Dysphagia Exam2

Front 1

8 Considerations for treatment?

Back 1

1 Dx
2 Prognosis
3 Reaction to compensatory strategies
4 Severity
5 ability to follow direction
6 Respiratory fxn
7 caregiver support
8 Pt motivation/interest

Front 2

5 types of management strategies

Back 2

-Compensatory strategies
-Swallow maneuvers
-Adaptive equipment
-Sensory stimualtion
-Biofeedback

Front 3

2 surgical options for
Improved glottal closure

Back 3

-Medialization Thyroplasty
-Injection of biomaterials

Front 4

5 surgical options to aid Protection of Airway?

Back 4

-Stents
-Laryngeal seperation
-Laryngectomy
-Tracheostomy
-Feeding tubes

Front 5

3 surgical options to
Improve pharyngoesophogeal opening?

Back 5

-Dialation
-myotomy
-injection to relax CP

Front 6

What is enteral support?

Back 6

tube placed surgically or endoscopically when GI tract functioning but pt cannot meet nutrition needs orally

Front 7

3 common Enteral Support Tubes?

Back 7

-NG - naso-gastral
-PEG-catheter direct to stomach.
- J-Tube- tube direct to jenjum of sm intestine.

Front 8

What is Parenteral support?

Back 8

feeding used when GI tract cannot be used due to medical complication

Front 9

Factors to consider when deciding oral v nonoral feeding?

Back 9

- Clincaland instrumental eval
- medical status
-nutritional status v needs
-behvaioral/ cognitive status

Front 10

Nonclincal Pt factors to consider

Back 10

-Pt decisin making ability
-Cultural beliefs
-Religion

Front 11

What is general rule of thumb concerning oralfeeding?

Back 11

If 10% or more of every bolus is aspirated, discontiue feeding.

Front 12

General rule if oral/ pharyngeal transit time is longer than 10 secs but no aspiration?

Back 12

may need to supplement feeding for nutrition and hydration.

Front 13

Physical considerations when deciding oral v non-oral?

Back 13

-Pt unable to sustain nutrition or unable to consume enough protein/calories for 7-10 days.
- Pt requirescalories to overcome acute medical problem.
-Pt is at risk of aspiration

Front 14

Purpose and Fxn of Compensatory Tx Procedures

Back 14

- to control flow of food and change the Pt's sympstoms.
-Compensatory procedures dont change the swallow
-offten under control of caregiver or therapist
-Less muscle effort.

Front 15

4 types of compensatory Strategies?

Back 15

Postural techniques
+ Sensory input
modify bolus
prostherics intra-orally

Front 16

Chin Down Benefits?

Back 16

-pushes tongue base & epiglottis to pharyngeal wall.
- Narrows airway entrance and widens vallecular space.

Front 17

Which Disorders should use Chin Down?

Back 17

- Pharyngeal trigger delay
- Pt has reduced tongue base retraction.
- Pt has reduced airwat closure

Front 18

Chin up Benefits?

Back 18

- gravity drains food from oralcavity.
- use for reduced tongue control.

Front 19

Caution when using Chin up?

Back 19

Pt needs to have airway protection because gravity is helping.

Front 20

Head rotationto which side?

Back 20

Weakened

Front 21

Head rotation Benefits?

Back 21

-closes damaged side of pharynx

Front 22

Which Pts to use head rotation?

Back 22

-Unilateral Pharyngealwall impairment.
- unilateralVocalfold weakness.

Front 23

Which side Head tilt?

Back 23

Stonger because it uses gravity to forcebolus to stronger side where there is beter control.

Front 24

Which Pt to use head tilt?

Back 24

- when both unilateral oral and pharyngeal is on same side.

Front 25

Purpose for increasing Oral sensory awareness?

Back 25

To change the timing of the swallow by reduing oral onset time and pharyngealdelay.

Front 26

Which Pt's to use Incresing Sensory awareness techiques with?

