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278 Cards in this Set

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Bedside exam
Provides the most info on eating behavior, language, cognition and oromotor function Precedes the MBS to make sure patient is good candidate for MBS.
Radiographic exam
Gives the most info on oral and pharyngeal physiology
Screening Procedures
Provide indirect evidence that the patient has a swallowing disorder but does not provide info on the physiology of that disorder. Tends to identify signs of dysphagia, including coughing behaviors, pneumonia, diagnoses at greatest risk, food squirting out of trach tube indication aspiration, or the presence of residual food in the mouth.
Screening procedures
Generally performed at bedside or in home of school and provide increased evidence that the patient needs an in-depth physiological assessment.
Screening Procedures
Should be quick, low risk and low cost. Purpose is to identify the highest risk patients for further assessment.
Screening: Procedural Sensitivity
Should correctly identify those who are actually aspirating or have residue (true positives).
Screening: Procedural specificity
Should not generate many false positives (those identified as aspirating but are not actually aspirating) or false negatives (those who are aspirating but are identified as not aspiration).
Recommended screening process
Should be noninvasive, low-risk and quick and easy. Do chart review, observation of pt. eating (if they are orally fed) or saliva swallow (if nonorally fed). If patient exhibits one or more of the following, should have more in-depth study: Rejection of food, food selectivity, gagging, open-mouth posture
Items to condiser when screening (see table 5.1, p. 137 in book)
History of recurrent pneumonia, diagnosis of partial laryngectomy, anoxia, PD, motor neuron disease, brainstem stroke, etc.; Hx of prolonged or traumatic intubation or ER trach; severe respiratory problems; gurgly voice/cry; coughing before/during/after swallow; poor awareness/control of secretions; Infrequent swallowing; copious chest secretions; during swallow: breathing difficulty, increased secretions, voice changes (gurgly), multiple swallows, reduced laryngeal lifting, throat clearing, coughing, fatique
4 abnormal behaviors observed during eating are important indicators of need for more in-depth study
Rejection of food; food selectivity; gagging; open-mouth posture
Rejection of food (observed during eating, important indicator of need for more in-depth study)
Nutritional intake is critical to survival. Rejection of all intake is an indication that eating is perceived more dangerous than sage and is a major indiator of chronic aspiration. MBS should be performed.
Food Selectivity(observed during eating, important indicator of need for more in-depth study)
When kids limit oral intake to only selected food and reject all others (w/ often preference for a specific taste), should test reaction's to various taste, temp and texture combos and then determine if there is a need for MBS.
Gagging(observed during eating, important indicator of need for more in-depth study)
Gagging as food is presented is often indication of oral hypersensitivity or abnormal oral sensation (kids w/ neuromotor involvement often don't mouth toys, etc. and are often hypersensitive to oral stim). Gagging may also result from tactile agnosia, causing gag to trigger and push foreign body out of mouth and pharynx.
Open-Mouth Posture(observed during eating, important indicator of need for more in-depth study)
Airway should be assessed to define if there is an adequate upper airway to allow nasal breathing during swallowing. Also assess dental structure to assure alignment allows lip closure. Should be able to maintain lip closure from the time the food is placed in the mouth until the pharyngeal stage is over.
Results of Screening
Should indicate whether the pt. is a normal swallower or whether risk of dysphagia is high and further assessment is needed.
Bedside/Clinical Exam
Designed to provide (1) Info on current medical dx and medial hx, and hx of swallowing disorder (including pt. awareness of swallowing disorder and localization & nature); (2) Medical status (including nutritional & respiratory status - presence of feeding tube, trach tube, etc.); (3) Pt's oral anatomy; (4) Pt's respiratory function and relationship to swallow; (5) Labial control; (6) Lingual control; (7)Palatal function; (8)Pharyngeal wall contraction; (9) Laryngeal control; (10) General ability to follow directions & monitor and control behavior; (11) reaction to oral sensory stim (taste, temp, texture); (12) reactions & symptoms during attempts to swallow.
Beside Exam: 2 Parts
(1) Preparatory Exam (w/no actual swallows); (2) Initial swallowing Exam (swallowing attempted & some aspects of physiology observed)
Bedside Part 1: Preparatory Exam
1) Chart Review - determine respiratory status (recent pneumonia, presence of trach tube, hx of mechanical ventilation/intubation); hx of swallowing problem (incl. duration); general medical status; ability to follow directions, motivation, general behavior; Nutritional status (oral feeding vs. nonoral nutrition & type).
Bedside Exam: Specific steps to chart review and history
Identify (1)current & past medical problems, focusing on those that may cause dysphagia, (2) current & immediate past meds. part. those causing dry mouth, reduced alertness or delayed reaction time; (3) hx of swallowing disorder, incl. time and nature of onset, symptoms, difficult & easy food and awareness of the problem; (4) presence, type, duration & method of placement (ER or planned) of airway devices (trach, mech. ventilation, intubation); (5) presence, type, duration of placement, adequacy, and complications of oral & nonoral nutrition.
Bedside - Observations upon entering patient's room
Posture in bed; alertness/reaction to entrance; presence or absence of trach tube and its status (cuff inflated or deflated); general awareness & handling of own secretions & of tube.
Bedside - Informal observations during history
Observe ability to follow directions, answer ?s, general alertness, as well as management of secretions and the trach tube, if present.
Bedside Exam - Respiratory Status
Examine upper aerodigestive tract according to hierarchy: respiration, swallowing and speech.
Effect of respiration problems on swallowing
Significant respiratory problems can impact swallowing b/c the mechanism will naturally make shifts to keep respiration at a functional level.
Bedside Exam - Respiratory Status at rest
Observe at rest - if any degree of distress, may be inappr. to begin swallowing therapy or proceed w/ assessment that may place stress on respiration.
Effects of Swallowing on Respiration
Even normal swallowing stresses respiratory status b/c it requires some degree of airway closure & cessation of breathing, even for 0.3 to 0.5 seconds)
Swallowing treatment and respiration
Some tx procedures (Swallowing maneuvers) require longer periods of apnea & may be inappropriate for pt. w/ respiratory problems
Bedside Exam - Respiratory Status
Should note: (1) timing of saliva swallows in relation to inhalation & exhalation, including which phase of respiration in which the pt. swallows and returns to; (2) Timing of any coughing in relation to the coordination of respiration and swallowing. Swallows followed by inhalation may put pt. at aspiration risk. (3) Duration of comfortable breath hold (if feasible) - determine if can hold breath for 1, 3 and 5 seconds. (4) Rest breathing pattern (oral or nasal). If mouth breathing, observe whether pt. can breathe through nose.
Bedside Exam - Tracheostomy Tubes: Reasons for placement
Normally placed for (1) upper airway obstruction at or above the level of the true vf's; (2) potential upper airway obstruction, such as may be created by edema following oral, pharyngeal or laryngeal surgery; and/or (3) provision of respiratory care
Bedside Exam - Tracheostomy tubes: How they are placed
Generally inserted into trachea through a surgical incision made btwn. the 3rd & 4th tracheal rings. Well below the true vf's, so avoids damage to larynx.
Bedside Exam - Tracheostomy tubes: Emergency placement and associated damage
In emergency situations, tracheostomas are sometimes placed higher than the 2nd trachel ring, which may cause laryngeal scarring.
Bedside Exam - Tracheostomy tubes: Removal
Generally left in place until airway obstruction/potential airway obstruction is past and until the need for respiratory care is completed. Occasionally, remain permanently.
Bedside Exam - Tracheostomy tubes: Parts
3 parts: Outer cannula, inner cannula and obturator.
Bedside Exam - Tracheostomy tubes: Normal Use
Outer cannula always stays in place to hold the trach site open, inner cannula stays in the tube except for cleaning, obturator is inserted only to provide a smooth, rounded tip for initial insertion of the tracheostomy tube.
Bedside Exam - Tracheostomy tubes: weaning the patient
When being weaned fro the trach tube, 2 procedures can be used. First, the tube (often size 8 in adults) will be changed to a smaller size to encourage oral-nasal breathing in combo w/ breathing through the trach site. If smaller tube (size 6 or 4) is tolerated well, will be plugged w/ the obturator or a cork for periods of time to assess ability to maintain oral-nasal breathing w/o distress before tube is removed altogether.
Bedside Exam - Tracheostomy Tubes: Placement in relation to trachea
Normally, small amount of space btwn. trach tube and walls of trachea, when pt. inhales & occludes outer end of trach tube w/ finger, air can pass around tube & through larynx to produce voice (softer & breathier than normal).
Bedside Exam - Tracheostomy Tubes: Cuffed
Sometimes places when there is (1) need for respiratory treatment or (2) potential for patient to aspirate material. Cuff surrounds lower portion of trach tube like a balloon.
Bedside Exam - Tracheostomy Tubes: Cuffed - Deflated
When cuff is deflated, trach tube is the same as if it had no cuff (space between tracheal wall and tube allows air to pass upward).
Bedside Exam - Tracheostomy Tubes: Cuffed - Inflated
When fully inflated, cuff contacts the tracheal wall & prevents air from passing up; seals the lower airway from secretions above. With cuff inflated, no material from above the larynx can pass through into the trachea & bronchi. Cuff must remain inflated if a patient is on mechanical ventilation that operated on positve pressure principles. May also be temporarily inflated to deliver respiratoy therapy to patients.
