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Medical techniques - surgical reduction of osteophytes
If the pharyngeal narrowing is severe, reduction performed by entering the paraesophageal space through a side of neck incision. Then the vertebral periosteum is reflected back and excess bone removed.
p. 346
Cervical ostephytes and dysphagia
If large enough, the mass of bone can signif. diminish the pharyngeal space, making passage of large or thick boluses difficult. May also press on the cervical nerve roots, creating the sense of dysphagia.
p. 346
Drawback to surgical reduction of osteophytes
Can create scar tissue or damage to nerves innervating structures involved in swallowing.
p. 346
Medical techniques - procedures to improve airway closure at the vf's
Injection of an inert substance into damaged vf is designed to add bulk to in order to improve closure at the vf's and airway protection during swallowing. Usually used in pt's whose laryngeal adduction for airway protection has not been sufficiently improved w. an exercise program, or in head and neck surgical pts (i.e. partial laryngectomy pt whose remaining tissues in larynx can't adduct enough).
p. 346
Medical techniques - Limitation to procedures to improve airway closure at the vf's
Denseness of the tissue into which the injection is made, i.e. there must be enough tissue to accept the injected material.
p. 346
Medical techniques - procedures to improve airway closure at the vf's: use for other populations
injection of substance into damaged vf also used in pts with PD and amyotrophic lateral sclerosis.
p. 346
Medical techniques - procedures to improve airway closure at the vf's: Types of materials used for injection
Glycerin, gel foam or some other temporary substance
p. 346
Medical techniques - procedures to improve airway closure at the vf's: Misuse
Injection into vf's only effective fore those whose aspiration is a result of reduced closure at the vf level, NOT at the airway entrance.
p. 346
___% or less of aspiration is caused by inadequate _____ ____ closure.
10, vocal fold
p. 347
Medical techniques - vocal fold medialization
Have been used to more the damaged vf's to midline.
p. 347
Medical techniques - Laryngeal Suspension for Reduced Laryngeal Elevation
Suture is placed from the middle of the mandible to the laryngeal cartilage, and larynx is raised and tilted under the tongue base. Done occasionally in head and neck cancer pts, rarely in neurologic pts
p. 347
Medical techniques - Dilatation of scar tissue in the cricopharyngeal region
Passage of mercury filled soft rubber tubes (bougies) of increasing diameter through the CP region to gradually stretch it open and tear any scar tusse that might be present.
p. 347
Medical techniques - Dilatation of scar tissue in the cricopharyngeal region: Effects
Temporary results, lasting 1-3 months. Also, dilatation won't help a pt w/ CP dysfunction related to neurologic damage.
p. 347
Medical techniques - Cricopharyngeal myotomy
External incision through the side of the neck (usually L side) into the cricopharyngeal muscle, slitting the fibers of the muscle from top to bottom at the posterior midline to permanently open the sphincter. Incision usually extends up to include some of the inferior constrictor fibers and down into the esphageal musculature.
p. 347
After cricopharyngeal myotomy, patients can generally begine to eat within __ ____ after the myotomy.
1 week
p. 347
Improvment rate of cricopharyngeal myotomy has been reported as __% to ___%. Success rate raises when patients are selected based on a predominant problem of _____________; patient is able to move the material through the oral and pharyngeal stages up to the _________, and the patient must be able to __________ ______ the airway during the swallow.
60% to 78% (p. 347)
Cricopharyngeal muscle dysfunction; cricopharyngeal region; voluntarily close
Historical use of cricopharyngeal myotomy
Has been used for swallowing disorders in those with PD, amyotrophic lateral sclerosis and occulopharyngeal dystrophy. (p. 348)
Cricopharyngeal myotomy - population appropriate for
Pts w/ cricopharyngeal dysfunction whose muscular portion of the UES is in spasm and does't allow the larynx to move up and forward. Small proportion of patients. p. 348
Cricopharyngeal dysfunction - tx for reduced anterior superior laryngeal movement
Many pts w/ CP dysfunction due to difficulty w/ anterior superior laryngeal movement component of CP opening, but normally relaxing CP muscle. Exercise programs to improve laryngeal movement, not myotomy, should be used (p. 348).
Cricopharyngeal myotomy - populations in recovery that should NOT receive a myotomy
Stroke, head injury or spinal cord injury, as most of these patients recover well (p. 348). MAY consider after 6 months with no improvement.
Cricopharyngeal myotomy and pts undergoing supraglottic laryngectomy or tongue base resection.
Has been performed as prophylactic (prevention) tx to potentially improve swallowing. Studies have shown that myotomy at time of surgery does not improve postoperative swallowing in these populations (p. 348).
Cricopharyngeal and Mendelsohn Maneuver
Some pts must use the mendelsohn maneuver or postural assist to benefit from the myotomy. Asked to turn head towards unoperatied side, directing material through the pyriform sinus on the operated/more open side. May need to use this in combo w/ the Mendelsohn (p. 349)
Poor candidates for CP myotomy
Pts w/ multiple dysfunctions in the vocal tract, including reduced lingual control, delayed pharyngeal swallow or reduced pharyngeal contraction in addition to CP dysfunction (p. 349).
Delayed Pharyngeal Swallow + CP dysfunction: Good candidate for myotomy (Yes or No)
No, b/c if pharyngeal swallow doesn't trigger, larynx will stay open to receive material that drains over base of tongue into pharynx. Complications could include hemmorhage, RLN damage, complications to surgery (p. 349)
Medical Tx: Botulinum Toxin Injection
Injection into the cricopharyngeal muscle reported to significantly improve swallowing in 1 case study. BUT difficulty in accurately placing the injection b/c the CP muscle is hidden behind the cricoid, and inaccurate injection could paralyze other muscles in the area (p. 349).
Procedures to Control Unremitting Aspiration (6)
1) Epiglottic pull-down, 2) Suturing vf's together, 3) Suturing false vf's together, 4) Laryngeal bypass, 5) Tracheostomy, 6) Total Laryngectomy. None should be done until adequate trial of swallowing tx done, as most require a tracheotomy and significantly change voice production (p. 349)
Epiglottic Pull-Down (To control unremitting aspiration)
Most common version includes making an incision arnd. the epiglottis, aryepiglottic folds, arytenoids and interarytenoid area and suturing the epiglottos tp the arytenoids. Porentially reversible. Epiglottis may pull away from attachment, making procedure unsuccessful (p. 349)
Suturing the VF's together (To control unremitting aspiration)
Usually involves stripping the epithelium from the vf's and suturing them together. Nonreversible. VF's often tear apart, making procedure unsuccessful (p. 350).
Suturing the False VF's together (To control unremitting aspiration)
Involves stripping epithelium from the false vf's and suturing them together. Reversible, false vf's less apt than true vf's to tear apart (p. 350).
Laryngeal Bypass/Tracheoesophageal Diversion (To control unremitting aspiration)
Involves seperating the air & food passages by cutting the trachea at the 3rd or 4th tracheal ring and suturing the proximal end into the esophagus w/ distal end bent forward and brought to the skin, where an opening is made. Relatively permanent (p. 350).
Tracheostomy (To control unremitting aspiration)
To prevent aspiration, a cuffed tracheostomy tube is used w/ the cuff inflated. However, still leakage around the cuff & cuff inflation can irritate the trachea (p. 350).
Total Laryngectomy (To control unremitting aspiration)
Involves removal of the hyoid bone & entire larynx. Tracheal stump bent forward & sutured to neck skin to form a tracheostoma. Permanent, results in complete seperation of eating and respiratory tracts. Should not be used unless no other solution for the aspiration. Usually used in pt's who have undergone partial laryngectomy and can't relearn to swallow (p. 350).
Techniques for nonoral feeding for patients unable to thake nutrition & hydration by mouth(5)
1) Nasogastric feeding, 2) Pharyngostomy, 3)Esophagostomy, 4)Percutaneous or surgical gastrostomy, 5) Percutaneous or surgical jejunostomy (p. 350).
Reflux and nonoral feeding
All of the procedures have a higher rate of GERD than oral feeding, but can be kept to a minimum w/ care (p. 351).
Nonoral feeding procedures - temporary or permanent
TEMPORARY. Many pts and families don't understand that they are temporary or can be. Should communicate this to them (p. 351).
Nonoral feeding procedures - counseling of pt and family
Counsel regarding the nature of the nonoral feeding recommended and what it will provide the pt (good nutrition and hydration)rather than focusing on loss of oral feeding (p. 351).
Nasogastric Feeding (Nonoral)- process
Uses a tube placed through the nose, pharynx & esophagus into the stomach. Tube varies in diameter, narrow preferred to create minimal irritation in pharynx as the tube passes through the CP junctiure. Food passes through the tube into the stomach (p. 351).
Nasogastric Feeding (Nonoral)- feedings per day
Vary. But, each feeding usually followed by 120-240 cc of water to cleanse the tube & provide proper hydration. Pt should be kept upright for 1 hr. after meal to reduce risk of GERD (p. 351).
Nasogastric Feeding (Nonoral)- disadvantages
Physical presence in nose, pharynx & esophagus; potential for reflux from the stomach up the esophagus and into the pharynx; feedings usally consist of prepared liquids (expensive), p. 351.
Nasogastric Feeding (Nonoral)-Dobhoff tube
Designed to reduce potention for reflux & aspiration by extending into the jejunum. Small diameter and creates less irritation in nose & pharynx (p. 252)
Nasogastric Feeding (Nonoral)-Changes in swallowing
No data showing swallowing changes resulting from the presence of a nasogastric tube. More studies needed (p. 253).
Nasogastric Feeding (Nonoral)-Temporary or permanent
Usually temporaty solution to problems w/ oral feeding, replaced w/ more permanent procedure after 3-4 months if pt remains dysphagic. Some pts have tube in place for 5-6 months or longer (can be taught to place tube for each meal and remove after feeding), p. 352
Pharyngostomy (nonoral feeding)
Creation of a hole/stoma from the skin into the pharynx, through which a tube is placed into the esophagus and then the stomach (p. 352)
Pharyngostomy & Esophagy(Nonoral)- Advantage over nasogastric tube
Eliminates tube through the nose (irritating and less socially acceptable), p. 352.
Pharyngostomy & Esophagy(Nonoral)-Disadvantage compared to nasogastric tube
Creation of a hole that may need to be closed surgically and may create pharyngeal scarring. Some head & neck cancer pt's develop a pharyngostomy spontaneously.
Esophagostomy(nonoral feeding)
Hole from the skin into the cervical esophagus and stomach.
p. 352
Gastrostomy (nonoral feeding)- general vs. local anesthetic
Can be performed as general surgical procedure w/ general anesthetic or can be done percutaneously under local anesthetic with an endocope.
p. 352
PEG
Percutaneous endocopic gastrostomy, the procedure where it is done percutaneously under local anesthetic with an endocope.
p. 352
Gastrostomy or PEG (nonoral feeding) - procedure
Either procedure creates an external opening in the abdomen leading to the stomach. Pt wears a light dressing on the opening,designed to close in sphinteric fashion around a soft tube.
p. 352
Gastrostomy or PEG (nonoral feeding) - feeding
Food is passed through the tube directly into the stomach. Pt can take blenderized table food.
p. 352
Gastrostomy or PEG (nonoral feeding) - long term or short term?
Considered long-term solution to severe swallowing disorder b/c it removes the risk of nasal and pharyngeal irritation that may result from a nasogastric tube. Can be reversible if pt regains ability to eat orally.
p. 353
Gastrostomy or PEG (nonoral feeding) - disadvantages
Stoma site can leak, become infected, sore, or uncomfortable.
p. 353
Jejunostomy (nonoral feeding)
External opening is created on the abdominal wall that leads into the jejunum.
p. 354
Jejunostomy (nonoral feeding) - general or local anesthetic
Can be performed under general or under local if an endoscope is used with a percutaneous approach (PEJ)
p. 354
Jejunostomy (nonoral feeding) - feedings
B/c the jejunum enters the digestive tract below the stomach, a jejunostomy of either type requires prepared feedings (expensive).
p. 354
Jejunostomy (nonoral feeding) - reasons for placement
Often placed to reduce risk of reflux (which can still occur, even when fed through jejunostomy).
p. 353
Fundoplication - Antireflux surgery: Reasons for procedure
Often done in children w/ a gastrostomy or jejunostomy or adults who receive these nonoral feedings and have a hx of reflux.
p. 354
Fundoplication (Antireflux surgery): Procedure
General surgical procedure that involves twisting the top of the stomach around the LES to reinforce it and thereby reduce reflux. IF wrapped too tight, may have problems getting food into the stomach.
p. 354
Implementation of Nonoral Feeding Procedure: Criteria
1) Should satisfy a pt's nutritional and hydration needs; 2)Any pt who(a)aspirates more than 10% of all food consistencies despite therapy or (b)is taking longer than 10 seconds to swallow a single bolus of all types of food, regardless of consistency, are candidates for nonoral feeding at least to supplement nutritional intake.
p. 354
Nonoral feeding: If pt's swallowing disorder is thought to be short term (1 month or less) a ______________ is the treatment of choice.
Nasogastric tube
p. 354
Nonoral feeding: If swallowing rehabilitation is anticipated to take more than 1 month, a _________ may be appropriate.