Back 26

-Swalloe apraxia
-Tactile agnosia
-dealyed onset of oral swallow or pharyngeal trigger.
- reduced oral sensation.

Front 27

7 types of sensory techniques?

Back 27

-increase downward pressure of spoon against tongue when presenting food.
- sour bolus.
- cold bolus
- introduce bolus that needs chewing.
-large volume bolus
- thermal-tactile stimulation
- suck swalow.

Front 28

Pt you would increase Bolus volume for?

Back 28

Delayed Pharyngeal swallow

Front 29

Pt you would decrese Bolus volume for?

Back 29

Weak phayngeal swallow

Front 30

When to eliminate a particular consistency of food?

Back 30

As a last resort, when compensatory strategies dont work.

Front 31

3 types Intraoral prosthetics?

Back 31

- Palatal lift
- Palatal obtruator
- Palatal reshaping

Front 32

When would palatal lift prosthesis be needed?

Back 32

Used for paralysis to lift soft palate in order to close VP port.

Front 33

When would a palatal obtruator be needed?

Back 33

- when velum has been resected in helps to occlude VP port.

Front 34

When would Palatal reshaping prosthesis be needed?

Back 34

- when tongue resected or paralyzed it recontours hard palate.

Front 35

Therapy technique that improves pharyngeal paralysis and/or pharyngeal contraction at all levels?

Back 35

NONE-

Front 36

What is the purpose of therapy techiques?

Back 36

- To CHANGE the swallow physiology.
- To IMPROVE Range of Motion.
- To improve Sensory Input.
- PT takes control of timing and coordination of swallow

Front 37

Difference between Direct and Indirect treatment?

Back 37

Direct introduces food or liquid.

Indirect no food or liquid given.

Front 38

What should an SLP do before moving from indirect swallow to direct?

Back 38

Instrumental assessment

Front 39

3 types of Therapy Techniques?

Back 39

- Range of Motion Exersizes.
- Sensory-Motor Integration.
- Swallow Manuevers and Exersizes.

Front 40

5 Range of motion techniques

Back 40

-tongue elevation
-bolus control and propulsion
-vocal fold adduction
-tongue base
-laryngeal elevation

Front 41

What does evidence say about Range of Motion exersizes.

Back 41

No Research to support.

Front 42

6 Swallow Maneuvers and exersizes?

Back 42

- Supraglottic Swallow
- Super-supraglottic Swallow
- Effortful Swallow
- Mendelsohn maneuver
-Masaka maneuver
-Shaker exersize

Front 43

Purpose of Supraglottic Swallow?

Back 43

Close the airway at the True vocal folds.

Front 44

Rationale for Supraglottic Swallow?

Back 44

A voluntary breath hold usuall closes true vocalfolds before and during a swallow

Front 45

What Pt should use Supraglottic Swallow?

Back 45

-Pt with reduce or late VF closure.
- Pt with delayed pharyngeal swallow.

Front 46

4 steps for Supraglottic Swallow?

Back 46

1- take a deep breath.& Hold
2- Keep holding Breath
3- While holding Breath, Swallow.
4- Immediately after swallow, COUGH!

Front 47

4 steps to Dump and Swallow?

Back 47

1- Hold breath tightly
2- While holding breath toss head back and dumpliquid into throat all at once.
3- Keep holding breath while swallowing 2-3 times or until liquid clears.
4- COUGH to clear residue liquid.

Front 48

Which Pt should use Dump and Swallow?

Back 48

One with Severe Lingual Impairment

Front 49

Purpose of Super-Supraglottic Swallow?

Back 49

To voluntarily close the entrance to the airway by tilting the arytenoids anteriorly to the base of the epiglottis before and during the swallow and to close VF tightly.

Front 50

Rationale behinf Super-Supraglottic Swallow?

Back 50

An effortful breath hold tilts the arytenoids forward.