Bedside Exam - Tracheostomy Tubes: Cuffed - Saliva build-up
Sometimes cuff fully inflated for patients who are aspirating saliva, to prevent aspiration pnemonia. Saliva & other secretions then build up above the cuff so that when the cuff is deflated suctioning is needed to catch material draining around the tube into the lower airway.
Bedside Exam - Tracheostomy Tubes: Cuffed - amount of time remained cuffed
Fully inflatted cuffed trach tubes generally not left in place for a long time, as the pressure of the cuff contacting the tracheal wall can create tracheal irritation, which can occur even though cuffs are designed to create minimal pressure against the tracheal wall. May be left cuffed long-term if the patient is terminal and long-lasting effects aren't relevant.
Bedside Exam - Tracheostomy Tubes: Cuffed - Tracheal Stenosis
If the cuff is fully inflated & contacting the tracheal walls, can cause ischemia in the tracheal wall, leading to tracheal stenosis, wich is difficult to manage.
Bedside Exam - Tracheostomy Tubes: Cuffed - Minimum Leak Technique
To avoid tracheal stenosis. Involves inflating the cuff until the pt. can no longer pass air around the tube, then taking out 1 - 2 cc of air so there is a minimal leak around the cuff, presenting stenosis but allowing some leakage of material (aspiration) around the cuff.
Bedside Exam - Tracheostomy Tubes: Cuffed tube and swallowing
Inflated cuff may inhibit relearning of swallow by restricting laryngeal elevation, reducing laryngeal sensitivity or by placing pressure on the esophagus via the common posterior wall btwn. trachea & esophagus.
Bedside Exam - Tracheostomy Tubes: Cuffed - Placed in emergency situation
If tracheostomy done in emergency situation or placed with sutures attaching the superficial tissues to the trachea, likely that effects of restricted laryngeal elevation, reduced laryngeal sensitivity or pressure on the esophagus via the common posterior wall btwn. trachea & esophagus will worsen. Also, if present for > 6 months, scar tissue may develop & cause reduced closure of vf's b/c of reduced stimulation of the sensory receptors under the vf's.
Bedside Exam - Tracheostomy Tubes: Aspiration with a cuffed tube
Sometimes an inflated or cuffed trach tube won't completely occlude the trachea b/c of tracheal wall deviations or misfit tubes, resulting in some aspiration past the inflated cuff.
Bedside Exam - Tracheostomy Tubes: Fenestrated
Window (fenestration) may be cut into the tube to allow for greater airflow if a pt. is having difficulty producing voice w/ a normal trach tube. Often only made in the outer cannula, so when pt. wants to talk, inner cannula is removed. When inner cannula placed in the trach tube, fenestration is closed.
Bedside Exam - Tracheostomy Tubes: Use of Fenestrated Tubes
May be used in pts. who are close to being weaned from the trach tube or in those whose communication is ineffective with the small amount of airflow possible w/ an unfenestrated tube.
Bedside Exam - Tracheostomy Tubes: Fenestrated Tubes and relationship to cuffed tubes
Rare for a cuffed tube to be fenestrated, as the fenestration negates the occlusive effets of the inflated cuff. If pt. no longer needs the cuff inflated, fenestration might be made in a cuffed tube.
Bedside Exam: Management of Trach Pt. during swallowing assessment & treatment - Initial Steps
Must examine the trach tube to determine the size of the tube, presence of fenestration and if it is cuffed, if so if the cuff is inflated or deflated. Must also review chart to determine length of time tube has been in place.
Bedside Exam: Management of Tracheostomy tubes in place over 6 months
If in place > 6 months, scar tissue may have formed that can restrict laryngeal elevation. Will also have reduced airflow & stimulation to subglottic sensory receptors that play a role if vf closure. May have reduced vf closure for swallowing & vocalization.
Bedside Exam: Management of Tracheostomy tubes in place less than 6 months
May have little effect on laryngeal elevation if cuff is deflated.
Cuffed Tracheostomy tube during bedside or radiographic exam: Inflated or deflated
If medically feasible, cuff should be deflated during the bedside or radiographic study, b/c an inflated cuff can reduce laryngeal elevation by creating friction against the tracheal wall. BUT should not be deflated until medical clearance is given. If it remains inflated during exam, note it it the report.
Bedside Exam: Management of Trach Pt. during swallowing assessment & treatment - Instructions for patient during swallow
Teach them to lightly cover external end of trach tube w/ gauze or floved finger during the moment of swallow & for several seconds after the swallow, if this is found to improve swallow when examined radiographically. This should direct increased airflow through the larynx, which stimulates subglottic sensory receptors before the swallow & may improve vf closure.
Bedside exam: Respiratory cycle and swallowing with a trach tube
If pt's trach tube is occluded during & immediately after the swallow, the small exhalotory airflow after the swallow may potentially contribute to clearance of residual food from the top of the airway, lessening the chance of aspiration after the swallow. Covering tube also thought to restore more normal subglottic pressures during swallowing, thus improving closure of the vf's during swallow.
Bedside exam: Studies regarding aspiration related to covering of trach tube during swallow
Many reports indicate elimination of aspiration w/ tube covered. Logemann exper. less consistent positive results. Recent dtudy found that tube occlusion digitially does not negatively affect swallowing & may result in improved laryngeal eleveation. Effects not universal, must be tested during radiographic study.
Bedside exam: One-way valve on trach tube
Use of a 1-way valve on the trach tube may be helpful in place of light digital occlusion if the pt.'s repiratory status is stable. May also facilitate speech production. 1-way valve open during rest breathing & closes when exhalatory pressure increases for speech. W/ valve closed, air is directed up & around the trach tube. Tolerance for valve should be determined by respiratory services & swallowing therapist.
Bedside exam: Studies regarding On-way valves on trach tubes
Effects of the valve on swallow should be examined radiographically. One report indicates universally positive effects, variable effects have been found in Logemann's clinical experience.
Bedside exam: Ventilator Dependent Patients
Pts on ventilator often complain swallowing became worse when they went on the ventilator. Since swallowing & respiration are reciprocal, b/c the ventilator controls the respiratory cycle the pt. can't lengthen the exhalation to allow for the swallow. If pt. has slightly slow oral or pharyngeal stages which can't be completed in the time period alloted for exhalation by ventilator, swallow may be further disrupted by restart of inhalation.
Bedside exam: Ventilator Dependent Patients
Normally have a trach tube in place w/cuff inflated, which may reduce laryngeal elevation & thus reduce closure of entrance of airway which may in turn allow food to enter or penetrate the entrance of the airway & be aspirated after swallow.
Bedside exam: Ventilator Dependent Patients
B/c normal swallowing usually occurs during the beginning of exhalation, helpful to present food to the patient during bedside study at the beginning of the exhalation phase of respiratory cycle.
Bedside exam: Ventilator Dependent Patients - Blue Dye Test
Used at bedside for a tracheotomized pt. as a screening for aspiration. Pt. given measured amounts of blue-dyed foods & the tracheostomy suctioned immediately after the swallow for the presence of the blue-die foods, indicating aspiration. If positive result, should recommend radiographic study.
Bedside exam: Intubation - placement
Usually involves placing tube through mouth or nose, through pharynx & larynx to the lower trachea.
Bedside exam: Intubation - reasons
Often placed during emergency situations & usually considered a more stable airway. May be maintained for hours, days or weeks, depending on severity & nature of pt's damage.
Bedside exam: Intubation - resulting damage
If placement of tube is traumatic, may be damage to larynx. If tube placed for days or weeks, variety of types of laryngeal tissue damage may affect laryngeal closure during swallow including edema, redness, nodules, polyps, unilateral adductor paresis or paralysis.
Bedside exam: Intubation - resulting damage
Bottom edge of tube may rub & irritate the soft tissue posterior common wall of the trachea, causing tissue breakdown & formation of TE fistula.
Bedside exam: Intubation - replaced with tracheostomy
At some point when pt's respiratory status is stabilized, tracheostomy may replace the intubation.
Bedside exam: Intubation and Swallowing Therapy
Swallowing therapy NOT appropriate until intubation is removed. When removed, may be reduced range of motion of the lips, tongue, pharynx, and larynx for speech & swallowing, which may last up to a week. Gentle range-of-motion exercises may be needed.
Bedside Exam - History
Important of gather info from the patient, family or nursing staff re. the exact nature of symptoms indicative of a possible swallowing disorder.
Bedside Exam - History of symptoms indicative of a possible swallowing disorder
When did it begin? Did it worsen gradually or rapidly? How does the problem vary with different consistencies of food? What specifically happends when the pt. tries to swallow? Does material stop somewhere along the way? If so, where (high or low in the throat)? Does the pt. cough and choke? If food collects, can the pt. point to the spot in his or her mouth or throat where he feels material collect?
Bedside Exam - Pt. awareness of problem
Radiographic studies have shown pts who are aware of an oropharyngeal swallowing problem are highly reliable in their identification & description of the disorder. If pt. denies having a swallowing disorder, frequently in error & often has a swallowing problem, sometimes severe, to which they are oblivious.
Bedside Exam - Pt. description of symptoms: Stuck at base of tongue epiglottis
Typically, when pt points to one of these areas indicating food has collected there, material is likely to be hestitating in valleculae at base of tongue.