PEG. PEG appropriate in this instance unless pt can be taught to place the nasogastric tube for each meal and remove it between meals. In some facilities, PEG's used even for short-term dysphagia.
p. 354
Medications to improve nonoral feeding
None exist at this time. But, pts on meds for PD, myasthenia gravis or multiple sclerosis may gain improved swallowing when put on medications for their disease.
p. 354
Reasons for multidisciplinary assessments - correct diagnosis
In many cases, pts have been seen by a variety of allied health professionals who have been unable to define the reason for the dysphagia, usually b/c the physiology of oropharyngeal swallow hasn't been assessed in detail. Pt's are sometimes treated for psychological illnesses when in fact they have a physiologic disorder. Pt should have detailed swallowing assessment and a complete eval by a multidisciplinary team to rule out physiologic causes before diagnosed with a psychological problem.
p. 368
Reasons for multidisciplinary assessments - complexity of management
Although the majority of dysphagia pt's have a known etiology for their problem (stroke, head injury, head/neck cancer), many have oropharyngeal & esophageal disorders that require input from both the swallowing therapist and the gastroenterologist.
p. 368
Populations at high risk for oropharyngeal and esophageal disorders
Those over age 60 and children w/ congenital neurologic impairment.
p. 368
Professions included on multidisciplinary team: Initial intake and eval
Performed by Swallowing Therapist (usually SLP). Involve hx of symptoms & progression of swallowing complaints, detailed medical hx &oropharyngeal motor eval.
p. 368
Professions included on multidisciplinary team: Oropharyngeal radiographic exam
Swallowing therapist & radiologist. Involves MBS.
p. 368
Professions included on multidisciplinary team: Gastroenterologist (if needed)
Esophageal assessment
p. 368
Professions included on multidisciplinary team: Neurologist (if needed)
Neurologic eval focusing on the CN's innervating swallow-related muscles & on symptomology for neurologic diseases that may present w/ dysphagia symptoms (PD, motor neuron disease, myasthenia gravis)
p. 368
Professions included on multidisciplinary team: Otolaryngologist (if needed)
Structural eval of the head and neck, as well as sensorimotor assessment of pharynx & larynx.
p. 368
Professions included on multidisciplinary team: Pulmonologist (if needed)
Hx of recurrent or recent pneumonia or other recurrent pulmonary problems.
p. 368
Professions included on multidisciplinary team: Physiatrist (physical medicine physician)
Pts in rehab center, assessment key to fitting the dysphagia rehab plan into the pt's overal rehab schedule
p. 368
Professions included on multidisciplinary team: Gerontologist
If pt. is over 80 years old, helpful in assuring that realistic goals are set for the pt and determining if the pt's meds may be contributing to dysphagia.
p. 369
Professions included on multidisciplinary team: Maxillofacial Prosthodontist
Shld be available for pt's w/ impaired tongue function needing prosthetic intervention or postoperative surgical defects requiring obturation.
p. 369
Professions included on multidisciplinary team: General Dentist
May be helpful for refitting dentures.
p. 369
Professions included on multidisciplinary team: Pharmacist
Provide info. on potential drug interaction effects on swallowing (drugs that cause dry mouth or xerostomia, which can contribute to difficulty in initiating the oral & pharyngeal stages of swallow).
p. 369
Professions included on multidisciplinary team: Occupational Therapist
Can provide assistive devices for eating, as well as direct therapy for arm and hand control for food placement in mouth.
p. 369
Professions included on multidisciplinary team: Physical Therapist
Can assist in establishing optimal positioning for the pt. during meals.
p. 369
Professions included on multidisciplinary team: PT & OT
In some settings, they serve as the swallowing therapists, providing eval and tx.
p. 369
Professions included on multidisciplinary team: Dietician
Dietary evaluation of the pt through blood chemistries, wieght monitoring, and calorie counts.
p. 369
Professions included on multidisciplinary team: Communication between swallowing therapist & dietician
Regular communication is essential, as the pt progresses from nonoral nutrition to some oral intake on food consistencies best tolerated to full oral intake. During these transitions, dietician must monitor daily oral calorie intake and decrease pt's nonoral intake accordingly.
p. 369
Professions included on multidisciplinary team: Decision as to when pt can safely take adequate intake orally and discontinue nonoral intake.
Decided by swallowing therapist, physician and dietician
p. 369
Professions included on multidisciplinary team: Respiratory Therapy and Nursing staff
Can be critical to early identification of pt's w/ dysphagia in the inpatient setting (they see the symptoms). Inservices should be held to provide them info abt. signs & symptoms of dysphagia.
p. 369
Professions included on multidisciplinary team: Feeders
Feed pt's who can't feed themselves. Pt can begin to aspirate if fed too much too quickly. Feeders should be under supervision of the swallowing therapist and follow feeding instructions w/o deviation. Must check pt's tray to make sure correct foods are presented & the food is w/in the pt's visual field, and must discontinue feeding and notify swallowing therapist if any signs of distress shown during a meal.
p. 370
Professions included on multidisciplinary team: Inservice for Feeding Staff
Swallowing Therapist should provide training re. the complexity of normal swallowing physiology, range of swallowing disorders and need for individualized feeding plans for each patiet.
p. 370
Professions included on multidisciplinary team: Points to emphasize to feeding staff
Each pt's feeding must be individualized, the swallowing therapist will provide the feeding staff with each pt's specific feeding protocol and will serve as a consultant as needed.
p. 370
Multidisciplinary management: Establishing the Radiographic procedure
To initiate, swallowing therapist should be knowledgeable in the radiographic symptoms of the various anatomic and physiologic disorders of oropharyngeal deglutition. Shld meet w/ chief of radiology to discuss establishing the radiographic procedure in which both the swallowing therapist & radiologist participate and write a single report.
p. 370
Multidisciplinary management: Establishing the Radiographic procedure - Meeting with chief of radiology
Swallowing therapist should be prepared to discuss the necessary radiographic procedure, the rationale for all aspects of the procedure, and the ways it differs from the standard barium swallow of upper gastointestinal exam.
p. 370
Multidisciplinary management: Establishing the Radiographic procedure - setting cost
Once procedure has been agreed upon, cost should be established. Most of the time 3 fees charged: Room fee for use of the equipment, radiologist's fee and swallowing therapist's fee. These fees should be discussed with the administrator of the institution (as should the establishment of the new procedure).
p. 370
Model of Communication Between Team Members
Weekly face-to-face meetings, phone conversations, e-mail. Method of communication less important than the quality - must respect each other's expertise & communicate quickly & easily w/ each other.
p. 370
Efficacy of Multidisciplinary Rehab for Dysphagia
In the context of specific medical problems & management, only a small amnt of data support the efficacy of multidisciplinary intervention from the perspective of establishing reduced rates of pneumonia & improved nutrition/hydration.
p. 371
Efficacy of Multidisciplinary Rehab for Dysphagia: Cost Effectiveness
Each team must examine the cost effectiveness of operations and determine if every dysphagic pt needs to be evaluated routinely by every team member or can some pt's be seen only by some members of the team? If so, which pt's can be seen only by selected team members?
p. 371
Efficacy of Multidisciplinary Rehab for Dysphagia: Pts seen by all team members vs. select team members
Often, only dysphagic pt's w/ no known diagnosis are seen by all team members until a diagnosis is made. Pt w/ swallowing disorder of known etiology is not seen by all team members.
p. 371
Referral of Pt with dysphagia of unknown etiology
Refer first to neurologist b/c most pt's w/ dysphagia of unknown etiology have neurologic disease/damage.
p. 371
Multidisciplinary Team: Staff Education
When team established, team should offer a short, systematic educational program for other medical & allied health staff in the facility to increase awareness of swallowing problems and their symptoms and relate haow to refer pt's to the team. Types of services (diagnostic and rehabilitative) offered should be described and illustrated.
p. 372
Multidisciplinary Team: Staff Education
Usually best done w/ small meeting format, often at departmental staff meetings. Departments of internal medicine, neurology, otolaryngology and rehab medicine targeted first.
p. 372
Multidisciplinary Team: Staff Education: Info provided
Radiographic diagnostic procedure should be described, highlighting the safety of the procedure for pt's who aspirate and the value of providing accurate diagnosis of anatomic or physiologic disorder. Also briefly review therapy procedures.
p. 372
Dysphagia and Closed Head Injury
Many pts suffer severe swallowing disorders following closed head trauma or neurosurgical procedures involving the cortex or brainstem after head injury
p. 315
Most prevelent swallowing problem in head trauma and neurosurgical patients
Delayed pharyngeal swallow (also most common in stroke pts)
p. 315
Complexity of swallowing problems of pts who have suffered closed head trauma
Can be quite complex b/c of the various types of injuries pts may sustain during accident and the nature of their emergency care.
p. 315
Gaining hx of pts following closed head trauma
Critical to explore pt's hx relative to exact nature and extent of damage during the accident as well as the care provided in the first few weeks.
p. 315
Relationship of coma length and severity of swallowing problems.
Early study found that swallowing problems become more severe in pt's whose coma lasted longer.
p. 315
Neurogenic damage during head injyre can result from 3 things
direct head injury, effects of contra-coup damage (brain bouncing against opposite side) and effects of twisting on the brainstem.
p. 315
Associated potential injuries with head trauma
Cld be puncture wounds in the neck if pt landed on sharp object, laryngeal fracture if pt didn't wear a seatbelt and flew into the dashboard or penetration wounds to the chest affecting the esophagus.
p. 315
Closed Head Trauma - Placement of tracheostomy
Sometimes performed at site of injury and placed too high, creating scar tissue in larynx.
p. 316
Closed Head Trauma - Intubation
Often intubated, which can cause laryngeal damage.
p. 316
Oral disorders in pts w/ head injuries
Reduced lip closure, reduced range of tongue motion w/ poor bolus control, abnormal oral reflexes (bite reflex), delay in triggering the pharyngeal swallow or absent pharyngeal swallow.
p. 316
Neuromuscular abnormalities related to the pharyngeal stage of swallow in closed head patients
Reduced laryngeal elevation, reduced closure of airway entrance, reduced tongue base motion, reduced airway closure, reduced CP opening (generally related to reduced laryngeal motion), unilateral or bilateral pharyngeal wall paresis, tracheoesophageal fistula, and/or reduced VP closure.
p. 316
Swallowing problems generally caused by physical damage to the neck during accident in which head injury occurs
Reduced closure or larynx and reduced CP opening (relate to changes in laryngeal motion)
p. 316
Swallowing problems generally not related to neurologic damage in the closed head injury population
Airway closure disorders and cricopharyngeal disorders.
p. 316
Reconstuction of the injuries suffered in closed head injury pt's
Clinician must try to reconstruct various types of damage that could creat the pt's swallowing disorder iin order to understand their deglutition
p. 316
Characteristics in closed head injury pt's that make return to oral intake difficult (in addition to physical swallowing disorder)
Implusivity, tendency to put too much food in the mouth, cognitive difficulties (making understanding of therapy procedures/maneuvers difficult), reduced sensation (makes awareness of swallowing disorders poor)
p. 316
Pattern of swallowing recovery
Bedside study reportec taht the frequency of swallowing difficulties diminished significantly from the acute care setting through the initial and final rehab stages (pattern of consecutive improvement). But, study based only on bedside - may have underestimated those w/ swallowing disorders and overestimated recovery.
p. 316
Closed head injury pts - compliance w/ dietary recommendations
Can be difficult, esp. if the swallowing problems aren't assessed in acute care and the pt. is able to eat what they want, then later in rehab swallowind is assessed and feeding patterns changed. Families and pt's less compliant at this stage and since swallowing disorders can't be externally seen, so they don't understand the reasoning.
p. 317
Aspirationin young adult pts w/ head injuries
Can continue to aspirate, particularly on liquids, w/ no apparent pulmonary consequence. But, if continues to aspirate over a year or more and does not recover swallowing function, will usually develop pneumonia and require prolonged hospitilization.
p. 317
Counseling of head injury pt and family following radiographic study
Critical to help them understand why diet changes or other treatment strategies may be needed.
p. 317
Counseling of head injury pt and family following radiographic study - resistance to recommendations
Even w/ videofluroscopic study as an educational tool, many pts unwilling to accept rec. to avoid thin liquids or other changes since the pt shows no external signs of difficulty when eating
p. 317
Reactions of closed head pts who were young, healthy men prior to injury and are recommended to change thier diet.