Front 51

Which Pt should use Super-Supraglottic Swallow?

Back 51

PT with reduced closure of airway...
- supraglottic laryngectomy
-improves tongue base retraction

Front 52

3 steps to Super-Supraglottic Swallow?

Back 52

1-Inhale and hold breath while bearing down.
2- Keep holding breath and bear down as you swallow.
3- COUGH immediately after swallow

Front 53

Purpose of Effortful Swallow?

Back 53

increase posterior motion of tongue base during pharyngealswallow and improve bolus clearance from valleculae.

Front 54

Rationale for Effortful Swallow?

Back 54

Effort increases the posterior motion of the tongue base

Front 55

Which Pt should use Effortful swallow?

Back 55

Pt w/ reduced posterior movement of tongue base.

Front 56

Purpose for the Mendelsohn maneuver?

Back 56

Increase the extent and duration of laryngeal elevation which increases CPopening and improving coordination of swallow.

Front 57

Rationale for Mendelsohn maneuver?

Back 57

Laryngeal elevation opens the UES so prolonging laryngeal elevation

Front 58

Which Pt should use Mendelsohn Maneuver?

Back 58

- Pt w/ reducedlaryngeal opening and uncoordinated swallow.

Front 59

Steps to Mendelsohn Maneuver?

Back 59

Begin by modelling and allow Pt to feel thyroid elevate.
1- swallow several times and pay attention to your neck as you swallow.
2- Now this time I want you to pay attention to what lifts when you swallow... dont let Adam'sapple drop
3-Tighten muscles and hold it up for 3 seconds or hold the squeeze for 3 seconds.

Front 60

What is purpose of Masaka Maneuver?

Back 60

exersizes the glossopharyngeus muscle to pull pharyngeal wall more forward

Front 61

Rationale of Masaka maneuver?

Back 61

stabilizes the anterior attachment and directs all effect of musclecontraction on the posterior attachment.

Front 62

Which Pt should use Masaka?

Back 62

Pt w/ bi-lateral reductionof pharyngeal sontraction.

Front 63

Instructions to perform Masaka maneuver?

Back 63

1.Stick out your tongue and hold the front portion between your lips and teeth.
2. THen swallow using the middle and back of your tongue while keeping the front of your tongue between your lips and teeth.
3. You should feel the pull on the back of your throat while doing this

Front 64

Purpose for Shaker Exersize?

Back 64

Increases CP sphincter opening

Front 65

Rationale for Shaker exersize?

Back 65

Reduces Pyriform suinus residue and aspiration of that residue

Front 66

Instructions for Shaker exersizes?

Back 66

1- Lie flat on your back
2-keep your sholders on the floor and lift head from floor only until you can see your toes
3-hold for 10 seconds
4- Lay head on floor and rest for one minute
5- Repeat 3 times

Then raise head 30 times without holding it

do entire exersize pattern 3 times per day for 6 weeks.

Front 67

What is Cervical Osteophytes?

Back 67

Bony Outgrowth from cervical vertebrae

Front 68

What can be done to compensate for Cevical Osteophytes>

Back 68

1- may be surgically removed.

2- change head posture and/or thin bolus

Front 69

What is Psuedoepiglottis?

Back 69

Sometimes occurs after total laryngectomy.

Front 70

What can be done to compensate for Psuedoepiglottis?

Back 70

1-Can be surgically removed.

2- Rotate head and/or swallow only liquids and thin paste consistencies

Front 71

What is etiologyof Cricopharyngeal Dysfunction?

Back 71

Reduced Laryngeal motion up and forward.
Poor pressure to drive the bolus through UES.

Front 72

What is Cricopharyngeal dysfunction?

Back 72

Failure of UES to realx and open adequatly.

Front 73

How to manage Cricopharyngeal muscle spasm?

Back 73

Cricopharyngeal Myotomy

Front 74

How to manage poor laryngeal elevation?