Bedside Exam - Pt. description of symptoms: Stuck lower on neck, just below larynx
If pt. points here & indicates that material is sticking, usually collecting in pyriform sinuses
Bedside Exam - Pt. description of symptoms: Coughing and Choking
When present, indicate aspiration or entry of material into airway, but are nonspecific signs of the cause of aspiration. Over 50% of pts who aspirate don't cough.
Bedside Exam - Best consistency of food for pts w/ difficulty in oral transit b/c of poor control of the tongue
May find liquids easier to swallow but pastes & thicker materials very difficult.
Bedside Exam - Best consistency of food for pts w/ delayed or absent triggering of pharyngeal swallow
Generally do best w/ thicker consistencies that tend to cling to the tongue base & valleculae until the pharyngeal swallow triggers. Have greater difficulty w/ liquids b/c they splash into the pharynx & airway before the pharyngeal swallow has triggered.
Bedside Exam - Pt. description & demonstration of swallowing problem
Ask pt. to demonstrate what they did when starting to swallow. May become clear they took too much material, positioned it inappropriately in the mouth or used an instrument or untensil they couldn't manage well. Does not need to actually swallow, simply repeat motions leading to the swallow to give the clinician info.
Bedside Exam - Info. obtained from taking a careful history
May gain info on (1) Localization of disorder in terms of the oral or pharyngeal stage of swallow, (2) Easiest & most difficult types of material for the pt to swallow, (3) Nature of the swallowing disorder
Bedside Exam - of Oral Anatomy
Should include careful observation of lip configuration, hard palate configuration (height & width), soft palate & uvula dimensions relative to the distance to the posterior pharyngeal wall, intact nature of faucial arches (both anterior & posterior), lingual configuration & adequacy of sulci at the sides & front of mandible.
Bedside Exam - of Oral Anatomy: Scarring & Asymmetry
Any scarring in the oral cavity or neck & any asymmetries in structures should be examined carefully
Bedside Exam - of Oral Anatomy: Dentition & Oral Secretions
Is mouth moist or dry? If dry, dampened gauze shld be placed in mouth to gently loosen secretions & wipe them from the mouth.
Bedside Exam - Oral-Motor Control Exam
Should include eval of the range, rate & accuracy of movements of the lips, tongue, soft palate & pharyngeal walls during speech, reflexive activity & swallowing.
Bedside Exam - Oral-Motor Control Exam: Ability to Open Mouth Voluntarily
For some pts w/head injury or severe neurologic impairment, difficult & slow, taking 3 - 5 minutes. May benefit from bedside assessment w/ oromotor stiumulation, including work on control of mouth opening, rather than immed. radiographic study, which can be scheduled when they are able to open mouth more easily.
Bedside Exam - Oral-Motor Control Exam: Radiographic Study w/ pts with very slow mouth opening
May wish to do at times to determine that they pharyngeal swallow is triggered normally & has normal neuromotor control. Can do more agressive tx of the oral cavity if this is known w/o worry that the pt will aspirate.
Bedside Exam - Oral-Motor Control Exam: Tx to facilitate ability to Open Mouth Voluntarily
Those w/ slow mouth opening usually need oral massage to achieve mouth opening. Combo of rotary massage of the cheek (masseter) on one side w/ firm downward pressure on the chin & contiunual verbal reinforcement over several minutes will enable to pt. to achieve mouth opening.
Bedside Exam - Oral-Motor Control Exam: Ability to Open Mouth Voluntarily and Bite Reflex
Determine whether bite reflex is present by using 4" by 4" gauze roll to touch the teeth & alveolar ridge. Using the roll will prevent pt. from breaking a tooth or biting off a piece of gauze if a bite reflex is present. If is present, use a spoonthat does not break or splinter easily to place food in the mouth & avoid touching the spoon against the pt's teeth or alveolar ridge. Can be difficult b/c of limited mouth opening, but w/ masssage & verbal reinforcement re. mouth opening, greater mouth opening can be achieved/
Bedside Exam - Oral-Motor Control Exam: Identification of Optimal Oral-Sensory Stimuli & Bolus Type
Pts w/ cognitive impairments may produce most oral activity in resp. to particular combos of tast, texture & temp. Can use 4"x4" pieces of cloth (gauze, burlap, satin) rolled around flexible plastic straw to present various textures to the mouth. Dip 1 end into liquids of various temps & flavors (sweet, sour, bitter, salty) to present a variety of stimuli to oral cavity to identify the combo of stimuli that elicits the most oral movements characteristic of chewing & normal oropharyngeal swallowing. Then introduce these stimuli mixed w/ barium in the radiographic study, in addition to as many calibrated boluses from the protocol as possible.
Bedside Exam - Oral-Motor Control Exam: Identification of and Compensation for Swallowing Apraxia
Pt usually performs best at bedside when no verbal directions are given re. eating or swallowing. When food tray presented w/o verbal instruction, pt often picks up fork & begins eating normally w/ normal swallow.
Bedside Exam - Oral-Motor Control Exam: Swallowing Apraxia and Radiographic Study
When brought to x-ray, pt. often has severe diff. initiating oral stage of swallow b/c verbal commands are given re. when to swallow. More consciously the pt. focuses on swallowing, more diff. they have. If only apraxia & no symptoms of pharyngeal swallowing disorder, no radiographic exam needed.
Bedside Exam - Oral-Motor Control Exam: Identification of & Compensation for Abnormal Oral Reflexes
Such as hyperactive gag, tongue thrusting, tonic bite. Usually counterproductive to acceptance of food in the mouth. Can be identified & desensitized at bedside. Must ideintify location in the mouth where reflexes are triggered & nature of the stimuli so they can be avoided during x-ray.
Bedside Exam - Oral-Motor Control Exam: Labial Function
Have pt. spread lips as wide as possible on /i/, round them as much as possible on /u/, rapidly alternate the two postures 10 times, rapidly repeat /pa/ to determine diadochokinetic rate, close mouth tightly to observe labila closure during rest & saliva swallowing. Ask pt. to repeat a sentence w/ lots of bilabial stops & examine completeness of bilabial closure on each articulation (i.e. "Put the paper by the back door")
Bedside Exam - Oral-Motor Control Exam: Labial Function for chewing
Observe ability to maintain lip closure despite changes in head posture & movements of the jaw in manipulating food. Ask pt. to move jaw & maintain lip closure or to shape lips around straw, spoon or fork. Check ability to maintain nasal breathing comfortably.
Bedside Exam - Oral-Motor Control Exam: Lingual Function (Anterior)
Ask pt to (1) extend tongue out of mouth as far forward as possible & retract as far back as possible (2) touch each corner of mouth & rapidly alternate, (3) attempt to clear lateral sulcus on each side of mouth as if it were full of food, (4) open mouth wide & elevate tongue tip to alveolar ridge, rapidly alternate elevation & depression of tongue tip while maintaining open mouth, (5)Rapidly repeat /ta/ to determine diadochokinetic rate, (6) repeat sentence containing a tip-alveolar stops and assess completeness of tongue tip to alveolar ridge contact, including lateral seal on lateral alveolus (i.e. "Take time to talk to Tom"). Also ask pt. to slide tongue along palatal vault from very front near alveolar ridge to back & rub tongue against palate, as if clearing food.
Bedside Exam - Oral-Motor Control Exam: Lingual Function (Posterior)
Ask pt to (1)Open mouth & lift back of tongue as if saying /k/ & hold back of tongue elevated in this position for several seconds, (2)Repeat /ka/ as rapidly as possible to assess a diadochokinetic rate, (3) repeat sentence w/ back velar stop phonemes to determine completeness of tongue-palate contact during productions (i.e. "Can you keep the kitchen clean")
Bedside Exam - Oral-Motor Control Exam: Chewing Function - use of gauze
Assessment most safely done w/ gauze. Diff. to determine at bedside where chewing ends & oral stage begins, so food chewing not recommended for bedside assessment.
Bedside Exam - Oral-Motor Control Exam: Chewing Function w/ gauze
4"x4" gauze pad roll shld be dipped into pleasant tasting liquid & excess liquid squeezed out. Damp end of gauze placed on midline of tongue, w/ dry end protruding from mouth. Pt. asked to move gauze onto teeth, chew on it, move to other side, chew on it, etc. Gauze is as flexible as food but can't be lost in the mouth & can be easily removed as dry end is outside of the mouth. Provides flexibility of food w/ no risk. Can become tx exercise if pt. has difficulty.
Bedside Exam - Oral-Motor Control Exam: Soft Palate Function
Ask pt to produce sustained /a/ and rapidly repeat /a/. Note action of levator muscle in elevation of palate & palatopharyngeus muscle in retraction of palate, as well as any observable lateral or posterior wall movement & soft palate movement (although VP closure may not be as strong in this task as it is in swallowing).
Bedside Exam - Oral-Motor Control Exam: Soft Palate Function - palatal gag
To elicit, cold instrument such as the head of a size 00 laryngeal mirror (1/4" diameter) may be contacted against juncture of hard & soft palate or inferior edge of soft palate & uvula. Should elicit upward & backward movement of soft palate but no reaction in pharyngeal walls. Reflex stimulates palatal movement but does not generate total pharyngeal response of gag reflex. Least stable of the oral reflexes, often requires 2 strokes to elicit.
Bedside Exam - Oral-Motor Control Exam: Palatal Gag - neurological triggers
Afferent portion is glossopharyngeal (9)& possibly vagus (10), Efferent portion vagus ) possibly glossopharyngeal nerve. Trigeminal innervates part of the soft palate & may also be involved in the reflex.