Often don't comply, even with counseling. Pulmonary function generally good so they can tolerate prolonged aspiration w/o pulmonary consequences. But, if they are chronically aspirating, at higher risk for pneumonia.
p. 317
Closed head injury pts with cognitive defects
Need compensatory strategies such as postural changes and enhanced sensory input as intial tx strategies, if appropriate. Many can also cooperate w/ resistance and ROM exercises but not with swallow maneuvers. Luckily, often don't need maneuvers b/c the most frequent problems are reduced range/ccordination of tongue movement, delayed/absent pharyngeal swallow).
p. 317
Changing diet for pts with head injury
Try various viscosities in the diagnostic radiographic study to define the improvements seen in the swallow and the ability to manage particular foods. May need to restrict liquid b/c of problem w/ delayed pharyngeal swallow but allow them to eat thicker liquids and foods.
p. 318
Pts with head injury and severe dysphagia
May plateau in progress and appear to have reached maximum gains at a point where they are still unable to eat b/c they are aspirating or have very inefficient swallow. Should remain on nonoral feeding but be reassessed every 6 months to 1 year to see if any recovery has taken place (sometimes they will regain swallowing function 1-2 years later).
p. 318
Cervical Spinal Cord Injury and swallowing
May result in swallowing problems even w/ no head injury.
p. 318
Cervical Spinal Cord Injury w/o head injury - most common problems
Usually pharyngeal. May include delay in triggering pharyngeal swallow, reduced laryngeal elevation and anterior movement causing reduced CP opening, reduced tongue base motion and unilateral or bilateral pharyngeal wall dysfunction.
p. 318
Most common swallowing problems when cervical spinal cord injury occurs at cervical vertebrae 4, 5 or 6
Poor laryngeal movement and consequent reduced cricopharyngeal opening.
p. 318
Most common swallowing problems when cervical spinal cord injury occurs at cervical vertebrae 1 or 2
May have no sensory awareness of swallowing difficulty.
p. 318
Additional problems pts suffering a cervical spinal cord injury may have
Secondary to reduction in anterior laryngeal movement, may have problems closing the airway entrance or with closure at the vfs (usually related to direct laryngeal damage in the trauma or the emergency airwway management (tracheostomy or intubation) or to prolonged tracheostomy (> 6 months, which can result in reduced vf closure). Conditions may be worsened by presence of trach tube with cuff inflated, as it may restrict laryngeal elevation.
p. 318
Cervical Spinal Cord Injury Patients in cervical brace/mechanical ventilation
Especially present in acute care and if injury is at the level of cervical vertebrae 3 of above. If mechanical vent present, often also inflated cuff trach tube too to faciliate operation of the ventilator (b/c it is on positive pressure principles)
p. 319
Cervical Spinal Cord Injury Patients: Presence of mechanical ventilation and/or trach tube and bedside assessment
Makes bedside assessment more difficult b/c will have difficulty feeling any laryngeal elevation during swallow attempt and b/c of high incidence of pharyngeal stage swallowing problems in those who have suffered injury at CV 5 or above.
p. 319
Videofluroscopic study and spinal cord injury patients
Pt may not be able to elevate to complete vertical position or may be elevated only when some type of neck/chin braces is present. If can't elevate, complete in the position in which the pt is usually fed (may be 30 or 60 degrees from horizontal).
p. 319
Videofluroscopic study with spinal cord injury patients wearing a brace
If head and neck bracing in place, parts of the oral cavity or pharynx may be shadowed/covered. May need to angle wheelchari or cart to reveal all structures. Angling 15 to 30 degrees from straight line usually fine.
p. 320
Postural changes with spinal cord injury patients wearing a brace
Usually not possible b/c of brace. Sensory enhancement tx and swallow maneuvers often most helpful.
p. 320
Spinal Cord Injury Patients - Cervical Bracing
Effects of brace have not been fully defined. Many pts report worsening of swallow when placed in a SOMI or halo brace but no studies have investigated.
p. 320
ASHA 1992 study on effects of SOMI brace.
All subjects felt swallowing was less comfortable when wearing brace but only 1 measure of swallowing (duration of airway closure was prolonged w/ brace) changed significanty w/ brace. Cld have resulted from pt's trying to protect themselves.
p. 320
Effects of bracing on swallowing
ASHA study suggests no negative effects of bracing on oropharyngeal swallow, but pts w/ cervical spinal cord injury may react differently than normal young adults used in the study. More research needed.
p. 320
Brace positioning and swallowing difficulty
Generally, if braced with the chin pulled back and the chin or head retracted on the neck or head is extended, pts have greater complaints of swallowing difficulty.
p. 321
Spinal Cord Injury - Anterior Cervical Fusion: Process
Pts w/ cervical injuries, degenerative disc disease, etc. may have cervial fusion to stabilize their cervical vertebrae. Can be anterior or posterior fusion. May have significant amnt of hardware implanted in and between the vertebrae.
p. 321
Spinal Cord Injury - Anterior Cervical Fusion: Post-Op Swallowing Problems (Physiologic)
Swelling in posterior pharyngeal wall often seen, contributing to dysphagia. Also usually exhibit reduced laryngeal elevation and airway movement, w/ consequent reduced closure of the airway entrance and reduced CP opening. Reduced unilateral or bilateral pharyngeal wall movement common, as well as oral stage problems and a delay in triggering the pharyngeal swallow
p. 321
Spinal Cord Injury - Anterior Cervical Fusion: Reasons for Post-Op Swallowing Problems (Physiologic)
May occur for a variety of reasons, including trauma to peripheral nerves, pharyngeal swelling and reaction to hardware in neck.
p. 322
Spinal Cord Injury - Anterior Cervical Fusion: Recovery of Swallowing
Generally have significant recovery of swallowing w/in 3 months post-op. Duration of recovery generally reflects the number of complications.
p. 322
Spinal Cord Injury - Anterior Cervical Fusion: Strategies most helpful
Generally swallowing maneuvers, particularly Mendelsohn and supraglottic or super-supraglottic swallow.
p. 322
Neurosurgical procedures affecting the medulla
Often result in signficant swallowing problems, sometimes complete inability to trigger the pharyngeal swallow. Could have oral tongue, tongue base and laryngeal struggling motions but no true pharyngeal swallow.
p. 322
Neurosurgical procedures affecting the medulla: Treatment
Use thermal-tactile stim and suck-swallow to heighten stimulation to the CNS in an attempt to lower the threshold of the swallowing center and enable a trigger of the pharyngeal swallow.
p. 322
Surgical removal of an acoustic neuroma/tumor from a cranial nerve
May exhibit unilateral damge to CN's IX, X, XII and possibly VII. May occur from surgical trauma or from actual cutting of the nerves in order to remove tumor. Extent of damage depends on size of the acoustic neuroma/tumor and difficulty of resection
p. 322
Surgical removal of an acoustic neuroma/tumor from a cranial nerve: Symptoms
1 or more of the following: Unilateral facial weakness, unilateral pharyngeal wall paresis/paralysis, unilateral vf adductor paralysis, unilateral soft palate weakness and unilateral tongue paresis.
p. 322
Surgical removal of an acoustic neuroma/tumor from a cranial nerve: Damage to CN IX
Often a delay in triggering the pharyngeal swallow
p. 322
Surgical removal of an acoustic neuroma/tumor from a cranial nerve: Helpful Postural Strategies
B/c unilateral, benefit from head rotation to damaged side and chin-down to improve airway protection and help prevent aspiration b/c of delayed pharyngeal swallow.
p. 322
Surgical removal of an acoustic neuroma/tumor from a cranial nerve: ROM and resistance exercises
Often benefit from agressive ROM/resistance exercises for lips, oral tongue, tongue base and larynx. Include the falsetto and effortful swallow for laryngeal elevation, super-supraglottic of super-supraglottic breath-hold. Can practice 1- times/day for 5 minutes each time.
p. 323
Poliomyelitis - Oral stage swallowing problems
Reduced lingual control of bolus in chewing, disturbed pattern of lingual bolus propulsion during oral stage.
p. 323
Poliomyelitis - Pharyngeal stage swallowing problems
Reduced pharyngeal contraction, reduced VP closure during swallow causing nasal regurgitation, unilateral pharyngeal paralysis.
p. 323
Guillain-Barre
Viral based disease causing rapid onset of paresis which may progess to complete paralysis requiting trachestomy and mechanical ventilation. General weaknss and paralysis generally begin w/in 1-2 days after swallowing problem noticed.
p. 323
Guillain-Barre - radiographic study
Usually reveals generalized weakness in oral and pharyngeal swallow, resulting in reduced ROM of oral tongue, tongue base and larynx.
p. 323
Guillain-Barre - progressive paralysis and recovery
Progressive paralysis is rapid, revoery can be very slow, over months or years.
p. 323
Guillain-Barre - respiration and swallowing therapy
Respiration often unstable for a period of time in these pts, so swallowing therapy that affects duration of airway closure (maneuvers) should not be used until respiratory control has stabalized. Cuff deflation shouldn'e be done w/o medical approval.
p. 323
Guillain-Barre: Swallowing therapy
Begin w/ gentle ROM and resistance exercises, increasing effort as patient improves. When respiratory control has stabilized, may benefit from supraglottic swallow and Mendelsohn maneuver.
p. 323
Occassionally, the first sign of ______________ is swallowing difficulty.
Guillain-Barre
p. 323
Cerebral Palsy - oral dysfunction
Varies widely. May have inappropriate oral reflexive behaviors, inability to hold material in cohesive bolus (esp. if has to be chewed), and/or disorganized lingual movements that don't contribute to smooth peristaltic action of the tongue in moving material posteriorly.
p. 324
Cerebral Palsy - results of oral dysfunction
Often, as chewing, particles of food may break away and spread throughout the oral cavity. May fall in pharynx and open airway. Rarely does this trigger the pharyngealk swallow b/c the voluntary oral phase of swallow hasn't been initiated.
p. 324
3 categories of kids with Cerebral Palsy (based on study at NU)
1)Moderate to severe oral function problems, including reduced lip closure & tongue thrust and reduced tongue coordination, 2)The same moderate to severe oral problems as 1, but also w/ a delay in the pharyngeal swallow, 3) Moderate to severe oromotor problems, pharyngeal delay and neuromuscular abnormalities in pharyngeal swallow (reduced tongue base retraction & reduced laryngeal elevation, resulting in residue in pharynx after the swallow and increased risk of aspiration after the swallow). Many of these pt's aspirate on every food consistency.
p. 324
Most common problems w/ kids with Cerebral Palsy (based on NU study)
1)Moderate to severe oral function problems, including reduced lip closure & tongue thrust and reduced tongue coordination, as well as a delay in the pharyngeal swallow
p. 324
Most common swallowing problems w/ kids with spastic quadriplegia(based on NU study)
Range of oral problems including tongue thrust, poor lateralization of the tongue, discoordinated front-to-back tongue movement and delayed pharyngeal swallow.
p. 324
Problems with certain consistencies for kids w/ Cerebral Palsy exhibiting delayed pharyngeal swallow, reduced lip closure and tongue thrust and reduced tongue coordination
Have problems w/ food requiring chewing b/c of oromotor diff. and with liquids b/c of pharyngeal delay. Syringe feeding/dumping liquids not appropriate.
p. 324
Management strategies for kids w/ Cerebral Palsy exhibiting delayed pharyngeal swallow, reduced lip closure and tongue thrust and reduced tongue coordination
Oromotor therapy, thermal-tactile stim of the pharyngeal swallow, diet change (thickened liquid and purees). Diet change should be the last choice b/c it is less appealing.
p. 325
Cricopharyngeal dysfunction or abnormal opening of the UES is ______ a problem in those w/ cerebral palsy.
Rarely. Cricopharyngeal myotomy should be delayed b/c as child grows the laryngeal position lowers and opening of the UES may normalize.
p. 325
Aspiration in kids with cerebral palsy generally occurs ______ the swallow.
Before or after, usually b/c of reduced tongue control for chewing or b/c of delayed pharyngeal swallow (both cause aspiration before) or b/c of poor tongue base action or laryngeal elevation resulting in residue in pharynx after the swallow.
p. 325
Is aspiration during the swallow common in those with cerebral palsy?