Back 74

Mendelsohn Maneuver

Front 75

How to manage inadequate esophogeal pressure?

Back 75

Exersize to improve tongue base action (Masaka)

Front 76

4 sources of biofeedback in therapy?

Back 76

1- Surface Electromyography (EMG)
2- Ultrasound
3- Videoendoscopy (FEES)
4-Videofluorography

Front 77

Cultural aspects that should be considered?

Back 77

1- Food Preferences, foods to take or avoid during illness.
2- PT's role in familial structure.
3- Communication patterns during meals

Front 78

Advice for all Pt's for mealtime?

Back 78

Several smaller meals throughout the day so they are not self conscious about being the last eating.

Front 79

What is the Biggest Issue in Management in Various settings?

Back 79

Continuity of Care

Front 80

What is critical in nursing home setting?

Back 80

Interaction with and eduction of the staff so that recommendations and maintenence plan is carried out.

Front 81

Sensorimotor impairmennts depend on ...(4)?

Back 81

1- Location
2- Extent
3. Unilateral v Bilateral
4. Nature of underlying disease process.

Front 82

40% of pt's with dysphagia have damage to?

Back 82

Parietal lobe.

Front 83

When is recovery most rapid after a stroke?

Back 83

first 3 weeks

Front 84

When do most stroke pt's regain functional swallow?

Back 84

1-6 months post onset

Front 85

CVA damage to pre-motor areas usually yield.

Back 85

1- volitional motor control
difficulty with motor intiation.
2- Paresis/paralysis
transport difficulty

Front 86

CVA that yield Sensory recognition deficits

Back 86

- neglect
- unaware of material in mouth or throat.

Front 87

Communication deficits from CVA may yeild

Back 87

inability to describe difficulties

Front 88

Anterior Left CVA,

What would you expect?

Back 88

- Apraxia of swallow
- Mild Oral transit delays
- delay in phrayngeal swallow trigger.

Front 89

Right Hemisphere

What would you expect?

Back 89

- mild oral transit delays
- longer pharyngeal delays.
- delay in laryngeal elevation.

Front 90

Hemispheric CVA swallowing Deficits?

Back 90

- Reduced ability to initiate saliva swallow.
- Uncoordinated oral movements
-Increased pharyngeal transit time.
-reduced pharyngeal contraction.
- Aspiration
- UES dysfunction
- Impaired LES relaxation

Front 91

Treatment considerations after hemispheric CVA?

Back 91

- Strategies change due to rapid changes over time.
- commorbitities
- Medications
- Age

Front 92

Treatment strategies after CVA

Back 92

- Postural changes
- Change to sensory input
- Direct Tx strategies
- (ROM)
- Mendelsohn Maneuver
- Super/Supraglottic Swallow

Front 93

Dementia swallowing deficits

Back 93

- unexplained weight loss
- Oral phase dysfunction
- slow or delayed pharyngeal dysfunction

Front 94

Dementia Treatment Considerations?

Back 94

- special food considerations
- Diet Restrictions
- Taste/ Flavor enhancements
- changes during mealtime
*** evidence suggests that feeding tubes to not reduce risk of aspiration.

Front 95

TBI swallowing deficits?

Back 95

Most prevelent is delayed trigger of pharyngealswallow

Front 96

TBI treatment consideration?

Back 96

-counseling is a mustm-multifactoral.
- must deal with cognitive deficits.
- Re-assess every 6 months
- Diet modification.
- Postural adjustments
- Feeding adaptations
- behavioral maneuvers
- compensatory strategies

Front 97

Purpose of MBS (VFSS) (Videofluroscopic procedure)?

Back 97

-Determine abnormalities in anatomy and physiology causing dysphagia.
- Identify and evaluate tx strategies
-Obtain information to collaborate and educate others

Front 98

7 indications & top 2 for MBS?