Bedside Exam - Oral-Motor Control Exam: Gag Reflex
Elicited by contacting tongue blade or head of laryngeal mirror against base of tongue or posterior pharyngeal wall. Strong, symemetrical contraction of entire pharyngeal wall & soft palate should be observed. Any asymmetry in pharyngeal wall contraction may indicate unilateral pharungeal weakness likely to affect swallowing. Note that many pp. w/ normal swallows have reduced or absent gag reflexes. Absence is not an indication of impaired ability to swallow.
Bedside Exam - Oral-Motor Control Exam: Gag Reflex - neurological triggers
Afferent portion carried mainly by CN X. IX may also be involved. Triggered by noxious stimuli such as vomit or reflux, motor response is designed to squeeze material up & out of pharynx. Is in contrast to swallow, which is desinged to move food from mouth to stomach, clearing noxious material from the pharynx. Gag triggered by surface & tactile receptors, swallow triggered from deep proprioceptive receptors.
Bedside Exam - Oral-Motor Control Exam: Oral Sensitivity
Assessment of light touch to identify any areas in the mouth w/ reduced sensitivity. No clear guidelines for interpretation, can only compare the various areas of the pt's oral cavity to identify locations w/ greatest & least sensitivity.
Bedside Exam - Oral-Motor Control Exam: Oral Sensitivity - how to conduct it
With cotton swab, make light contact at various points along the tongue from anterior to posterior, along the buccal mucosa & at the base & up the faucual arches to determine awarenss of light touch. If no gag elicited, do similar testing on the posterior pharyngeal wall.
Bedside Exam - Oral-Motor Control Exam: Oral Sensitivity - Indications on placement of food
Results will impact placement of food in the oral cavity, as all food should be positioned at the point of maximum sensitivity.
Bedside Exam - Oral-Motor Control Exam: Oral Sensitivity - Implications of low awareness of light touch
Lack of awareness of light touch in the pharynx may indicate a pt. who will have poor awareness of any pharyngeal residue remaining after a swallow.
Bedside Exam - Oral-Motor Control Exam: Management Information to be collected from labial assessment
Should alert the clinician to any facial paralysis and any problem the patient has in maintaining lip closure when food is placed in the mouth.
Bedside Exam - Oral-Motor Control Exam: Management Information to be collected from lingual assessment
Should identify any limitation in tongue function that may affect ability to propel food posteriorly or to hold food in a cohesive bolus, therefore identifying the area in the oral cavity where food can be positioned for best tongue control. Identification of impairments in tongue function will also help to select the consistencies the patient can best manage.
Bedside Exam - Laryngeal Function Exam
Begin with assessment of voice quality.
Bedside Exam - Laryngeal Function Exam: Gurgly voice
Important sign of possible aspiration, warranes referral for a radiographic exam.
Bedside Exam - Laryngeal Function Exam: Hoarse voice
Should be suspected of having reduced laryngeal closure during the swallow. Pts w/ swallowing disorders whose voice is also hoarse should have a laryngeal exam via referal to an ENT. Should also examine diadochokinec rates of /ha/, listening for clear productions of the vowel and voiceless /h/, as patients w/ some types of neuro impairments tend to produce a single intermediate adduction of the larynx w/ a continuous breathy /ha/ instead of individual syllables.
Bedside Exam - Laryngeal Function Exam: Eval of Cough
Ask pt to cough as hard as possible & clear throat as strongly as possible. Evaluate apparent strength & quality of cough to determine its potential for expectorating aspirated material (although doesn't necc. indicate pt will have a reflexive cough in response to aspiration)
Bedside Exam - Laryngeal Function Exam: Pitch Glides
Ask pt. to slide up & down vocal scale, enables evaluation of function of the cricothyroid muscle & intrinsic muscles of vocal cords & to test the superior laryngeal nerve as it innervates the cricothyroid muscles. B/c pharyngeal swallow may trigger from the SLN, as may the cough reflex, inability to change pitch may imply reduced sensitivity within & surrounding the larynx.
Bedside Exam - Laryngeal Function Exam: Sustained Phonation
Ask patient to take breath and prolong /z/ or /s/ can provide some info on the relative control of the larynx. Phonation time is also a test of respiration, so during prolonged artic, the clinician should observe chest wall & abdominal movement during exhalation.
Bedside Exam - Laryngeal Function Exam: Conclusions
At end of exam, should have some suspicion about the involvement of laryngeal function in the swallowing disorder. If appears to be borderline, may teach the supraglottic or super-supraglottic swallow in an attempt to increase the patient's airway protection prior to initiating any swallows.
Bedside Exam - Pulmonary Function Testing
Helps determine whether the pt. can tolerate any amount of aspiration. Test battery is ordered & interpreted by physician. Info provided should be used when contemplating oral feeding regimens that may involve some degree of aspiration. No data exists re. how much aspiration a pt. can tolerate before contracting aspiration pnemumonia or the level of pulmonary function that must be present in order for patient to tolerate some degree of aspiration. Physicians must establish thier own guidelines to determine when oral feeding in presence of aspiration is acceptable. Pulmonary function data has been helpful in making this determination.
Bedside Exam - Aspiration & Pneumonia
Pt's who are observe to aspirate on radiographic study have been found to be at significantly higher risk for developing pneumonia in the next 6 months thatn those who exhibit no aspiration. Some patients who aspirate may not cough immediately but may cough w/in the next half hour and clear all of the aspirated material. May be one reason why every patient who aspirates doesn't get pneumonia.
Bedside: Information Collected from Preparatory Exam
On basis of the preparatory portion of the bedside clinical exam, should know (1) the posture that may result in best swallowing, (2) the best position for food in the mouth, (3) the potentially best food consistency, and (4) some indication of the nature of the patient's swallowing disorder.
Initial Swallowing Exam: Contraindications for attempting trial swallows at bedside
If patient is acutely ill, has significant pulmonary complications, has a weak voluntary cough, is >80 years and/or can't follow directions & is suspected of having a pharyngeal swallowind disorder (b/c will have to undergo radiograph anyway)
Initial Swallowing Exam: Indications for attempting trial swallows at bedside
Alway consider risk-benefit ratio. But, if pt can follow directions, cough on command, and has good pulmonary function, risk is low and a few trial swallows can be assessed.
Initial Swallowing Exam: Observations to be made if patient is being orally fed
Observe feeding to note (1) reaction to food (2) oral movements in food manipulation & chewing (3) Coughing, Throat Clearing or struggling behaviors or changes in breathing & thier frequency relative to swallowing & their occurence during the meal (beginning, middle, end); (4)Changes in secretion levels throughout the meal; (5)Duration of meal & total intake; (6) Coordination of breathing & swallowing
Initial Swallowing Exam: Decisions on Potential Best Posture - Chin Down followed by head back
Ask pt to tilt head downward as food is introduced into the mouth and then throw head back to drian material when ready to initiate the swallow. Good for symptoms of poor tongue control, diff. maneuvering bolus in mouth or bolus trickling over base of tongue & into pharynx before the voluntary swallow is initiated. Tilting head back is fine for those w/ normal pharyngeal & laryngeal control.
Initial Swallowing Exam: Decisions on Potential Best Posture - Hemilaryngectomy/inadequate laryngeal closure
For hemilaryngectomy pts or any reason for a delay in tiggering pharyngeal swallow, may be helpful to tilt head down so the vallecular space is widened, airway entrance is narrowed & epiglottis is positioned more posteriorly. Material is then more likely to rest in the valleculae long enough for the pharyngeal swallow to trigger & the valleculae & epiglottis will divert material away from the airway. Will also provide greater protection of the airway bu the overhanging epiglottis for those with inadequate laryngeal closure.
Initial Swallowing Exam: Decisions on Potential Best Posture - Unilateral pharyngeal paresis
Common with medullary stroke. May be helpful to turn head towards affected side to close the pyriform sinus on that side, directing material down the more functional side.
Initial Swallowing Exam: Decisions on Potential Best Posture - Lingual hemiparesis or unilateral reduction in oral function combined with same side pharyngeal disorder
Tilting the head to the stronger side may result in directing the material down that side, in both the oral & pharyngeal stages. Pt. will often have to tilt head before food is placed in the mouth b/c with the head in the normal position, material will tend to fall toward the affected side.
Initial Swallowing Exam: Postural Decisions as related to bedside feedings
Postural decisions should be made prior to attempting any swallows at bedside w/ the patient & should be based on the info collected in the preswallowing eval, including careful hx taking & chart review.
Initial Swallowing Exam: Selection of Optimal Food Position in the Mouth
Positioning food in the mouth should depend on info on oral sensitivity & oral function. Food should be positioned on the side of the best function & sensitivity. If liquid must be placed posteriorly in oral cavity, can sue straw or syringe. Tongue blade helpful in positioning thicker foods.
Initial Swallowing Exam: Selection of Possible Best Food Consistency/Texture
Should depends on (1)info collected in hx, (2)data on oral control & (3)info on pharyngeal & laryngeal control.
Initial Swallowing Exam: Selection of Possible Best Food Consistency/Texture - Patients with poor oral control
Will generally do best with a thickened liquid first, them moving towards materials of thin consistency.
Initial Swallowing Exam: Selection of Possible Best Food Consistency/Texture - Patients with a delayed pharyngeal swallow
Will generally do best w/ materials of ticker consistencies, such as applesauce or mashed potatos.