No, b/c laryngeal closure is usually adequate.
p. 325
Therapy for those with severe developmental delay and cerebral palsy
Some evidence they may need chronic therapy (thermal-tactile stim) to maintain function. Should define optimal therapy fro caregivers.
p. 325
Dysautonomia (Riley-Day Syndrome)
Inherited, widespread effects including autonomic imbalance, sensory deficits, motor incoordination, episodic phenomena.
p. 325
Dysautonomia (Riley-Day Syndrome)- mild swallowing problems
Some exhibit only mild disturbances with the oropharyngeal swallow, possibly mild reduction in oral tongut coordination of the bolus and reduced tongue base and pharyngeal wall contraction.
p. 325
Dysautonomia (Riley-Day Syndrome)- severe swallowing problems
Some children demonstrate more severe oral involvement and a delay in triggering the pharyngeal swallow sufficient that they can't handle liquids safely and thus receive a gastrostomy for liquid intake. Usually also have dysfunctional LES, allowing reflux, especially on thin liquids (Adding to reason for gastrostomy). Reduced tongue base action and reduced pharyngeal contraction can also be a problem and sometimes difficulty opening the CP sphincter. Manometry has also revealed abnormal esophageal motility.
p. 325
Dysautonomia (Riley-Day Syndrome)- Treatment for severe swallowing problems
Oromotor exercises to improve oral tongue function and thermal-tactile stimulation to improve triggering of pharyngeal swallow.
p. 326
Treatment of malignant tumors of the oral cavity
Surgical resection or radiotherapy w/ or w/o chemotherapy, or a combo of the two with chemotherapy. Selection of tx depends on the exact site and extent of the tumor. All of the tx's can cause deglutition problems.
p. 251
General treatment for smaller oral cavity tumors
Frequently treated w/ radiotherapy alone or surgery alone. Radiation tx in the oral cavity may be by implant into the gross tumor, external beam methods, or both. Chemo may be given concurrent with or following.
p. 251
General treatment for larger oral cavity tumors
Positioned more posteriorly in the oral cavity and may be treated w/ combined methods - surgical resection and radiotherapy or radiotherapy w/ or w/o chemo as an organ preservation protocol.
p. 251
Organ preservation protocal
Designed in an attempt to reduce morbidity (functional impact of tumor tx) by preserving the pt's oropharyngeal structures and function.
p. 251
Adjuvant experimental treatment - chemo
Chemotherapy for head and neck cancer patients. It is designed to attempt to control regional and metastatic disease rather than a primary tx desinged to eradicate the tumor.
p. 251
Tumor shrinkage w/ chemotherapy
Many pts have shrinkage during or immediately after chemo, but of short duration.
p. 251
Adjuvant experimental treatment - radiation
For larget tumors, when both surgery and radiation are used, radiation is considered as the adjuvant tx, designed to control disease w/in the region of the tumor whereas surgery is designed to eradicate the tumor itself.
p. 252
Rule when surgery is used to control tumors in the oral cavity
The malignant tumor must be resected along with at least 1.5 to 2 cm of normal tissue (results in large surgery for small lesion).
p. 252
Structures often removed in resection of tumors in the oral cavity
Often requires removal of more than one structure of parts of more than 1 structure, such as mandible, floor of mouth and tongue.
p. 252
Simple resection
When only 1 structure is resected during surgery.
p. 252
Composite resection
When more than 1 structure or parts of more than 1 structure are included in resection. In the oral cavity, usually includes some part of floor of mouth and mandible.
p. 252
1 Major Rule of Cancer Surgery
No ablative surgery procedure should be compromised b/c of the desire to maintain pt's function. Rehab and reconstruction can't be considered until the cancer is removed with normal margins.
p. 252
Reconstruction to maximize functional capacity
Surgeon can attend to this once the tumor and required margin of tissue have been resected. Sometimes sufficient tissue remains or can be borrowed from another site for reconstruction.
p. 252
Radiotherapy in addition to surgery - Timing
Usually given postoperatively b/c it tends to devascularize tissue and make healing after surgery more difficult.
p. 252
Radiotherapy in addition to surgery - Course
Full course lasts 5-6 weeks to a dose of 6,000 to 7,000 cGy. The exposed field usually includes all of the regional lymph nodes. Often initiated 4-6 weeks after surgery to give time to heal.
p. 252
Optimal time to initiate radiotherapy
4-6 weeks after surgery, b/c gives time to heal and malignant cells that may have been released during surgery will be at their weakest.
p. 252
Pretreatment (radiotherapy) Dental Assessment
Must assess careful dental eval b/c if pt. enters radiotherapy w/ poor oral hygiene and dental disease, can worsen after radiotherapy b/c of reduced salivary flow.
p. 252
Infected teeth and radiotherapy
Any infected teeth should be removed prior as extractions after can put pt at risk for osteoradionecrosis of the mandible.
p. 253
Osteoradionecrosis of the mandible
Portions of the mandible become infected and gradually break from the main body of the mandible to extrude or protrude through the soft tissue, making removal of infected portions necessary. Difficult condition to manage.
p. 253
Tumor staging
Stages according to size and location, generally conducted by the attending physician and permits comparisons of the results of various tx's across pt's w/ the same tumor.
p. 253
Tumor staging - why?
Provides standard comparison of tumor reaction to treatment.
p. 253
Tumor staging - process
Divided into 8 sites, staged according to T (tumor size), N (nodal status) and M (presence or absence of metastasis.
p. 253
Tumor staging - TNM
T1 smallest size, T4 largest. Metastasis to the nodes is noted by recording an N followed by the # of nodes thought to be involved in the tumor. M indicates presence of metastasis of the tumor outside of the region and is followed by a number indicationg the # of distant metastases (in an areas other than the head and neck, such as the brain or lung).
p. 254
Tumor Staging - Stage 1
T1 N0 M0
p. 254
Tumor Staging - Stage 2
T2 N0 M0
p. 254
Tumor Staging - Stage 3
T3 N0 M0; T1, T2 or T3 with N1 M0
p. 254
Tumor Staging - Stage 4
T4 N0 or N1, M0; any T with N2/N3 and MO, any T with any N and M1
p. 254
Tumor Staging - Treatment
The larger the tumor, the more agressive the tx. T3 and T4 more frequently treated by combined therapies.
p. 254
Tumor Staging - Common tx of T3 and T4
Usually combined tx, i.e. surgery followed by radiotherapy and chemo (sometimes preoperatively continuing postoperatively).
p. 254
6 Most Common Locations of Tumors in the Oral Cavity
1. Anterior Floor Of Mouth or lower alveolar ridge in the anterior floor of mouth, 2.Tongue (anteriorly or laterally), 3. Lateral floor of mouth or lateral alveolar ridge, 4. Tonsil (btwn. pillars of fauces), 5. Base of Tongue, 6. Hard and soft palate
p. 255
Tx for small tumor located on anterior floor of mouth under the tongue or on the alveolar ridge in the anterior floor of mouth
Frequently treated by small resection including only tissues of fllor of mouth or the rim of the mandible.
p. 255
Tx for large tumor located on anterior floor of mouth under the tongue or on the alveolar ridge in the anterior floor of mouth
Composite resection including removal of floor of mouth, portion of mandible and often a portion of the tongue and a radical neck dissection on the side of the tumor.
p. 255
En Bloc resection
Tissue removed en bloc so that tissues that may contain cancerous cells are taken in continuity and cancer is not spread by the surgical procedure itself.
p. 255
Andy Gump appearance
Often results from resection of the anterior floor of mouth and a full section of the anterior mandible. Mandible is smaller and retracted in relation to the maxilla.
p. 255
Tx for small tumors in the lateral margin or anterior portion of the tongue
Can often be removed by resecting only tongue tissue.
p. 255
Tx for large tumors in the lateral margin or anterior portion of the tongue
May be treated w/ a simple resection of part of all of the tongue (total glossectomy). Composite resected may be needed if tumors are close to or involve adjacent tissues. Alveolar ridge and larger portion of the mandible and floor of mouth and radical neck dissection on the side of the tumor needed.
p. 256
Radical neck dissection
Removes submandibular lymph nodes, lymph nodes in the neck and the sternocleidomastoid and omohyoid muscles. Spinal accessory nerve (CN 11) may also be sacrificed, but not generally.
p. 256
Tx for small tumor of lateral floor of mouth
Wide local excision, including only tissues of the floor of mouth.
p. 257
Tx for large tumor of lateral floor of mouth
Removal of part of floor of mouth and portion of lateral mandible adjacent to the tumor and part of the tongue, as well as radical neck dissection on the side of the tumor. Mandible may be spared if it does not have a tumor by splitting it verically and swinging it out of the way for the resection, then wiring it back in place.
p. 257
Tx for tumor in tonsil or base of tongue
Classified as w/in oropharyngeal region. Require composite resection, including removal of the tonsilar area, portion of base of tongue and portion of lateral mandible w/ radical neck dissection.
p. 259
Tx for tumor in tonsil or base of tongue that spreads up to faucial arches
Require composite resection, including removal of the tonsilar area, portion of base of tongue and portion of lateral mandible w/ radical neck dissection, as well as potentially a portion of the soft palate and pharyngeal wall.
p. 259
Tx for small tumor on the hard palate or soft palate
May require only partial resection of the maxilla or soft palate
p. 259
Tx for large tumor on the hard palate or soft palate
May require total removal of the hard palate or soft palate
p. 259
Rehab: Complete removal of soft palate vs. partial removal
Easier with total removal b/c prosthodontist can more easily develop a prosthesis that adequately occludes the VP port when no scar tissue is present than when a portion of the soft palate is scarred/immobile.
p. 260
Reconstruction for relatively small tissue resection
Wound may be closed w/ primary closure (soft tissues remaining are pulled together and sutured).
p. 260
Reconstruction of tongue and soft palate w/ small tissed resection
Often primary closure b/c the tongue is composed of viable muscle that can be easily closed upon itself and remaining tissues in the soft palate can be easier pulled together (?)
p. 260
Primary closure
When the soft tissues remaining after a resection are pulled together and sutured.
p. 260
Contraindications to primary closure
When resection of tissue is so large there isn't sufficient tissue remaining or, if primary closure was accomplished, the natural tension/pull of the tissue after closure would be strong enough to separate the tissues, create a fistula or reopen the wound.
p. 260
Closure of large resection areas.
Flap or graft. Borrow tissue from another area of the body.
p. 260
Flap - Reconstruction
Piece of tissue that has been elevated away from its normal site. One portion is left attached to its donor site to allow the flap to receive blood supply. Connecting bridge of remaining tissue permits a supply of blood to feed the flap until the portion that is sewn into the wound has an opportunity to head in place.
p. 260
Local Flap (Reconstruction)
Uses tissue in an area close to the surgical defect. Ex: If portion of anterior floor of mouth is resected along w/ portion of mandible, a tongue flap may be raised to fill the defect (w/ piece of lingual tissue filling the surgical defect but remaining attached to the tongue posteriorly).
p. 260
Distal Flap (Reconstruction)
Uses tissue in an area distant from the defect.
p. 260
Skin Flap (Reconstruction)
Consists of skin & subcutaneous tissue that is moved from one part of body to another, while an attachment is maintained btwn it and the body for nourishment. May be taken from neck, shoulder, nasolabial fold, etc. to fill a floor of mouth defect (from shoulder would be considered distal).
p. 261
Myocutaneous Flap (Reconstruction)
Used when a large amnt of tissue is needed to close a surgical gap and added bulk is needed in wound closure. Includes muscle and overlying skin. Flap is passed beneath the skin to the reconstruction site and the donor site is closed at the primary surgery (2 surgeries not needed).
p. 261
Myocutaneous Flap (Reconstruction) - muscles commonly used for reconstruction of the oral cavity
Pectoralis major, platysma and trapezius
p. 261
Reconstuction: Graft/Microvascular free tissue transfer
Microsurgical technique to transplant tissue from far distant parts of the body into the oral cavity w/ veins & arteries attached to blood supply at the site to assure viability of tissue.
p. 261
Reconstuction: Graft/Microvascular free tissue transfer
The flap is a portion of tissue entirely supplied by a specific artery and drained by a specific vein. Capable of being revascularized by microvascular techniques at a new site.
p. 262
Reconstuction: Graft/Microvascular free tissue transfer - Advantages
Donor sites for these flaps less conspicuous than conventional flaps and can be used when conventional flaps are difficult to use.
p. 262
Reconstuction: Graft/Microvascular free tissue transfer - Disadvantages
The surgical techniques are time consuming and more costly. Infection if the oral cavity after microsurgery procedures w/ subsequent loss of the graft can be a complication.
p. 263
Sensate flaps
Being attempted to improve postoperative function. Concept is to bring sensation to the region by including a nerve in the flap or graft and anastomosing a nerve from the site to the nerve in the flap or graft, thereby hopefully bringing sensation to the area. Whether this works still open to question.
p. 263
Changes experienced by oral cancer patients
Changes in salivary flow, speech and swallowing posttreatment, depending on the tx modalities used.
p. 263
Changes experienced by oral cancer patients post radiotherapy
May have changes in swallowing, mucositis and reduced salivary flow. The reduced salivary flow or intraoral sensory loss may cause swallowing disorder.
p. 264
Changes experienced by oral cancer patients post radiotherapy - specific to tongue and jaw
ROM of tongue and jaw may be reduced toward end or after the radiation (resulting from fibrosis, can be counteracted w/ ROM exercises to be completed morning and night).
p. 264
Changes experienced by oral cancer pts treated surgically.
Amount of oral tongue/tongue base resected is correlated w/ the extent of speech and swallowing impairment. Nature of the reconstruction may also impact postoperative functioning.
p. 264
Studies re. the relationship between 1)Surgical resection & reconstruction of the oral cavity and 2)Speech & swallowing changes postoperatively
Only a few done. Results point toward primary closure as providing optimal function in comparison to distal flaps. Primary closure provides the most normal oral sensory input.
p. 264
Multimodality pattern of care for advanced oral cancers
Surgery followe by full course of radiotherapy (5,000 to 7,000 cGy). Often works against pt's rehab process.
p. 264
Impact of tx on recovery from advanced oral cancers: Pattern
After surgery, pts provided w/ swallowing & speech tx to improve function. See improvement, then radiation is started 4-6 weeks postop and lasts 6 weeks. About 4 weeks in pts often have worsening of swallowing and speech problems.
p. 264
Impact of tx on recovery from advanced oral cancers: Emotions
Pt experiences function slowly improving and then beginning to deteriorate. Emotionally upsetting, pt may withdraw from rehab 3-4 months after surgical tx and receive no further rehab.
p. 264
Oral cancer pt's speech and swallowing: 3 months cancer treatment and 12 months posttreatment
Generally no better at 12 months post than 3 months post. Important that they receive regular postoperative swallowing and speech tx and throughout radiation as tolerated.
p. 264
Intervention for oral cancer pts - prosthesis
Intervention may include palatal obturator (obturates VP deficit created in posterior oral cavity resections and/or may recontour the hard palate, lowering it to interact more effectively w/ remaining tongue and its reduced ROM.
p. 264
When do patients generally benefit from palatal reshaping (reconstruction)?
