NG tube that can be used to help prevent irritation and reflux?
A Dobhoff tube
Disadvantages of NG tubes include:
1) Physical presence of the tube is irritating; 2) Potential for reflux; and 3) Feedings usually prepared = expensive
True or False: Data indicates that the presence of an NG tube changes the physiology of the swallow.
An NG tube is generally temporary, replaced by a more permanent solution in _____ months if the patient can't transition back to oral feeding.
3-4 months
List six options for non-oral feeding:
NG tube, pharyngostomy, esophagostomy, gastrostomy, jejunostomy, and fundoplication
What are the advantages and disadvantages of pharyngostomy / esophagostomy?
AD: No tube through the nose - less irritating and more socially acceptable. DIS: Creation of scar tissue
What are the advantages and disadvantages of gastrostomy?
AD: Patient can take blender-prepped foods through the tube. This is a long-term solution to severe swallowing problems. DIS: Stoma site can leak, become infected/sore.
What are the advantages and disadvantages of jejunostomy?
AD: It reduces the risk of reflux. DIS: Requires prepared feedings which is more expensive.
Children with gastrostomy or jejunostomy require an additional procedure to reinforce the LES by wrapping the top of the stomach around it. What is this procedure called?
A patient needs non-oral feeding if they aspirate more than ______ of all food consistencies or take longer than ______ seconds to swallow a single bolus of all food types despite therapeutic intervention.
10% / 10
The most common etiology of dysphagia of unknown origin is…
Neurologic disease
Which patients are most at risk for a combination of oropharyngeal and esophageal disorders?
Those over 60 and children with congenital neurologic impairment.
Who is responsible for esophageal assessment?
The neurologic evalaluation will focus on ______________________.
Cranial nerves innervating muscles of swallowing and symptoms of neurologic disease which may lead to dysphagia.
Who is responsible for a structural evaluation of the head and neck as well as sensorimotor assessment ofpharynx and larynx?
What team member will be enlisted if a patient has a history of recurrent or recent pneumonia?
Which team member is crucial for patients in rehab centers? What does this person do?
Physiatrist - helps fit the dysphagia rehabilitation plan into the patient's overall rehab schedule.
The Gerontologist is responsible for…
Determining REALISTIC goals for the patient as well as monitoring whether combinations of medications are contributing to the dysphagia.
Who makes prosthetic devices?
The Maxillofacial Prosthodontist
The physical therapist assists with…
Optimal positioning of the patient during meals
The occupational therapist can assist with…
Providing assistive devices for eating
What are the responsibilities of the dietician?
Monitoring blood chemistry, weight, and ensuring adequate nutrition.
Which team member decides when to transition the patient back to oral feeding?
Swallowing therapist + Dietician + Attending Physician
Provide an inservice for the respiratory and nursing staff to educate them on _________________.
Signs and symptoms of dysphagia
Provide an inservice for staff members responsible for feeding the patient to educate them on ___________________________.
Complexity of normal swallowing physiology, range of swallowing disorders, and the need for INDIVIDUALIZED feeding plans.
When establishing the radiographic procedure, be prepared to explain what three things?
1) The necessary radiographic procedure; 2) The rationale for all aspects of the procedure; 3) The ways it differs from a standard barium swallow/upper GI exam.
There are generally three fees to factor into the cost of the radiographic procedure. They are…
The room fee, the radiologist's fee, and the swallowing therapist's fee
What have studies shown about the cost and efficiency of dysphagia care using a multidisciplinary approach?
There is not a lot of data in terms of cost OR reduced rates of pneumonia, improved nutrition, and hydration.