Initial Swallowing Exam: Selection of Possible Best Food Consistency/Texture - Patients with reduced tongue base or pharyngeal wall contraction
Will do best w/ liquids
Initial Swallowing Exam: Selection of Possible Best Food Consistency/Texture - Patients w/ reduced closure of the laryngeal entrance
Will do best w/ materials of a thicker consistency.
Initial Swallowing Exam: Selection of Possible Best Food Consistency/Texture - Patients w/ a combination of disorders (example)
Patient w/ disturbance in oral function & delayed pharyngeal swallow may do best w/ a consistency somewhere between liquid & paste. Gravity can assist oral propulsion of the bolus during oral phase but material will tend to cling to valleculae & epiglottis while waiting for the pharyngeal swallow to trigger, rather than splashing into the pharynx & larynx.
Initial Swallowing Exam: Selection of Optimum Swallowing Instructions
Give series of instructions to elicit most normal swallow possible. Sequence should be based on info collected in the preparatory exam. Posture or sequence of postures should be noted, as should need for voluntary protection of airway during swallow. Details of the sequence will vary by patient and are entirely dependent on results of the preparatory clinical exam. Not possible w/ patients w/ dementia, etc.
Initial Swallowing Exam: Selection of Optimum Swallowing Instructions: Example - Pt w/ Slightly reduced tongue control and reduced laryngeal control
May need to begin by tilting head down while putting food in mouth, then tip head back when he is going to swallow, then hold breath during swallow to voluntarily protect the airway.
Initial Swallowing Exam: Utensils to be used
Size 0 or 00 laryngeal mirror; tongue blade for wiping material onto posterior tongue; cup to give pt small amount of material; spoon for presenting liquids & paste; straw to be used as a pipette for placing liquid in the back of the mouth; syringe to squirt small amounts of liquid (1 ml) into the posterior oral cavity
Initial Swallowing Exam: Patient Prep
If patient is exhibiting any excess secretions, suctioning should be completed both orally & transtracheostomy, if trach tube is present.
Initial Swallowing Exam: Management of the Trach Tube - Deflating the Cuff
Deflate the trach cuff prior to attempting any swallows. Inflated cuff may irritate the trachea as the larynx elevates during swallowing or it may restrict laryngeal elevation. Before proceeding w/ swallow or deflating the cuff, check w/ the physician.
Initial Swallowing Exam: Management of the Trach Tube - Suctioning
Suction the patient well both orally & via the tracheostomy to assure a clear oral cavity & airway prior to beginning tx. Also suction well immediately after the cuff is deflated so any secretions sitting above the cuff will be cleared away as they drain around the tube into the trachea. Nurse may do suctioning/assist.
Initial Swallowing Exam: Management of the Trach Tube - During the swallow
During the swallow, pt should gently occlude his tracheostomy tube w/ gloved finger or gauze pad to establish as near-normal tracheal pressure during swallowing as possible. Should be incorporated into the set of instructions until videofluoroscopy can verify if it is helpful.
Initial Swallowing Exam: Management of the Trach Tube - Advantages to initiating swallow with trach in place
Can observe aspiration more directly by examining any expectoration through the tube; Elimination of aspirated material by coughing or suction can be done more easily.
Initial Swallowing Exam: Management of the Trach Tube - Specific but infrequent problems related to the presence of trach tube during swallowing therapy
(1)Restriction of upward laryngeal movement to protect the airway by anchoring the trachea to the strap muscles & skin of the neck along scar tissue, increasing risk of aspiration, (2)Compression of the esophagus by the tube pushing posteriorly on the common wall btwn. the trachea & esophagus (esp. w/ cuffed tubes); (3)Change in intratracheal pressure b/c of the presence of the tube. BUT for majority of swallowing pts, advantages of a tracheostomy outweigh the disadvantages (but keep problems in mind, esp. if tube has been in place >6 months)
Initial Swallowing Exam: Management of the Trach Tube - Instructions to swallow
Before swallow, review & write down w/ patient his particular set of directions. Pt should be given opp to practice several dry swallows according to instructions. Pts do best if given adequate time to absorb instructions & review them w/therapist before trying to swallow any food or liquid. Should also coach them through the sequence.
Initial Swallowing Exam: Management of the Trach Tube - Actual Swallow following practice of instructions
Once pt has demonstrated ability to follow outlined instructions, several actual swallows can be tried, assuring the pt the amnt to be swallowed will be minimal. Encourage them to cough when needed but to try to get through the sequence.
Initial Swallowing Exam: Management of the Trach Tube - Reassurances during attempts at actual swallows
Reassure pt that the small amount should prevent difficulty w/ breathing during or after the swallow. Reinforce coughing to clear the airway (sometimes pts feel coughing indicates poor performance).
Initial Swallowing Exam: Management of the Trach Tube - Materials for intial swallow
Use 1/3 teaspoon for both liquid and paste/pudding type consistencies. These small amounts aren't sufficient to block airway and should cause minimal difficulty if aspirated.
Initial Swallowing Exam: Placement of hand during trial swallows
Helpful to place hang under patient's chin w/ fingers spread & making light contact. Index finger should be lightly positioned immediately behind the mandible anteriorly, middle finger at hyoid bone, 3rd finger at top of thyroid, 4th finger at bottom of thyroid. Thus can assess submandibular, hyoid & laryngeal movement during swallow. No pressure applied, just a light touch.
Initial Swallowing Exam: Observations during trial swallows
As pt swallows, fingers on neck can assess initiation of tongue movement, hyoid bone movement, laryngeal movement & where the pharyngeal swallow triggers. Comparing the elapsed time btwn. initiation of tongue movement & initiation of hyoid & laryngeal movement can provide rough estimate of OTT & PDT. Can follow inital swallow w/ a thermal-tactile stimulated swallow to assess the difference in timing. If total time is reduced by several seconds, may hypothesize time reduction was part of pharyngeal delay. Gross estimate of OTT & PDT.
Initial Swallowing Exam: Tasks after the swallow
Immediately after, ask pt to phonate /ah/ for several seconds, examining vocal quality for any sign of gargling (indicating material sitting on vf's). Next, ask pt to pant for several seconds so that ny material in pharyngeal recesses will shake loose & fall in airway. Then ask to vocalize again to evaluate voice quality.
Initial Swallowing Exam: Tasks after the swallow
After phonation & panting, ask pt to turn head to each side while phonating, which results in pressure on each pyriform sinus & may squeeze residual material out into the pharynx causing the voice to become gurgly. If voice is clear, ask to lift chin, hold, then vocalize. Chin-up posture will cause tongue base to push on valleculae & result in clearing material which may then cause gurgly voice.
Initial Swallowing Exam: Tasks after the swallow
If pt coughs during any part of after swallow sequence & expectorates material or gurgly voice quality is heard, aspiration can be suspected.
Initial Swallowing Exam: Tasks after the swallow - silent aspirators
Tasks after the swallow can help identify aspiration, but 50-60% of aspirators don't cough. Bedside exams do not identify aspiration approx. 40% of the time for pt's who are aspirating.
Videofluoroscopic Procedure - Modified Barium Swallow (MBS)
Fluoroscopy well suited to study the physiologic function of the dynamic & rapid process of swallowing.
Videofluoroscopic Procedure - Modified Barium Swallow (MBS): Framing
Recorded on video for permenent storage and simultaneous voice recording w/ the image. Framing is possible using a video counter timer, which places a # in the corner of the videoscreen, each # representing one frame. Framed at 30 frames w/ 60 fields per second, so #s placed at rate of 30 or 60 per second. Need to do slow-motion, frame by frame analysis of the movement of structures and bolus.
Modified Barium Swallow procedure/Cookie Swallow Test
Designed to examine the details of oral, pharyngeal & cervical esophageal physiology during swallowing.
Modified Barium Swallow - differences from traditional upper gastrointestinal/barium swallow
Differs by purpose of the study, type & amount of material used in the study & procedures used, including rehab strategies introduced.
Modified Barium Swallow - Purposes
(1) To define the abnormalities in anatomy & physiology causing the patient's symptoms & (2)To identify & evaluate tx strategies that may immediately enable the pt. to eat safely and/or efficiently
Modified Barium Swallow - What is observed
OTT & PTT; functioning of the valves in the system (velopharynx, larynx & cricopharyngeal region); cervical esophageal peristalsis
Traditional Barium Swallow - what is observed
Gives info on structural competence of the esophagus, with little attention paid to details of swallowing physiology in the oral cavity & pharynx.
Modified Barium Swallow - Whether & Why
Designed to assess not only whether patient is apirating but also why so appropriate & efficient tx can be initiated.
Modified Barium Swallow - Placement of Food in Patient's mouth
Place in mouth on a disposable plastic spoon. If pt has bite reflex, use heavier plastic spoon. With infants, use bottle/nipple.
Modified Barium Swallow - Placement of Food in Patient's mouth: Special device for babies
Plastic tube w/ an end for attachment of ordinary bottle nipple. 50-cc syringe or a plastic bag w/ 450-cc volume capacity is attached to the open end. Infant can then suck liquid w/o therapist's hand entering the field of exposure. Infant can also be given formula mixed w/ barium in a bottle, which is held w/ lead-gloved hand.
Modified Barium Swallow - Types & Amounts of Materials Used
At least 3 consistencies used to investigate complaints of variable swallowing ability: thin liquid barium (as close to water as possible), barium paste (pudding mixed w/ Esophatrast), and material requiring mastication (cookie coated w/ pudding mixed w/ esophatrast).