When they have had 50% or more of the oral tongue resected.
p. 264
Rehab needs for the oropharyngeal cancer patient - areas typically affected by the cancer
Tongue base and/or pharyngeal wall typically affected.
p. 265
Rehab needs for the oropharyngeal cancer patient - areas involved if VP closure affected
VP closure may be impacted if the surgery involved the tongue base and lateral pharyngeal walls or the muscles extending from the pharyngeal wall to the palate (palatopharyngeus).
p. 265
Rehab for the oropharyngeal cancer patient
Should begin early postoperatively and involve exercise programs and possibly intraoral prosthetics.
p. 265
Oropharyngeal Cancer Patient - Rehab techniques
May include obturation of VP deficit and exercise programs to improve tongue base motion during swallowind (improve efficiency and safety of pharyngeal swallow).
p. 265
Oropharyngeal Cancer Patient - When to initiate rehab
Postoperative intervention is initiated when pt's suture lines have healed sufficiently to enable agressive exercies, usually 10-14 days post surgery (pt usually an outpt by now - may be difficult for older pts and those w/ less available transportation to the rehab center).
p. 265
Optimal Schedule for Rehab
1) Treatment Planning, 2) Pretreatment Counseling, 3)Schedule of Posttreatment Intervention
p. 265-66
Treatment Planning
Rehab begins w/ treatment planning, where the challenge is to identify the optimal tx strategy for tumor eradication or control while causing the least functional impact in swallowing. Best decisions made in a tumor conference.
p. 265
Members involved in treatment planning tumor conference
Radiation oncologist, medical oncologist & surgeons discuss options. Rehab specialists including SLP's, maxillofacial prosthodontist and social workers can contribute expertise on functional effects of the various tx's in light of the pt's history.
p. 266
Treatment selection - factors to consider
Consider patient characteristics and preferences (some pt's can't tolerate/afford daily trips for radiation, some can't tolerate surgery b/c of medical hx, some may have a strong preferance for a particular treatment modality
p. 266
Critical members of the treatment planning team
patient and family/significant other should be part of pretreatment planning team and consulted in the treatment decision.
p. 266
Pretreatment Counseling
Pts should get rehab counseling prior to initiation of treatment for head and neck cancer.
p. 266
Pretreatment Counseling - professionals who should be involved
Multidisciplinary rehab team, including swallowing therapist, social worker, dentist or maxillofacial prosthodontist, dietician, physician, nurses.
p. 266
Preoperative Counseling by the swallowing therapist
Includes a swallowing screening, sometimes a videofluoroscopic study to define any swallowing disorders.
p. 266
Preoperative Counseling by the dentist
Critical to identify any dental disease/ensure preservation of critical teeth that may be needed for prosthetic stabilization after treatment. Optimal prosthetic devices may not be possible if key dental units needed to stabalize a prosthesis are missing.
p. 266
Psychosocial Preoperative Counseling
May identify any existing psychosocial problems and enable the social worker to become acquainted with the pt. at a time when the pt can communicate more easily.
p. 266
Physician concerns re. pretreatment counseling
Sometimes concerned that it may scare the pt & cause him to refuse treatment. In fact, it is designed to reduce pt fears & assure them rehab professionals will be available after their treatment to improve their functional status.
p. 266
Information conveyed in pretreatment counseling.
Exact details of functional effects of treatment can't be and aren't provided. Focuses instead on informing the pt there are likely to be changes in swallowing after treatment and that rehab professionals will be available to assist.
p. 267
Patient Control of rehab
Pt must realize during treatment that he is in control and responsible for his rehab. Others will be providing exercise programs & interventions to improve function, but it is pt's responsibility to practice and follow through.
p. 267
Posttreatment Intervention: Surgical Treatment Patients - when to provide additional counseling
Provide additional counseling to pt & family 2-3 days postoperatively. Pts will likely have more ?s at this time abt the functional effects of surgery and more info. can be given about swallowing changes.
p. 267
Posttreatment Intervention: Surgical Treatment Patients - when to provide intensive rehab
When pt's healing has progressed sufficiently to enable agressive exercise (usually 1-2 weeks postop, depending on site and nature of the surgery). Will reevaluate the pt and begin intensive rehab w/ dauly inpt therapy and weekly outpt.
p. 267
Posttreatment Intervention: Surgical Treatment Patients - what to do if swallowing changes result from treatment
Pt should receive MBS to assess oropharyngeal function and evaluate the effectiveness of treatment strategies to improve the swallow as quick as possible.
p. 267
Posttreatment Intervention: Surgical Treatment Patients - Parties (besides swallowing) who should be involved
Dental status critical w/ consideration of future need for intraoral prosthesis. Pychosocial and counseling support should also be provided.
p. 267
Posttreatment Intervention: Surgical Treatment Patients - Additional party who should be involved for radical neck dissection pts
Physical Therapy assessment
p. 267
Posttreatment Intervention - Pt's first postoperative attempt at swallow
Should be measured during MBS when exact details of anatomy and physiology can be defined and treatment stratgies introduced and evaluated. Can try to eliminate aspiration through introduction of simple postural changes.
p. 267
Posttreatment Intervention - Reason for MBS at pt's first postoperative attempt at swallow
Usually facilitates the sped of recovery for head and neck cancer patients.
p. 268
Posttreatment Intervention - For pt undergoing postop radiotherapy or radiotherapy as primary treatment in combo w/ chemo
May receive rehab throughout the period of radiation and after. If side effects prevent regular rehab management, pt encouraged to continue some exercises to preserve ROM of lips, tongue, jaw, larynx and palate.
p. 268
Prospective Payment Plans and Inpatient Rehab
Pts permitted shorter and shorter stays following surgery, so often sent home w/ minimial contact from rehab team. May not be strong enough to return immediately for outpatient, could be weeks before outpt started and may coincide with postop radiotherapy and after 3-4 weeks of radiotherapy pt may suffer increasing functional impairment.
p. 268
Prospective study of 186 oral and oropharyngeal cancer pts treated surgically at 10 major medical centers
Results indicated only 50% of patients received speech and swallowing therapy and less than 10% received maxillofacial prosthetics. At 3 months posttreatment, 50% of pts were lost to follow-up.
p. 268
Early and active rehabilitation is _______ to the ___________ ____________ of head and neck cancer patient.
critical, successful functioning
p. 268
Responsibility for establishing rehab plan and educating the pt and family
Members of the rehab team, including the pt's physician
p. 269
2 most improtant pieces of info. needed by the swallowing therapist to understand the oral cancer pt's swallowing difficulties are __________________ and ___________________ (multiword answers)
1) The exact nature and extent of the resection that was necessary to totally remove the tumor and (2) the exact nature and reconstruction of the oral cavity.
p. 269
Function in pt's who have had less than 50% of their tongue resected
The nature of the reconstruction is the major determinant of the pattern of function.
p. 269
Function in pt's who have had more than 50% of their tongue resected
The extent of the resection and the nature of the reconstruction determine the functional abilities of the patient.
p. 269
First 2 pieces of info. needed before seeing a postsurgical oral cancer pt
The exact nature of the resection and the reconstruction.
p. 269
Determining the extent of surgical resection and reconstruction
Don't use labels such as "anterior floor of mouth", etc. but ask the surgeon to define, in terms of the structures involved, the exact extent.
p. 269
Swallowing Disorders in Partial Tongue Resection Disorders, when less than 50% resected and resection is limited to the tongue and reconstructed by primary closure
Relatively temporary. Initially problems occur b/c of edema or b/c tongue movement is changed.
p. 269
Swallowing Disorders in Partial Tongue Resection Disorders, when less than 50% resected and resection is limited to the tongue and reconstructed by primary closure
Often short-term difficulty in triggering the pharyngeal swallow, even in pt's whose resection was not in the tongue adjacent to the faucial arches. Also, some have sense of clumsiness with tongue.
p. 269
Treatment for Swallowing Disorders in Partial Tongue Resection Disorders, when less than 50% resected and resection is limited to the tongue and reconstructed by primary closure
Thermal Tactile Stim for delay in triggering the pharyngeal swallow, ROM tongue exercises for clumsy tongue and exercises to control the bolus. Usually effective w/in first 3-4 weeks postoperatively.
p. 269
Swallowing Disorders in Partial Tongue Resection Disorders, when >50% resected
Lingual propulsion and control of material severely reduced, as can't contact tongue segment to palate.
p. 269
Compensation for Swallowing Disorders in Partial Tongue Resection Disorders, when >50% resected
Liquid or thinned paste can often be managed by tilting the head back. May need to learn supraglottic swallow to protect airway (but if surgery was limited to tongue and pharyngeal and laryngeal aspects fine, won't need this part).
p. 269
Treatment for Swallowing Disorders in Partial Tongue Resection Disorders, when >50% resected
ROM exercies for the tongue to get max movement from the remaining tongue. Prosthesis should be considered, often allows for eating of all food consistencies except those requiring chewing (if can manipulate food to the teeth may be able to chew some softer foods like spaghetti)
p. 270
Impact of Anterior Floor of Mouth Resection on Swallowing
Oral phase impaired, pharyngeal usually normal unless floor of mouth muscles have been cut or partially resected.
p. 270
Anterior Floor of Mouth Pt who has the upper margin of the mandible and a portion of the floor of mouth removed with closure of the defect with a flap of tissue from a site other than the tongue.
Has relatively few functional changes in swallowing b/c the remaining tongue segment is mobile & the inferor rim of mandible has been left to maintain mandibular contour and lingual propulsion & contol are normal.
p. 270
Treatment for Anterior Floor of Mouth Pt who has the upper margin of the mandible and a portion of the floor of mouth removed with closure of the defect with a flap of tissue from a site other than the tongue.
Initially, place food on tongue posteriorly to speed oral transit time when there is edema. Later, can have a dental prosthesis or full lower denture.
p. 270
Swallowing probs in Pt w/ resection of upper margin of mandible and portion of floor of mouth with closure by suturing the tongue into the surgical defect
Severe difficulties w/ lingual control, bolus propulsion & mastication. B/c tongue is sutured down, anterior range of motion is reduced and ability to cup and hold material affected. Disruption of mylohyoid support for the tongue contributes significantly to these problems.
p. 270
Compensation for Pt w/ resection of upper margin of mandible and portion of floor of mouth with closure by suturing the tongue into the surgical defect
Position food more posteriorly. Restrict to liquids or pastes. Chewing impossible b/c can't lateralize the tongue & can't wear dentures b/c no alveolus as a foundation.
p. 270
Compensation for Pt w/ resection of upper margin of mandible and portion of floor of mouth with closure by suturing the tongue into the surgical defect
If tongue movement severely reduced, liquid may have to be syringed or dumped into the back of the oral cavity and pt needs to use dump and swallow or prolonged supraglottic swallow (to voluntarily protect the airway, as they may lose material over the tongue into the airway before initiating swallow).
p. 271
Effects of Composite resection including portion of anterior mandible, the anterior floor of mouth, portion of tongue and radical neck dissection
May result in a variety of swallowing disorders from mild to severe, depending on the way the defect is reconstructed, extent of resection of tongue and whether floor of mouth muscles are left intact
p. 371
Composite resection including portion of the anterior mandible, floor of mouth, portion of tongue and radical neck dissection with a flap
If tissue from a distant site, a local flap, or a tongue flap is used to accomplish closure, mobility of remaining tongue may be good enough for functional swallowing.
p. 272
Tongue Flap
Involves splitting the tongue longitudinally and using 1 small portion to close the surgical defect while leaving remaining bulk of tongue to move normally.
p. 272
Differences in swallowing transit time based on method of surgical reconstruction in pts w/ anterior floor of mouth resection
Pts w/ no tongue used in surgical closure functioned most normally, followed by pt's w/ tongue flap. Pt's whose tongue was sutured into the surgical defect functioned most poorly and were not able to handle liquids.
p. 272
Treatment for anterior floor of mouth resection pt's whose tongue is sewn into the surgical defect anteriorly
Tongue ROM exercises, positioning food more posteriorly in mouth, tilting head back during swallow and palatal reshaping prosthesis.
p. 273
Restrictions for anterior floor of mouth resection pt's whose tongue is sewn into the surgical defect anteriorly
Will be unable to handle chewing & thicker food consistencies unless tongue is surgically freed from floor of mouth and floor of mouth relined w/ other tissues such as a skin graft.
p. 273
Anterior Floor of Mouth resection pts whose floor of mouth muscles are cut or partially resected
Muscles will at least temporarily lose ability to pull hyoid and larynx up and forward to open the UES. Pts may have pharyngeal dysphagia w/ reduced laryngeal movement and residue in pyriform sinuses.