Back 98

-Oral stage Dysphagia
-Esophogeal Dysphagia

-Vague complaints
-clinically inexplicable weight loss
- Initial exam for Pt with long Hx of Dysphagia
- Food stuck at thyroid above or below thyroid notch.
-Biofeedback (oral stage)
- Re-test

Front 99

Type and amount of food Protocols for MBS?

Back 99

1) At least 3 consistencies
2) At least 2 swallows of each material.
3) Pt should feed themselves as appropriate.
4) Note amount Pt intakes
5) Intervention strategies introduced to eliminate aspiration.

Front 100

Preperation/ positioning the patient Protocols for MBS?

Back 100

1) Educate Pt A/O caregiver about procedure.
2) Lateralview intially w. Pt seated upright.
3) Pt's arms and shoulders down at side to not shadow.
4) AP view with swallows of interest only... helpful totilt head back

Front 101

Administering materials protocol for MBS?

Back 101

1) Liquid Barium first
2) Thicker foods
3) Lorna Doone cookie

Front 102

Measurements and Observation Protocols for MBS?

Back 102

1) oral and Pharyngeal transit times
2) Movement pattern and location of bolus.
3) Oral prep stage structures
4) Oral Phase
5) Pharyngeal phase
6) Cervical Esophogeal phases
7) Etiology of Aspiration

Front 103

Treatment Efficacy Trials Protocols for MBS?

Back 103

1) Postural Techniques
2) Improving Oral Sensory Awareness.
3) Swallow maneuvers
4) Diet changes
5) Other compensatoy techniques.

Front 104

CPT code for Modified Barium Swallow study?

Back 104

92611

Front 105

Interpret: during oralphase Pt cannot hold food in mouth

Back 105

Reduced lip closure

Front 106

Interpret: during oral phase material spread throughout and spills into valleculae and pharynx

Back 106

Reduced tongue shaping/coordination

Front 107

Interpret: during oral prep phase food falls into anterior sulcus

Back 107

Reduced labial tension/tone

Front 108

Interpret: during oral prep phase food falls into lateralsulcus

Back 108

Reduced Buccal tension

Front 109

Interpret: during oral prep phase Pt displays compensatory techniques like tongue thrust/pump

Back 109

Reduced tongue control

Front 110

Interpret: during oral phase delayed onset ?

Back 110

Reduced oral sensation

Front 111

Interpret: during oral phase involutary swallow is normal but volitional swallow is not

Back 111

apraxia of swallow

Front 112

Interpret: during oral phase tongue thrust?

Back 112

indicativeof neurological impairment

Front 113

Interpret: during oral phase food falls to floor of mouth?

Back 113

failure of perhipheral seal of tongue

Front 114

Interpret premature spillage/ nasal regurgitation during oral phase?

Back 114

reduced tongue elevation

Front 115

CPT code for Swallow Therapy

Back 115

92526

Front 116

CPT code FEES

Back 116

92612

Front 117

Rationale for FEES?

Back 117

- Best visualizes components of nasopharynx and pharynx

Front 118

Purpose of FEES?

Back 118

-Identify normal and abnormal physiology of swallow.
-Providde recommendations.
-Evaluate effectiveness of posture, maneuvers etc
-Evaluate integrity of airway
-Alternative/adjunct other assessments

Front 119

Indicators for FEES

Back 119

1) Symptoms pharyngeal dysphagia.
2) Abnormal vocal quality
3) Painful swallow
4) Increased difficulty of swallow.
5) Hypernasality or nasal regurgitation.
6) biofeedback
7) difficulty swallowing oral secretions
8) safety issues w/ radiation exposure.
9) difficulty transporting to radiology.
10) documented pharyngeal dysphagia on MBS that can be retested with FEES

Front 120

Contraindications for FEES?

Back 120

-Agitation
- High Anxiety
-Allergy to anesthetic
-Small/deviated nasal passage
- movement dyskenesia
- Bleeding disorder