Modified Barium Swallow - Types & Amounts of Materials used by special circumstance
Use certain types if pt complains of difficulty w/ particular foods, if particular consistencies are routinely given to the patient or if the patient responded well to a certain taste, temp or texture combo in the bedside testing.
Modified Barium Swallow - Types & Amounts of Materials Used: Standard
2 swallows of each material are given in the following amounts: 1 ml, 3 ml, 5 ml, 10 ml and cup drinking of thin liquid; 1/3 tsp of puddingl 1/4 of small Lorna Doone cookie coated w. barium pudding. If patient progresses through all w/o trouble, proceed to give more foods of different types mixed w/ barium.
Modified Barium Swallow - Observation of Normal Eating
Pt should be allowed to feed himself as appropriate to observe normal eating radiographically.
Modified Barium Swallow - simulating same conditions under which patient eats
Need to do this if the patient has a specific complaint, or if the staff in the patient's facility observe behaviors not seen in the radiographic study.
Modified Barium Swallow - volume of liquid
Volume of liquid is increased until/unless the patient aspirates
Modified Barium Swallow - Intervention Strategies
Once the reason of aspiration is determined, intervention strategies are introduced to eliminate the aspiration. They are selected bsaed on those that have been found to be effective w/ the swallowing disorder observed in the patient.
Modified Barium Swallow - Swallowing of other consistencies
If pt can swallow other consistenceis, such as honey-thickened or nectar-thickened liquids w/o aspiration, these will be given in 1,3,5 and 10 ml amounts
Modified Barium Swallow - Self Feeding
Valuable to have the pt self-feed so clinician can see the amount the pt places in the mouth, as they may "overstuff" the mouth with food
Modified Barium Swallow - Intervention Strategies (Order)
Compensatory strategies, including postural changes, procedures for heightening sensory input, and changes in the way the pt is fed are attempted first, followed by therapy procedures such as swallow maneuvers. Compensatory strategies are used first b/c they require minimal direction following & little increased muscle effort.
Modified Barium Swallow - Amount of volume
Must initially give only very small amounts of material. Pts referred are often ill, have poor respiratory status & are aspirating. If any large amnt (> 1tsp) of barium enters their airway, complications, including respiratory arrest, may result. Only small amount is needed initially to make an accurate diagnosis.
Modified Barium Swallow - Rationale behind beginning w/ liquids
Ensures the material won't block the aireay, if aspirated. Some evidence that pneumonia is less likely from aspiration of liquids than from aspiration of thicker foods. Lungs may be better able to clear liquids from the trachobronchial tree by cough or ciliary action.
Modified Barium Swallow - Positioning the Patient
Often the most difficult & time-consuming part. Pt should be seated & initially viewed in the lateral plane. A number of chairs for positioning pts have been designed & are commercially available.
Modified Barium Swallow - Positioning the Patient
If pt is mobile & able to sit w/o a back rest, can be seated on the horizontal platform attached to the fluoroscopy table and raised or lowered to the desired height. Most fluoroscopy machines fitted w/ handles so pt can grip to stabilize position. Initially, pt is seated so his side rests against the table of the fluoroscopy machine & the vocal tract is viewed laterally.
Modified Barium Swallow - Positioning the Patient who can't sit unassisted
Some machines won't accomodate a pt who can't sit unasssited, sits in a wheelchair or needs to lie in a cart. B/c of the many designs in fluoroscopy equipment, distance btwn the tube & table not wide enough to fit a wheelchair or cart. But, w/ a narrow back support added to the cart, any fluoroscopy machine can accomodate the pt. Many machines have limited vertical tube movement & can be lowered only a limited distance, usually not low enough to view the laryngopharynx if pt is seated in wheelchair. Can use a special cart and position the head of the cart by elevating it to at least a 90 degree angle for this population.
Modified Barium Swallow - Focus of the Fluoroscopic Image
Tube should focus on the lips anteriorly, the hard palate superiorly, the posterior pharyngeal wall posteriorly and the bifurcation of the aiway & esophagus inferiorly. Pt's arm should hange at sides & not rest on the arms of the chair, which will elevate the shoulders. Shoulders should be as low as possible so they do not shadow or cover the pharynx.
Modified Barium Swallow - Focus of the Fluoroscopic Image: Image Magnification
Many machines permit image magnification. If pt suspected of aspirating, sometimes helpful to magnify the area arnd the bifurcaction of the airway & esophagus to get a clear picture of the amount of aspiration on the first swallow or two. Then image can be reduced to include the entire vocal tract on the remaining swallows to identify the reason for aspiration.
Modified Barium Swallow - Measures & Observations in Lateral View: OTT
OTT defined as the time taken for the movement of the bolus through the oral cavity from the initiation of posterior movement of the bolus by the tongue until the leading edge of the bolus passes the point where the mandible crosses the tongue base.
Modified Barium Swallow - Measures & Observations in Lateral View: PTT
Pharyngeal phase begins when the pharyngeal swallow triggers & terminates when the bolus tail passes through the cricopharyngeal juncture. PTT defined as the time elapsed as the bolus moves between these 2 points.
Modified Barium Swallow - Measures & Observations in Lateral View:
Time interval from the end of oral transit time until the pharyngeal swallow triggers, as indicated by hyolaryngeal elevation followed by other muscular actions comprising the pharyngeal stage of swallow.
Modified Barium Swallow - Measures & Observations in Lateral View: Esophageal Transit Time
Can also be measured, but usually not in this study b/c exercise programs for swallowing disorders are generally not effective in remediating esophageal disorders, which are often treated medically or surgically.
Modified Barium Swallow - Measures & Observations in Lateral View: Esophagus
Don't assess the esophagus on the same swallows in which the pharyngeal & oral aspects are examined, b/c the fluoroscopic tube should remain focused on the oral cavity and pharynx throughout the entire modified barium swallow.
Modified Barium Swallow - Measures & Observations in Lateral View: Location of bolus
Lateral view allows for identification of location of bolus as it moves along the upper aerodigestive tract from anterior superior to posterior inferior. Permits analysis of patterns of lingual movement, gross estimate of the amount of vallecular residue after the swallow, and estimate of the amount of material aspiratd per bolus, as well as anatomic or physiologic reason for the aspiration. Timing of aspiration relative to triggering of the pharyngeal swallow (before, during, after) also best observed in the lateral view.
Modified Barium Swallow - Posterior-Anterior View
In this view, as bolus enters the pharynx, it fills the valleculae, giving it a scalloped appearance b/c of the hyoepiglottic ligament at midline, which subdivides the valleculae. Then bolus divides and goes around the airway into the pyriform sinuses. Usually divides fairly equally btwn the 2 sides, coming togetehr again around the level of the opening to the esophagus. But about 20% of normal swallowers swallow down only one side.
Modified Barium Swallow - Posterior-Anterior View: What it is good for viewing
Helpful in looking at asymmetries in function, esp of pharyngeal walls & vf's, and in viewing residues of material in the valleculae and in one or both pyriform sinuses.
Modified Barium Swallow - Posterior-Anterior View: Limitations of viewing
Not easy to measure transit times and observe aspiration. Best in this view to repeat only swallows of particular materials that exhibit the most severe disturbances in swallowing, which assures minimum radiation exposure.
Modified Barium Swallow - Posterior-Anterior View: Viewing residue
Important to examine the residue in the pharynx after the swallow, comparing the 2 sides.
Modified Barium Swallow - Posterior-Anterior View: Viewing VF movement
Helpful to have pt tilt head back and ask him to vocalize continuous and rapidly repetitive /a/ to provide clear picture of vocal fold movement (make gross judgment about relative movement of the 2 cords on adduction and abduction) to assess ability to close vf's during swallow.
Modified Barium Swallow - Instructions to the Patient
When positioned, explain that they will be asked to swallow several different kinds of foods & that only small amnts of each food will be given at first. Show the 1 ml amnt on the spoon before placing in mouth. Tell pt to feel free to cough or spit out material if necessary, but to try their best throughout the exam.
Modified Barium Swallow - Procedures to be followed w/ the various materials to be swallowed - 1 ml liquid barium
First give 1 ml liquid barium and ask pt to hold the material in his mouth until the examiner says to swallow. Liquid always presented first even if pt known to aspirate b/c usually best to define the reason for aspiration and amnt of asporation during first several swallows. Liquids may be the most easily aspirated yet are least apt to block the airway, reducing the pt's fear of swallowing. Follow by a second 1 ml swallow.
Modified Barium Swallow - Procedures to be followed w/ the various materials to be swallowed - 3 and 5 ml liquid barium
After two 1 ml swallows given, two 3 ml swallows should be given on teaspoon, then two 5 ml swallows are given via teh syringe placed gently in mouth or placed in empty cup and given that way.
Modified Barium Swallow - Procedures to be followed w/ the various materials to be swallowed - 10 ml liquid barium and cup drinking
If no aspiration occurs at 5 ml, 10 ml liquid barium should be given. Changing volume allows observation of mechanism's ability to modulate volume. Finally, pt should be given a cup and told to swallow normally (2 cup drinkings)
Modified Barium Swallow - Procedures to be followed w/ the various materials to be swallowed - what to do if pt aspirates on liquid
If pt aspirates on a particular volume of liquid, attempt tx strategies to eliminate aspiration on the same volume. If aspiration is eliminated on several swallows of that volume as a result of the intervention, volume should be increased as far as tolerated, goal being to allow the pt to take thin liquids orally of as many volumes as possible.