p. 273
Treatment for Anterior Floor of Mouth resection pts whose floor of mouth muscles are cut or partially resected
Falsetto, Mendelsohn maneuver to improve laryngeal movement
p. 273
Swallowing Difficulties in pts w/ lateral floor or mouth, tonsil and tongue base area resections
Both oral and pharyngeal difficulties. Oral b/c tongue & other structures are involved. Resection is in area of faucial arches & may involve portion of pharynx, so problems triggering pharyngeal swallow and w/ pharyngeal stage.
p. 273
Specific difficulties in pts w/ resection in tonsil and base of tongue area
Mild to severe disturbances in oral prep, chewing & OTT w/ impaired lingual propulsion of bolus. Material may collect in lateral sulcus or on hard palate b/c pt. can't clear due to reduced tongue ROM. Also delayed pharyngeal swallow, reduced tongue base retraction and reduced pharyngeal wall contraction b/c fibers of glossopharyngeaus are cut, causing residue in valleculae after the swallow.
p. 274
Laryngeal function in pts w/ resection in tonsil and base of tongue area
Usually normal unless a fistula has developed in healing w/ scar tissue formation in the pharynx that will inhibit laryngeal elevation. Can lead to crevice that collects material.
p. 274
UES function in pts w/ resection in tonsil and base of tongue area
Sometimes pts have difficulty opening the UES b/c of reduced laryngeal movement. Use Mendelsohn and Falsetto to help.
p. 274
Therapy for pts w/ resection in tonsil and base of tongue area
Tx to improve oral and tongue base ROM, improve triggering of pharyngeal swallow and promote voluntary airway protection of the aiway during swallowing and clearing of the pharynx after the swallow.
p. 274
Maxillary reshaping prosthesis for pts w/ resection in tonsil and base of tongue area
If pt has teeth, can be made to clip on to teeth. If edentulous, can be retained by suction. To speed oral and pharyngeal transit times and facilitate chewing.
p. 274
Edentulous
Without teeth
p. 274
Pts w/ composite resection of lateral floor of mouth, tongue and mandible w/ no teeth
Can't wear a lower denture b/c of altered anatomy.
p. 274
Effects of full course of radiotherapy to the oral cavity
Reduced saliva flow or xerostomia (dry mouth) if some or all of the salivary glands are in the fleid of radiation, as well as edema and sometimes mucositis (sores in the mouth)
p. 274
Mucositis
Sores in the mouth
p. 274
Salivary changes resulting from radiotherapy - temporary or permanent?
Permanent. Upsetting to pt's b/c there are no good, effective management strategies.
p. 274
Medications to stimulate saliva and pseudo-saliva products - effective?
Only partially. Pt's usually become dissatisfied w/ these and discontinue their use.
p. 274
Xerostomia and swallowing
Can cause reduced speed of tongue movement causing a delay in oral transit time and a change in pattern of tongue movement contributing to delay in triggering pharyngeal swallow.
p. 275
Fibrosis (result of radiotherapy)
Forms from damage to the small blood vessels in the radiated area. Changes muscle fibers to connective tissue in a process that can continue for years.
p. 275
Dentures/Prostheses and radiation
May need to discontinue wearing them during and immediately after, as the contact against the oral tissues may create irritation and open sores that will have difficulty healing b/x of reduced blood supply resulting from radiation.
p. 275
Fluoride treatments and radiation
Prior to and during radiation to the oral cavity, pt's w/ some or all of their own teeth should have regular fluoride treatments to prevent caries.
p. 275
Delay in triggering the pharyngeal swallow and radiotherapy
Sometimes experienced as a result of.
p. 275
Impact of pharynx being in radiation field (i.e. when back and base of tongue and tonsil area are the tumor site)
Reduced pharyngeal contraction, tongue base movement and laryngeal elevation. Result in residue in pharynx after swallow, often causing aspiration after the swallow. Use super-supraglottic swallow and Mendelsohn to treat.
p. 275
Timing of radiotherapy effects - immediate?
Not all. May develop increasing swallowing problems a year or more after completion of radiotherapy.
p. 275
Most frequent swallowing problems resulting from radiotherapy
Delay in triggering pharyngeal swallow, reduced contraction of the pharyngeal walls and reduced laryngeal elevation.
p. 275
ROM exercises and radiotherapy
Pts who will undergo radiotherapy to the oral cavity and/or pharynx should begin range of motion exercises for the tongue, jaw and larynx before radiotherapy begins and continue at least twice daily throughout radiotherapy and for months afterward (potentially forever to prevent fibrosis)
p. 275
General principles of swallowing therapy for oral cancer pts
1. Counsel before treatment to discuss potential swallowing problems. 2. Inform patient of their responsibility in rehab by cooperating and carrying through. 3. Begin aggressive tx (tongue & jaw ROM exercises)on surgically treated pts when surgeon indicates healing has progressed to the point where there is no danger to suture lines (abt. 10-14 days). 4. Design tx program to improve any physiologic dysfunctions noted from fluoroscopy. 5. Continue tx until swallowing has reached pt. where therapist & pt. agree maximum goals have beeb obtained (usually after 2-3 months in outpt.), 5. Develop intraoral prosthesis and work on more diff. tongue exercises to improve bolus control, if needed, 6. For pts, such as 75% tongue resection & partial mandibulectomy, consider restriction to liquids & soft foods. 7. Determine ultimate functional outcome several months post-op and discuss w/ members of team.
p. 276
Maximum rehab goals in head neck cancer patients - how to attain
With team, including nursing, SLP/swallowing therapist, social worker, dentist and maxillofacial prosthodontist.
p. 277
What professionals usually follow pt most intensively after hospital discharge to define maximum obtainable functional goals?
Social worker, SLP, maxillofacial prosthodontist.
p. 277
Changes in swallowing rehab in laryngeal cancer pts
In the past, only initiated when pt. complained of functional impairment. Today, potential effects of treatment consideed as part of treatment planning & selection. Began in '50s when partial laryngectomy procedures were introduced as alternative to total laryngectomy.
p. 281
Organ Preservation Protocols
Recent development. Driven by consideration of potential functional losses prior to treatment.
p. 281
Types of Organ Preservation Protocols
High-dose chemo and radiation as alternatives to total laryngectomy in pt's w/ advanced laryngeal cancer.
p. 281
Weiss quite re. importance of considering pt's functional status when planning treatment
Larynx preservatiion protocol hard on pt, may not end out effective and many laryngectomees are rehabbed well. He shares this info. w/ pts and it rarely keeps them from choosing larynx preservation option. Pt's perception of QOL drives the decision. Their QOL should matter just as much to the team.
p. 282
Exact nature of the treatment modality dictates...
the functional impairments the head and neck cancer patient will suffer posttreatment.
p. 282
Tumor management in larynx - larger tumors
Primarily radiotherapy and/or surgery, with chemo as adjuvant treatment.
p. 282
Tumor management in larynx - for smaller tumors ____________ is typically the tx of choice, particularly when tumor on the true vocal fold.
Radiotherapy
p. 282
Staging of tumors in the larynx
TNM system (tumor-node-metastasis)
p. 282
Division of larynx for purpose of staging
Divided into 3 areas: Supraglottic, glottis and subglottis
p. 282
Approximately ___ of malignant laryngeal tumors occur in the glottic area
60%
p. 282
Approximately ___ of malignant laryngeal tumors occur in the supraglottic area
35%
p. 282
Approximately ___ of malignant laryngeal tumors occur in the subglottic area
5%
p. 282
Common metastasis sites for laryngeal tumors
lung, liver
p. 282
T1N0M0
Small lesion w/ no nodal or distant metastasis
p. 282
Who stages the tumors of laryngeal cancer patients?
Primary physician diagnosing the pt, otolaryngolist or gneral surgeon
p. 283
Lymphatic system and supraglottic larynx
B/c of the way the lymph system drains in the supraglottic larynx, a tumor here won't spread down to the true vocal cord and/or subglottic larynx unless the tumor is located at the base of epiglottis.
p. 283
Lesion in the supraglottic larynx - amount of tissue removed
Minimum of normal tissue removed at the inferior edge b/c tumor cells are known not to spread in that direction (b/c of drainage of lymph system)
p. 283
Extent of normal tissue resected along w/ tumor in the larynx
Depends on the site. The rule of 1 1/2 to 2 cm margin used for oral cancer not always followed in larynx b/c of the knowledge of the lymphatic system.
p. 283
Normal tissue resection at superior end of a laryngeal resection
2 cm margin of normal tissue rule maintained
p. 283
Small Supraglottic Tumors
Predominantly involve the epiglottis, aryepiglottic fold, or false vfs. Freq. treated w/ supraglottic laryngectomy (aka horizontal laryngectomy).
p. 284
Lesion that extends below the false vfs vs. one that involves the epiglottis, aryepiglottic fold or false vf
Requires diff. procedure. Resection generally includes part or all of the hyoid bone and epiglottis superiorly, the aryepiglottic folds & the false vf's inferiorly.
p. 285
Supraglottic laryngectomy
Takes the epiglottis, aryepiglottic folds and false vfs (the structures contributing to airway protection during swallowing), leaves the base of tongue, arytenoids and true vfs as the only protective mechanism.
p. 285
Supraglottic laryngectomy - reconstruction
Surgeon usually elevates the remaining larynx & tucks it under tongue base for additional protection during swallow.
p. 285
How does supraglottic laryngectomy pt relearn to swallow?
Must completely occlude the airway entrance by retracting the tongue base to make contact with the anteriorly tilting arytenoid, which prevents material from entering the airway during the swallow.
p. 285
Supraglottic laryngectomy and laryngeal elevation
W/ hyoid partially or totally removed, laryngeal suspension & elevation are damaged.
p. 285
Supraglottic laryngectomy and laryngeal elevation - therapy
Supersupraglottic can serve both as ROM exercise for tongue base and arytenoid and as a swallow procedure.
p. 285
Supraglottic laryngectomy and tongue base movement.
If tongue base doesn't make complete contact w/ the posterior pharyngeal wall, will be residue in pharynx that will fall directly into airway after the swallow b/c the pt has no valleculae and smaller pyriform sinuses than normal.
p. 286
Extended supraglottic laryngectomy
Sometimes extended inferiorly or superiorly, depending on location & size of the tumor.
p. 286
Superiorly Extended supraglottic laryngectomy
If tumor invades anterior surface of epiglottis and extends into base of tongye, superior limits of the resection begin at the foramen cecum, extends into base of tongue.
p. 286
Superiorly Extended supraglottic laryngectomy - Additional difficulties
More precipitous drop off from tongue into the airway, Food and liquid tend to fall into airway entrance, or, if airway entrance fails to close, onto the true vocal cords. Elevation of larynx also must be intact so it can adequately deflect material. May have reduced lingual movement and control of bolus. Sensation in larynx may be reduced b/c of sacrifice of one SLN, w/ cough reflex reduced and pt. unaware of any aspiration. Occasionally, pharyngeal swallow also delayed.
p. 287
Anteriorly Extended supraglottic laryngectomy
Can be extended to include part of one true vf. May include all or part of 1 arytenoid.
p. 287
Anteriorly Extended supraglottic laryngectomy - Additional difficulties
B/c arytenoids are a major contributor to airway closure in the pt / supraglottic laryngectomy and the inferior extension includes larger amounts of a vf and the arytenoid, pt's chances for recovery of normal swallowing w/o chronic aspiration diminished.
p. 287
Long-term study regarding regaining of swallow - pts w/ standard supraglottic resection (no base of tongue or arytenoid removed)
Were able to regain normal swallow w/o aspiration during or after the swallow. Were able to swallow a normal diet an aver. of 1 month after surgery, w/ some pt's taking 3 to 6 months.
p. 288
Long-term study regarding regaining of swallow - pts w/ extended supraglottic resection (taking all or part of the arytenoids)
Spent a minimum of 2 months & more frequently 6-12 months. Several were never able to drink liquids w/o significant aspiration and always required a trach tube.
p. 288
Pts w/ extension of supraglottic resection into tongue base
Also take significantly longer to return to oral intake (6 months or more). Those w/ larger resections may never be able to gaine enough tongue base movement to protect the airway and may need to be converted to a total laryngectomee.
p. 288
Tx for supraglottic laryngectomy pts who do not have complete airway entrance closure post-operatively
Program of tongue base and arytenoid ROM exercises in an attempt to improve muscle function. Should have effect w/in 2-4 weeks, if not, they can be continued as some pt's attain successful airway closure 3-4 months after surgery if they cont. exercises.
p. 288
Tx for supraglottic laryngectomy pts who do not have complete airway entrance closure post-operatively
If they have good tongue base action and are able to learn the super-supraglottic swallow,usually will rehabilitate normally within 1 month postop.
p. 288
Criteria for selection of pt's to receive a supraglottic laryngectomy
Must have the capability of relearning swallowing sequence. Those w/ mental disorders or who are not able to follow a sequence should bot be candidates.
p. 288
What to do if you ? the supraglottic laryngectomy candidate's learning ability during preoperative counseling and eval procedures
Ask pt to go through a series of instructions similar to a supraglottic swallow and assess pt's ability to handle them. If can't, speak w/ the surgeon.
p. 288
Postoperative radiotherapy and oral intake
Postop radiation should be delayed until oral intake is reinstated. Study found pt's w/ partial laryngectomy who had not acheived oral intake before radiation took significantly longer to attain oral intake.
p. 288
Tx of unilateral laryngeal tumors (on free margin of 1 vf w/ only local extension)
Vertical/hemilaryngectomy or an extended hemilaryngectomy
p. 289
What is removed in a hemilaryngectomy? What remains?