Modified Barium Swallow - Procedures to be followed w/ the various materials to be swallowed - thicker foods
Pudding mixed w/ esophatrast to provide pudding consistency and maintain good taste (give twice). If pt unable to take past material or liquid from spoon, tongue blade can be used to wipe material of a thicker consistency onto the back of the tongue. If aspiration occurs, strategies should be introduced to stop the aspiration.
Modified Barium Swallow - Procedures to be followed w/ the various materials to be swallowed - Cookie
1/4 of a Lorna Doone cookie w/ light coating of esophatrast pudding to give contrast. On these last 2 swallows, ask pt to chew material well & initiate swallow when ready. Here they don't wait for instruction to swallow, rather told to go ahead & swallow as soon as they have finished chewing. If can't follow directions, place the piece of cookie in pts mouth & observe spontaneous chewing & swallowing.
Modified Barium Swallow - Observation of self-feeding
If pt does well, or does well with interventions, should also observe self-feeding radiographically to ensure the pt followis the same procedure & is equally as successful w/ self feeding.
Modified Barium Swallow - Pts w/ severe dementia or cognitive problems
Can be successfully assessed w/ the modified barium swallow. Food can be placed in their mouth and the clinician's hand removed quicky so that the pharyngeal swallow can be viewed. In some cases, pt may not understand directions & may swallow quickly, so the oral phase may be missed, but the critical pharyngeal phase will be seen.
Modified Barium Swallow - Trial Therapy
When pt aspirates or has significant residue in pharynx after the swallow, decide on the nature of treatment for the specific swallowing disorder & attempt trial therapy w/ videofluoroscopy. If intervention strategies can't be done, should be noted w/ reasons why.
Modified Barium Swallow - Trial Therapy
Ask pt to position head or body in particular way, present sensory-enhancing boluses (cold, sour, larger volumes, etc.), or ask the pt to follow specific instructions (swallow maneuvers) while swallowing & examine the results, comparing them to the earlier physiology shown on the videofluoroscopy.
Modified Barium Swallow - Documentation of Trial Therapy
Often, postural changes or other compensatory strategies can result in dramatic changes in physiology and may permit the pt to begin oral intake. Helpful when these changes are documented using videofluoroscopy. Also cost-effective, b/c some pts will be able to return to oral intake quickly. Added exposure time w/ interventions usually < 5 minutes & presents less radiation exposure than would be received during barium swallow, etc.
Modified Barium Swallow - Guidelines for Videofluoroscopy Referral
Any pt suspected of aspirating whose swallowing disorder is suspected to be of pharyngeal orgin or who has a pharyngeal componet to the disorder should be referred, as pharyngeal physiology can't be derined at bedside , thus therapy planning & intervention for pharyngeal dysphagia can't be done w/o radiographic study.
Modified Barium Swallow - Who should do the videofluoroscopic study?
Best if swallowing therapist & radiologist collaborate as each brings particular expertise.
Modified Barium Swallow - Who should do the videofluoroscopic study? Particular skills of radiologist and swallowing therapist
Radiologist is trained to identify structural abnormalities byt typically have minimal knowledge of the details of oral & pharyngeal movement patterns during deglutition. Swallowing therapist is familiar w/ these patterns and the therapeutic regimen to treat particular disorders. The combo results in optimal diagnosis and management decisions.
Purpose of Radiographic Study
To define the swallowing physiology causing the aspiration and to examine the effectiveness of some selected tx options that fit the pt's oropharyngeal swallowing abnormalities w/ the goal of establishing some safe, efficient oral feeding immediately.
Modified Barium Swallow - order of interventions introduced
1) Postural techniques, 2) Increasing oral sensation (when appropriate), 3) Swallowing maneuvers, 4)Diet (food consistency) changes, if needed
Modified Barium Swallow - order of interventions introduced: Rationale
Based on the muscular effort required by pt's & the ease of application and learning of the various procedures
Modified Barium Swallow - order of interventions introduced: Postural changes
Tried first b/c in general they are easily used by a wide range of pts, even those w/ reduced cognition, children & pt's w/ some degree of restricted physical mobility.
Modified Barium Swallow - order of interventions introduced: Increasing Oral Sensation
Tried second (if appropriate). Can also be used w/ a wide variety of pt's, as the procedures are clinician controlled and do not require the pts to actively cooperate, other than allowing the clinician to place something in their mouth.
Modified Barium Swallow - order of interventions introduced: Swallow Maneuvers
Tried after postural changes and increasing of sensation b/c they require the ability to actively follow directions & voluntarily manipulate the oropharyngeal swallow as it is ongoing. Also involve increased work or muscular effort, increasing potential for fatique. However, some pts can't swallow successfully w/o swallow maneuvers.
Treatment Trial: Postural Techniques
Have been demonstrated to effectively eliminate aspiration on liquids & other foods in a wide range of patients when the postures were selected to match the patietn's anatomic or physiologic swallowing disorder. Postural techniques redirect food flow and change pharyngeal dimensions.
Postural Technique & Rationale for Inefficient Oral Transit (Reduced posterior propulsion of bolus by tongue)
Head back, b/c utilizes gravity to clear oral cavity
Postural Technique & Rationale for delay in triggering the pharyngeal swallow (bolus past ramus of mandible, but pharyngeal swallow not triggered)
Head down, b/c it widens the valleculae to prevent the bolus from entering the airway and narrows the airway entrance
Postural Technique & Rationale for reduced tongue base posterior motion (residue in valleculae)
Head down b/c it pushes tongue base backward toward pharyngeal wall
Postural Technique & Rationale for unilateral laryngeal dysfuncton (aspiration during swallow)
Head down b/c it places epiglottis in more posterior protective position & narrows the laryngeal entrance OR head rotated to damaged side b/c it increases vf closure by applying extrinsic pressure and narrows the laryngeal entrance
Postural Technique & Rationale for reduced laryngeal closure (aspiration during swallow)
Head down b/c it places epiglottis in more protective position and narrows airway entrance.
Postural Technique & Rationale for reduced pharyngeal contraction (residue spread throughout the pharynx)
Lying down on one side b/c it changes the directopm pf gravitational effect on pharyngeal residue
Postural Technique & Rationale for unilateral pharyngeal paresis (residue on one side of pharynx)
Head rotated to damaged side b/c twists pharynx and eliminates damaged side of pharynx from bolus path
Postural Technique & Rationale for cricopharyngeal dysfunction (residue in pyriform sinuses)
Head rotated b/c pulls cricoid cartilage away from posterior pharyngeal wall, reducing resting pressure in cricopharyngeal sphincter
Postural Technique - Populations appropriate for
In general, work equally well w/ neurologically impaired individuals, in pts who have experienced head & neck cancer resections or other structural damage, and in patients of all ages.
Postural Techniques - measures of effectiveness
Best measure of effectiveness is judgement of the amount of aspiration w/ and w/o the posture. Postures may also improve oral & pharyngeal transit times. Best to measure by videofluoroscopy. Could be observed by endoscopy before or after, but not during, swallow or by scintigraphy in terms of changes in residue and aspiration.
Techniques to improve oral sensory awareness
Generally used in pts w/ swallow apraxia, delayed onset of oral swallow, or delayed triggering of pharyngeal swallow. All the procedures involve providing a preliminary sensory stimuls prior to the patient's initiation of the oral stage of swallow.
Sensory technique: Pressure
Increase downward pressure of spoon against the tongue in presenting food in the mouth.
Sensory technique: Sour
Presentation of a sour bolus (50% lemon juice, 50% barium)
Sensory technique: Cold
Presentation of a cold bolus
Sensory technique: Chewing
Presentation of a bolus requiring chewing
Sensory technique: Volume
Presentation of a larger volume bolus (3 ml or more)
Sensory technique: Result of increased sensation on apraxia
In some pts w/ apraxia, increasing oral senation by preliminary stimulus (pressure, volume, taste, temp) may facilitate oral onset and oral transit.
Sensory technique: Thermal-Tactile Stim
Involves vertically rubbing the faucial arch firmly w/ size 00 laryngeal mirror which has been held in crushed ice for several seconds in advance of presentation of a bolus. Designed to heighten oral awareness & provide an alerting sensory stimulus to the cortex & brainstem such that when the patient initiates the oral stage of swallow, the pharyngeal swallow will trigger more rapidly. Has been demonstrated to facilitate faster triggering of the pharyngeal swallow after the stimulation & reducing the delay for several swallows thereafter.
Sensory techniques: Measures of effectiveness
(1) Duration of time from command to swallow until initiation of oral stage, (2)Oral transit time, (3)Pharyngeal delay time. All 3 can be measured from videofluoroscopy.
Swallow maneuvers
Designed to place specific aspects of pharyngeal swallow physiology under voluntary control.
Swallow maneuvers: Supraglottic Swallow
Designed to close the airway at the level of the true vf's before and during the swallow
Swallow maneuvers: Super-Supraglottic swallow
Designed to close airway entrance before and during the swallow
Swallow maneuvers: Effortful Swallow
Designed to increase tongue base posterior motion during the pharyngeal swallow and thus improve bolus clearance from the valleculae.
Swallow maneuvers: Mendelsohn maneuver
Designed to increase the extent and duration of laryngeal elevation and thereby increase the duration and width of cricopharyngeal opening (which can also improve the overall coordination of the swallow).