One vertical half of the larynx. Includes 1 false vf, 1 ventricle, and 1 true vf, usually excluding the arytenoid cartilage and a portion of the thyroid on the side of the resection. Hyoid and epiglottis usually left intact.
p. 289
Postop swallowing difficulties for hemilaryngectomy pts
Few, b/c some tissue bulk is reconstructed on the operated side, against which the unoperated side can attain normal laryngeal closure during swallowing (but for normal swallowing, reconstructed side must be at the same level as the normal vf).
p. 290
Aspiration and hemilaryngectomy pts
Occasionally have some temporary aspiration during the swallow. Chin down posture to push the epiglottis more posteriorly and narrow the airway entrance usually provides sufficient airway protection to eliminate aspiration. Combine chin down w/ head turn to operated side if needed for best airway protection.
p. 290
Frontolateral Laryngectomy (Anteriorly extended hemilaryngectomy)
Needs to include part or all of the anterior commissure if the lesion is located anteriorly on one of the vf's. Approx. 1/3 of the anterior portion of the larynx resected on each side.
p. 290
Reconstruction in Frontolateral Laryngectomy (Anteriorly extended hemilaryngectomy)
Usually reconstructed w/ some bulk of tissue on the operated side, possibley taken from the stap muscles, so there is something for the normal ture and false vf's to contact against. Epiglottis and hyoid remain, as do most of the strap muscles, for suspension & elevation of the larynx. Both arytenoids remain so the constricter mech at the level of the true vfs is intact.
p. 290
Rehabilitation of Frontolateral Laryngectomy pt's
Will probably be rehabilitated quickly, w/in 2-3 weeks postoperatively.
p. 290
Initial Compensatory measures needed for Frontolateral Laryngectomy pt's
Many will initially need the chin-down posture to prevent aspiration during the swallow (more so than those who underwent just a standard hemilaryngectomy)
p. 290
Hemilaryngectomy extension if lesion located even more anteriorly: 3/4 Laryngectomy
May be extended along the anterior commissure to include approx. 1/2 of the other side of the larynx.
p. 290
Airway Closure in 3/4 Laryngectomy
B/c patients have their arytenoids intact, a normal epiglottis, hyoid bone and tissue bulk placed on the operated side to add bulk, there is usually sufficient constriction at the level of the true vf's and at the airway entrance to prevent aspiration. Often neede chin down and head rotated posture initially. May also need adduction exercises and/or super-supraglottic swallow to improve airway protection.
p. 290
Posterior extension of hemilaryngectomy
Extended to include the arytenoid. Pts chances of returning to a normal swallow w/ no aspiration greatly decreased.
p. 291
Study re. return to normal swallow in patients w/ standard hemilaryngectomy
Pts w/ limited resection resumed normal swallowing w/in 1 week after initiation of oral feeding postoperatively.
p. 291
Study re. return to normal swallow in patients w/ extended hemilaryngectomy
Those who had extended hemilaryngectomy, including the arytenoid, had much longer periods of rehab. Several were never able to drink liquids b/c of aspiration during the swallow and needed a permanent trach.
p. 291
Extercises for pts w/ posterior extension of hemilaryngecomy including the arytenoid
Adduction exercises and chin-down, head rotated posture to facilitate swallowing w/o aspiration during the swallow.
p. 292
Partial laryngectomy procedures w/ extensive resection of the vf's
Preventing aspiration is a major problem in any extended partial laryngecomy procedure. If aspiration controlled by reconstructing a narrow glottic chink, airway usually compromised and functional tradeoff for elimination of aspiration is a permanent trach.
p. 292
Treatment for T3 or T4 lesions involving more than one region of the larynx
Usually require total laryngectomy or high dose radiation w/ or w/o chemow
p. 293
Risk of aspiration with total laryngectomy
None, b/c there is physical seperation of the gastrointestinal tract from the respiratory tract.
p. 293
Swallowing problems w/ total laryngectomy - pseudoepiglottis formation
Relates to the nature of closure of the surgical defect. Postop, some pt's have a fold of tissue at the base of tongue called a pseudoepiglottis. Hypothesis is that the pouch-like recess occurs b/c the tongue must be stretched in a vertical position to attain vertical closure at the base. When tension is released the suture folds on itself, leading to forming of the pseudoepiglottis
p. 294
Swallowing problems w/ total laryngectomy - pseudoepiglottis during swallow
Fold of tissue appears as a pseudoepiglottis on lateral fluoroscopy that forms a pocket at base of ttongue, collecting food & liquid during swallowing. May look benign when at rest as it lies against the tongue base. But during swallowing, contraction of the pharyngeal constrictor muscles pulls the pseudoepiglottic tissue posteriorly, widening the gap at base of tongue and forming the pocket where food can collect. Can widen to occlude the pharynx and prevent material from passing when pt. tries to swallow.
p. 294
Swallowing problems w/ total laryngectomy - pseudoepiglottis and struggle reaction during swallow
The greater the struggle reaction of the pt during the swallow, the greater the widening of the pocket and the more severe difficulty in swallowing. Some total laryngectomy pt's restricted to liquid b/c of this.
p. 294
Swallowing problems w/ total laryngectomy - treatment for pseudoepiglottis
Generally surgical resection of the tissue fold
p. 294
Swallowing problems w/ total laryngectomy - tightness of surgical closure
Pts w/ lesions in the pyriform sinus of extending into the hypopharynx require more extensive resection of the pharyngeal mucosa as part of their laryngectomy, which requires tighter closure.
p. 294
Swallowing problems w/ total laryngectomy - tightness of surgical closure and scar tissue
Some pt's form scar tissue strictures in the esophagus after surgery, which narrow the esophagus sufficiently to prevent any large amount of material or material of thick consistency from passing through.
p. 294
Swallowing problems w/ total laryngectomy - scar tissue b/c of tightness of closure: Treatment
Dilatation. Pt's asked to swallow increasingly larger sized, mercury filled rubber tubes which gradually stretch the tissue.
p. 294
Swallowing problems w/ total laryngectomy - scar tissue b/c of tightness of closure: Dilatation - effectiveness & frequency
Temporary, has to be repeated at regular intervals (often monthly).
p. 294
Pharyngoesophageal myotomy after total laryngectomy
To release scar tissue stricture and permit more normal swallowing. May also impact ability to put air in and out of esophagus to produce esophageal voice.
p. 294
Compensation for scar tissue stricture after total laryngectomy
No exercises to improve it. Sometimes, head rotation will stretch and open a strictured or narrow area if dilatation or surgery is not feasible.
p. 294
Both a ________ and __________ can result in backflow of food as the pt struggles to swallow
pseudoepiglottis, stricture
p. 295
Greater swallowing problems can occur, including backflow of food up into nose or mouth for a total laryngectomy pt if it includes ___________
a pharyngectomy or esophagectomy w/ reconstruction by a distal flap, stomach pull-up or jejunal graft. Can sometimes be managed by postural changes (extending neck or head rotation to stretch reconstructed tissues).
p. 295
If total laryngectomy pt has not returened to full preoperative diet at _________ post op, a radiographic study of oropharyngeal and cervical esophageal aspects of swallow should be completed to identify any structural abnormalities
2 months
p. 295
If a total laryngectomy pt complains of swallowing problems months or years after surgery and they had been eating well, they should ___________ as it could be a sign of _________.
return to their surgeon, recurrence of the disease.
p. 295
Surgical and prosthetic voice rehab for total laryngectomy pts
All have included some method of reconnecting pulmonary airflow to the pharyngoesophagus. Major problem has been aspiration of food into trachea from esophagus.
p. 295
Surgical and prosthetic voice rehab for total laryngectomy pts - Staffieri neoglottis procedure
Resulted in aspiration in a majority of pts, has been discontinued.
p. 295
Surgical and prosthetic voice rehab for total laryngectomy pts - Tracheoesophageal puncture
Most continuously successful surgical prosthetic procedure. Place small flexible prosthesis into puncture wound made at 12 o'clock on the pt's stoma that connects the trachea w. the esophagus below the vibratory segment. Prosthesis in puncture wound prevents backflow from esophagus into trachea, so aspiration eliminated.
p. 295
Tracheoesophageal puncture and Panje procedure
Prevent aspiration. The most uniformly successful procedures that have been attempted to rapidly restore optimum voice to total laryngectomy pt's post-op.
p. 296
Total laryngectomy pt's as candidates for Singer-Blom procedure (tracheoesophageal puncture)
May need a myotomy for prevention of pharyngospasm. Type of myotomy involves a much broader cutting of the pharyngeal musculature than the CP myotomy.
p. 296
Total laryngectomy pt's as candidates for Singer-Blom procedure (tracheoesophageal puncture): Neurectomy
Involves cutting the innervation to the pharyngeal wall musculature rather than cutting the musculature itself. As w/ myotomy for Singer-Blom candidates, can be used to eliminate pharyngospasm or contraction of the pharyngeal musculature in response to airflow introduced below it.
p. 296
Pharygospasm
Functional phenomenon that is not structural (not present except when air is introduced into pharynx from below).
p. 296
Changes in swallowing after totaly laryngectomy
Increase in lingual pressures to compensate for absence of larynx and reduced pharyngeal wall function post-op. Usually minor change.
p. 296
Total laryngectomee pt's usually return to to a full diet w/in ________ postoperatively.
1 to 2 months.
p. 296
Voice change and radiotherapy for T1 or T2 tumor
May experience only temp. voice change, including hoarseness or vocal roughness which improves in the month or two following completion of radiotherapy. May also have small changes in saliva flow. Rarely swallowing problems.
p. 296
Changes w. high-dose radiation therapy (6,000 to 7,000 cGy) w/ or w/o chemo
Radiation field usually smaller than that delivered to the patient w/ a tonsil or base or tongue tumor. Often results in significantly reduced laryngeal elevation and reduced pharyngeal wall motion during swallow, which impairs the efficiency and safety of swallow. May begin during course of radiation tx or anytime after, including years later.
p. 296
Reduced laryngeal elevation and pharyngeal wall motion resulting from high-dose radiation therapy (6,000 to 7,000 cGy) w/ or w/o chemo - why?
B/c the process of fibrosis resulting from damage to the capillaries feeding muscle fibers to the radiated area. Severity will vary from pt to pt.
p. 296
Reduced laryngeal elevation and pharyngeal wall motion resulting from high-dose radiation therapy (6,000 to 7,000 cGy) w/ or w/o chemo - Treatment
Mendelsohn maneuver and falsetto to improve laryngeal motion and take volitional control over airway closure and UES opening. Exercise programs to improve laryngeal elevation.
p. 297
Laryngeal cancer pt's whould be ______ prior to treatment by the swallowing therapist.
Counseled.
p. 297
Prior to treatment, in pretreatment counseling, should ensure the patient is _____________
aware that posttreatment changes may occur in voice and swallowing. Although exact nature of changes not know, should be told to anticipate need for some swallowing tx postop and the need for their participation in the process should be emphasized.
p. 297
_________ is much more _________ if the pt is unaware of his ultimate responsibilty and the need to work actively to rehabilitate his or hear swallowing and communication
Rehab, difficult
p. 297
Advisable for the radiated pt to begin ROM exercises for the ______ and _____ before or at beginning of radiotherapy and to do the exercises ______________. Pt should continue exercises __________ and ________.
for the tongue base and laryngeal elevation; 5-10 times/day for 10 minutes each time; continue throughout and after.
p. 297
Postop, swallowing therapist should review pt's chart and determine ____________ and __________.
Exact extent of the resection and the nature of the reconstruction and/or exact plan for radiotherapy.
p. 297
The __________ and _________ will determine the laryngeal cancer patients functional capacity after surgery.
resection, reconstruction
p. 297
Exercise treatment program for surgically treated laryngeal cancer pt can begin when the surgeon indicates that...
...the suture lines will withstand the pressure of swallowing.
p. 297
When treating a laryngeal cancer pt after their treatment, should first conduct an ____ to assess functioning & define the optimal therapy regimen.
MBS
p. 298
Based on the MBS, many laryngeal cancer patients will be able to...
...resume eating that same day if thier swallowing is found to be functional or normal
p. 298
If, despite tx attempts, pharyngeal/laryngeal physiology is still abnormal and aspiration is significant before, during or after the swallow...
...exercise program will be needed b/f actual oral feeding begins. Usually should be no more than 2-4 weeks before maximum function is attanied. But, some pts will slowly improve and be able to resume oral feeding 1-2 years after surgery.
p. 298
Laryngeal cancer pts receiving swallowing tx post-surgery/radiation for swallowing should be seen ______ in the hospital and _____ after discharge, as needed
Daily in the hospital, weekly after discharge
p. 298
Difficulties arise if 2 or 3 professionals give the patient...