Swallow maneuvers: When to use
During videofluorographic study, if postural techniques and oral sensitivity facilitation techniques don't improve the swallow physiology sufficiently to allow the pt to begin some oral intake. Not feasible for those w/ cognitive or significant language impairments b/c of need to follow careful directions.
Food Consistency (Diet) Changes
Elimination of certain food consistencies should be the last strategy examined. Done only when other strategies aren't feasible, such as a patient w/ a movement disorder whose posture changes continuously, who can't follow directions and use swallow maneuvers and for whom oral sensory procuedures are inappropriate.
Best food consistencies for reduced range of tongue motion
Thick liquid. Should avoid thick foods
Best food consistencies for reduced tongue coordination
Thick liquid. Should avoid thick foods
Best food consistencies for reduced tongue strength
Liquid. Should avoid thick, heavy foods
Best food consistencies for delayed pharyngeal swallow
Thick liquids and thicker foods. Should avoid thin liquids.
Best food consistencies for reduced airway closure
Pudding & thick foods. Should avoid thin liquids.
Best food consistencies for reduced laryngeal movement contributing to cricopharyngeal dysfunction
Liquid. Should avoid thicker, higher viscosity foods.
Best food consistencies for reduced pharyngeal wall contraction
Liquid. Should avoide thick, higher viscosity foods.
Best food consistencies for reduced tongue base posterior movement
Liquid. Should avoid higher viscosity foods.
Procedures that can't be introduced in the diagnostic setting b/c they don't result in immediate effects
Range of motion exercises for lips, tongue and/or jaw (take effect after 2-3 weeks). Chart change in range of motion over first and second studies.
Education of others with effective techniques
When effective techniques identified in MBS, videotape of the diagnostic procedure can be used as an educational tool w/ the patient, nurses, physicians, and others to educate and counsel them regarding the rationale for use of particular procedures with the patient. This visual evidence often improves compliance with therapy recommendations.
Videofluoroscopic Study Report - Intro, Oral Stage and Triggering of Pharyngeal Swallow
Should be written & signed by all professionals involves. Begins w/ description of symptoms or complaints, then measures of OTT should be given for each material swallowed, followed by description of any problems observed in the oral phase of swallow or any variability in swallowing with the various consistencies presented. If aspiration occurs in oral stage, reason why should be described. Duration of any delay in triggering pharyngeal swallow and its variation with bolus volume or viscosity should be indicated and the location of the bolus during the delay shoyld be identified. If aspiration occurs during the delay, should be described and approximate amount noted.
Videofluoroscopic Study Report - Pharyngeal Stage
PTT should be specified, noting variations w/ consistency of material, as well as any anatomic or neuromuscular problems observed in the pharyngal swallow described. Approx. amnt of aspiration on particular food consistencies and etiology of aspiration should be noted. Approx. amount of vallecular & pyriform residue should be defined. If aspiration or significant residue observed, intervention strategies should be attempted & their results reported. If no strategies introduced, reason why should be stated.
Videofluoroscopic Study Report - Recommendations
Should be outlined regarding (1)Management of nutritional intake (nonoral feeding, oral feeding, combo); (2)results of interventions & therapies used during the study; (3)Procedures for swallowing therapy; (4)reevaluation. Should include any recommendations for consultations to other professionals.
Videofluoroscopic Study Report - Incomplete Report
If report does not contain 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.
Compensatory tecnique for unilateral pharyngeal paralysis
Turn head to affected side to close the pyriform sinus on that side and direct material down the normal side.
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Posture
Compensatory tecniques/maneuvers for unilateral lingual and pharyngeal paralysis
1)Tilt head to stronger side, keeping material on stronger side. 2)Supraglottic swallow to expectorate residual material in pharynx 3)Alternate liquid and solid swallows to wash away thicker food that remains in pharynx after swallow.
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Techniques/maneuvers for scarred pharyngeal wall
Turn head to affected side to direct material down normal side; Supraglottic swallow may help to eliminate reside that remains in scar site after the swallow.
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Techniques/maneuvers for cervical osteophytes
May be surgically reduced or matient may acclimate to it by thinning out consistency of swallows. Rotating head to one side or the other may also be helpful
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3 things
Techniques/maneuvers for pseudoepiglottis at base of tongue in total laryngectomees
Fold of tissue from die of the pharynx can be surgically removed or pt can adjust by swallowing only liquids and thin paste consistencies. Sometimes head rotation will keep the fold out of bolus path.
p. 233
3 things
3 possible causes of cricopharyngeal dysfunction
May result from (1)failure of the CP muscular portion of the UES to relax, keeping larynx from lifting & moving forward (2)reduced laryngeal motion up and forward and/or (3)Poor pressure to drive bolus through the sphincter and widen the opening. Must determine which of these is impaired to define therapy.
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Techniques/maneuvers for cricopharyngeal dysfunction resulting from spasm in cricopharyngeal muscle preventing larynx from moving up & forward
Cricopharyngeal myotomy shoyuld be considered after opportunity to spontaneously recover (5-6 months)
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Surgical
Techniques/maneuvers for cricopharyngeal dysfunction resulting from poor laryngeal motion up and forward
Mendelsohn maneuver. May be used as therapy procedure to improve laryngeal motion or as strategy to enable the patient to eat.
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Maneuver
Populations with cricopharyngeal dysfunction resulting from poor laryngeal motion up and forward
Cervical spinal cord injury pts, cervical fusion, brainstem stroke, radiation therapy, surgery to pharynx
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Techniques/maneuvers for cricopharyngeal dysfunction resulting from inadequate pharyngeal pressure
Exercises to improve tongue base action.
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Techniques/maneuvers for cricopharyngeal dysfunction caused by reduced laryngeal movement and unilateral pharungeal weakness
Most common cause. Use combo of Mendelsohn maneuver and head rotation to weaker side.
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Maneuver for reduced laryngeal elevation
Mendelsohn maneuver. Also can compensate for reduced laryngeal elevation with supraglottic swallow which will expectorate reside left above the larynx after swallow. Some pts can simly clear the throat after the swallow to expectorate residue. Super-Supraglottic swallow may speed the onset of layrngeal elevation. Falsetto exercise may be used as range of motion exercise for laryngeal elevation.
p. 234
Maneuver for reduced laryngeal closure at airway entrance
Super-supraglottic swallow used as therapy, also to help pt swallow (although may not be able to maintain for whole meal). In therapy, instead of entire technique, pt can take breath, hold it, and bear down as a range of motion exercise for the anterior tilting of the arytenoid and false vf closure.
p. 234
Maneuvers for reduced laryngeal closure at the vocal folds
1)Supraglottic swallow (practice on dry swallows)/voluntary airway closure (hold breath and swallow simultaneously and release air into a cough after the swallow) to improve laryngeal adduction. Cheerlead along the way w/ reminders to continue to hold breath and to cough right after the swallow, before inhaling.
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Best consistencies for those with reduced laryngeal closure at the vocal folds
Thicker consistencies
p. 234
Best consistency for pts with reduced laryngeal closure combined with reduction in pharyngeal wall contraction
Thinner materials, as thicker would have tendency to remain in pharynx after the swallow.
p. 234
Posture technique for reduced laryngeal closure at vocal folds
Some patients benefit from a forward, chin-down head posture during swallow, which widens valleculae, narrow airway entrance, puts epiglittis in more posterior position and pushes the tongue base posteriorly.
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Hemilaryngectomee pt with swallowing disorder b/c of slightly reduced airway closure
May exhibit normal swallow w/ head tilted forward, but only if they have an epiglottis (so won't work for supraglottic laryngectomee)
p. 235
Best airway closure
Combo of head rotation and chin-down
p. 235
Thyroid pressure for reduced laryngeal closure
Turning patient's head to nonfunctional side or placing pressure on thyroid on the nonfunctional side may improve larungeal closure.
p. 235
Patients with severe problems w/ airway entrance closure should use ________ while using a ________ to get best airway protection.
head rotation to damaged side; super-supraglottic swallow
posture, maneuver. p. 235
Pts w/ poor tongue base motion should combine _____ and _______.
chin-down posture; effortful swallow
posture, manevuer, p. 235
Pts w/ poor cricopharyngeal opening b/c of redyction in laryngeal elevation and unilateral pharyngeal wall weakness should combine _____ and _____.
head rotation to damaged side, Mendelsohn maneuver
p. 235
When postures and maneuvers are combined they should be examined ________ during the MBS and then the _________ assessed.
seperately; combo
p. 235
Biofeedback - Surface EMG
Placed on lips, can give biofeedback abt, amount of effort used in attempts at lip closure. Under chin on submandibular muscles (above larynx), info on additional degree of muscle effort used in effortful swallow of Mendelsohn.
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Biofeedback - Ultrasound
Can provide biofeedback re. tongue movement patterns during swallowing. Pt can observe tongue motion over time while practicing upward and backward movement of the tongue to propel bolus through oral cavity.
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Biofeedback - Videoendoscopy
Could provide biofeedback re. closure of true vf's before swallow attempt or clousre of airway entrance before swallow attempt. Can also observe movement of vfs and airway entrance closure during various breath hold maneuvers.
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Biofeedback - Videofluorography
Pt can observe pharyngeal swallow movements during x-ray for biofeedback. Clinician can point out elements of swallow, identify those that are defective and need increased range of motion.
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