...different advise about his problems. Everyone involved needs to work together
p. 298
The best swallowing rehab occurs when a __________ is given to the patient and reinforced by all professionals caring for the pt.
single set of instructions
p. 298
2 types of neurologic disorders affect swallowing
1. Conditions that occur suddently and from which a pt can be expected to at least partially recover (stroke, head trauma, spinal cord injury) and 2. conditions that are degenerative in nature and will cause gradual deterioration of swallowing over time.
p. 303
?s to ask regarding management of the pt. who can be expected to improve
1)What tx should be initiated to normalize the pt's swallowing physiology; 2)Will the pt be able to eat a normal diet and if so, when?; 3)Is the pt's recovery typical for those w/ this type of lesion? 4)What other factors may interact w/ the neurologic damage to worsen the dysphagia?
p. 303
?s to ask regarding management the pt. w/ degenerative disease
1)Are there typical changes in swallowing that occur at the onset of each disease and that can be used to identify the disease?; 2)Are there progressive and predictable changes in swallowing physiology characteristic of each lesion location?; 3)How long can the pt. continue to eat by mouth before nonoral feeding may be necessary? 4)What techniques can prolong oral feeding for the pt?
p. 304
In all pts w/ a neurologic disorder _________ to aspiration appears to be significantly reduced as indicated by _________
sensitivity; indicated by their frequent failure to cough.
p. 304
Many pts w/ a neurologic disorder are ______ of their swallowing problems and _____ any problem despite MBS revealing that a significant portion of each bolus swallowed is being aspirated.
unaware; deny
p. 304
Why is sensitivity to aspiration reduced in those with neurologic disorder?
Many neurologic conditions affect the pt's sensory feedback regarding position of food in the vocal tract and entry of food into the airway. Not aware of residual material in pharynx and don't dry swallow to clear material.
p. 304
In assessing and treating the pt w/ neurologic impairment, must be constantly aware of potential for _______
silent aspiration.
p. 304
Study indicates that dysphagic stroke pt's exhibit reduced ____________ as compared w/ normal age-matched controls.
pharyngeal and supraglottic sensation
p. 304
Direct sensory testing in many pt's with neurologic disorders, whether of sudden onset of degenerative not possible b/c of _______________ problems
cognitive and/or language
p. 304
Indirect evidence of sensory loss is available from...
...the pt's reaction to presence of residual food in the pharynx (i.e. if aware, will dry swallow quickly to clear the food)
p. 304
Reduced reaction to aspiration or residue may also result from....
...desensitization due to the chronic presence of aspiration/residue
p. 304
Fatique throughout day/meal and the neurologic dysphagia pt
Important to observe pt at various times of day, as diff. strategies may be needed.
p. 304
If patient fatiques easily, what may not be appropriate?
maneuvers, as they will usually increase pt's fatique.
p. 305
What can help dysphagia pts who fatique easy?
Smaller meals, posture changes, heightening preswallow sensory input, diet changes
p. 305
ICU: If pt is intubated, swallowing assessment should __________
wait until the pt is extubated
p. 305
Some studies indicate it may take up to _______ for the pharyngeal swallow to be triggered normally after extubation
1 week
p. 305
Eval when pt is comatose - evaluation of frequency of swallowing
Evaluate the freq. of swallowing & apparent strength of pharyngeal swallow by resting hand lightly on submandibular and laryngeal areasof the neck. Rest fingers on these structures for 5-10 minutes to asssess the frequency of swallow and strength of laryngeal elevation that indicates triggering of the pharyngeal swallow.
p. 305
Eval when pt is comatose - evaluation of frequency of swallowing
Cld use surface electrode over submandibular muscles under the chin and/or on the neck above the thyroid, over the laryngeal elevator muscles. Electrodes record muscle activity during the swallow and enable the clinician to observe swallowing freq. over a longer period than the 5-10 minutes when you feel it.
p. 305
Eval when pt is comatose - in addition to observation of swallowing frequency.
1)Assess how pt. handles secretions. 2)Attempt TTS - any muscle contractions in response to the stimulation may be evaluated. Place very small amnt of iced ginger ale w/ a straw at base of anterior arch and assess the reaction to the presence of liquid & whether the pharyngeal swallow is triggered.
p. 305
Assessment in ICU if pt able to follow directions
Complete bedside exam can be carried out, including assessment of the functional status of each vocal tract structure during volitional and reflexive movement.
p. 305
Assessment in ICU if pt able to follow directions - after the bedside
May ask pt to repeat several swallows of small amounts of materials (no more than 1/3 of a tespoon of liquid in the full exam). If unable to follow directions, may perform some informal observational assessments of vocal tract function.
p. 306
Chances for success of bedside assessment in very ill or comatose pts
Poor and may place pt at risk
p. 306
Radiographic study of very ill/comatose pts
Can be done if they can be positioned in the fluorographic equip. while on a cart w/ back elevated and supported and nurse, resident or physician present.
p.306
Logemann and colleagues have successfully assessed over __ noncomatose pt's from ICU radiographically, including those on mechanical ventilation
500
p. 306
Examples of sudden onset conditions that may result in swallowing disorders from which a degree of recovery may be expected
stroke, closed head trauma, cervical spinal cord injury, anterior cervical fusion, neurosurgical procedures affecting brainstem and CN's, poliomyelitis, Guillain-Barre syndrome and congentital neurologic damage.
p. 307
Pts w/ unilateral or bilateral brainstem, cortical and subcortical strokes
Swallowing problems have been reported
p. 307
Pts who have suffered an infarct limited to the posterior cortex w/ no motor component will or will not experience swallowing difficulties?
Will not, unless the posterior lesion creates sufficient edema to affect the anterior cortex.
p. 307
Videofluorographic evidence (indirect) that stroke pts have some degree of sensory loss
Sroke pts often do noe respond normally to oral and/or pharyngeal residue (do not attempt to dry swallow in response to residue) and when asked if food is left in pharynx, they often indicate they don't feel anything.
p. 308
Knowledge of swallow abnormalities resulting from stroke at specific sites in the CNS is...
...still evolving
p. 308
Effects of Lesions in Medulla (lower brainstem)
Result in significant oropharyngeal swallow impairment b/c of the location of the major swallowing centers w/in the medulla.
p. 308
Effects of unilateral medullary lesions
Pts typically exhibit functional or near normal oral control with significantly imparied triggering of the pharyngeal swallow.
p. 308
Effects of unilateral medullary lesions on pharyngeal swallow
In first week poststroke may exhibit an absent pharyngeal swallow (often it is just too weak to be recognized), followed by a weak pharyngeal swallow w/ a 10-15 second or greater delay (usually in the 2nd week poststroke)
p. 308
Unilateral medullary lesions - effort/voluntary submandibular, tongue base and hyoid bone movements when trying to propel material from the oral cavity w/ the tongue
Can be misleading as can occasionally be mistaken for the hyoid and laryngeal movement that occurs as a result of triggering the pharyngeal swallow.
p. 309
Effects of unilateral medullary lesions on pharyngeal swallow: Once the pharyngeal swallow triggers
Pts usually exhibit 1)reduced laryngeal elevation & anterior motion, so reduced opening of the UES w/ symptom of residual food in the pyriform sinuses, esp. on one side; and 2)unilateral pharyngeal weakness, which further contributes to residual food remaining in the pyriform sinus on one side and reduce UES opening b/c bolus pressure contributes to UES opening. 3)Some pts also have unilateral vf adductor paresis.
p. 309
Effects of unilateral medullary lesions on pharyngeal swallow - oral or nonoral intake?
Often require nonoral intake at 1-2 weeks poststroke, but by 3 weeks post swallow has often recovered to be functional and allow full oral intake.
p. 309
The more severe the swallow abnormalities as 2-3 weeks poststroke and the more medical complications present, the ______ the swallow recovery period
longer
p. 309
After medullary stroke, some pts w/ a number of complicating factors will not recover functional swallowing for
4 to 6 months poststroke
p. 309
Medullary stroke pts who aren't recovering functional swallow post-stroke: Therapy
TTS, head rotation to the side of pharyngeal weakness, Mendelsohn maneuver and ROM exercises for laryngeal elevation.
p. 309
Cricopharyngeal myotomy and brainstem stroke pts
Sometimes used. Should not be considered until at least 6 months poststrike so that adequate time is allowed for recovery.
p. 309
Majority of pts w/ a CP problem post brainstem stroke have a ________________ rather than spasticity in the CP muscle.
reduction in laryngeal motion
p. 309
Observation at NMH of pharyngeal swallow measures 12 and 24 weeks post medullary stroke whose swallow was functional at 3 weeks post reveals...
that, although swallow is functional, measures of pharyngeal movement during swallow are outside of the normal range for their age and gender
p. 309
Effects of High Brainstem (Pontine) stroke
High brainstem stroke in region of pons generally leave pt w/ severe hypertonicity
p. 309
Hypertonicity seen as result of pontinte strokes manifests itself in the pharynx as a delayed or absent __________, unilateral spastic pharyngeal wall _______ and reduced ____________ with severe _____ dysfunction
delayed or absent pharyngeal swallow, unilateral spastic pharyngeal wall paresis or paralysis, reduced laryngeal elevation with a severe CP dysfunction.
p. 310
Treatment for pts w/ high brainstem (pontine) stroke
Try head rotation to each side to determine which works best, but they often don't respond to head rotation. TTS may be helpful but may also increase muscle tone. Massage to reduce muscle tone in buccal muscles and neck prior to initiating swallowing therapy may help.
p. 310
Recovery outlook for pts w/ hihg brainstem (pontine) stroke
Can be quite slow and difficult
p. 310
Subcortical strokes may affect ______ as well as ______ paths to and from the cortex.
motor, sensory
p. 310
Effects of subcortical stroke
Mild (3-5 second) delays in OTT, mild (3-5 second) delays in triggering pharyngeal swallow and mild to moderate impairments in timing of the neuromuscular components of the pharyngeal swallow.
p. 310
Effects of subcortical stroke - aspiration?
Small number exhibit aspiration before the swallow as result of pharyngeal swallow delay or after the swallow b/c of impairment in neuromuscular control in the pharynx.
p. 310
Subcortical stroke - recovery of full oral intake
May take 3 - 6 weeks poststroke if no medical complications are present, longer if complications (diabetes, pneumonia) are present.
p. 310
Swallowing therapy for subcortical stroke pts
Directed at improving triggering of pharyngeal swallow and improving ROM of larynx and tongue base
p. 310
Effects of Cerebral Cortex Strokes - Differences btwn. left and right hemisphere
Differences exist, but have not been well defined.
p. 310
Results of stroke within anterior left hemisphere of cerebral cortex
Apraxia of swallow (mild to severe) usually accompanied by some degree of oral apraxia
p. 310
Results of stroke within anterior left hemisphere of cerebral cortex - characteristics of apraxia
Delay in initiating the oral swallow w/ no tongue motion in response to presentation of bolus in the mouth or by mild to severe searching motions of the tongue prior to initiating the swallow. Better when they feed themselves and are not instructed to swallow.
p. 310
Results of stroke within anterior left hemisphere of cerebral cortex - mild oral transit delays and mild delays in triggering the pharyngeal swallow
Oral transit delays of 3-5 seconds and triggering of pharyngeal swallow of 2-3 seconds. Usually pharyngeal swallow is motorically normal.
p. 310
Results of stroke within anterior right hemisphere of cerebral cortex
Mild oral transit delays (2-3 seconds) and slightly longer (than L hemi) pharyngeal delays (3-5 seconds). Laryngeal elevation slightly delayed once swallow triggers, contributing to aspiration before or as the pharyngeal swallow is triggering.
p. 311
Results of stroke within anterior right hemisphere of cerebral cortex - therapy
Chin-down and TTS for the pharyngeal delay. Some use a supraglottic or super-supraglottic swallow to protect the airway during the delay. May also need ROM exercises for laaryngeal elevation.
p. 311
Results of stroke within anterior right hemisphere of cerebral cortex - therapy
Despite verbal and physical prompting, R hemi pt may have diff. integrating therapy or compensatory strategies into oral feeding b/c of cognitive disorders and inattention. May return to oral intake alter than L cortical stroke pts.
p. 311
Swallowing difficulties and pts who have suffered multiple strokes
Often more significant swallowing abnormalities. Oral function slower w/ repetitive tongue movements and OTT of >5 seconds. Delay in triggering pharyngeal swallow more severe, taking >5 seconds. Once pharyngeal swallow triggers, reduced laryngeal elevation & reduced closure of laryngeal entrance, resulting in penetration, as well as unilateral pharyngeal wall weakness resulting in residue on pharyngeal wall and in pyriform sinus on the affected side.
p. 311
Pts who have suffered multiple strokes - attention
Often affected and ability to utilize therapy strategies and focus on the task of eating and swallowing is also impaired.
p. 311
Pts who have suffered multiple strokes - why the increased severity of swallowing disorders?
May be b/c the mechanism doesn't return to normal swallow function after the first stroke
p. 311
Recovery of swallow poststroke - Study indicates that in noncomplicated stroke pt's, recovery was steady, vigourous and rapid, with over ___ of the subjects returning to full oral intake by ___, regardless of site of lesion.
95%, 9 weeks post-stroke. All pt's had active swallowing therapy.
p. 311
Recovery of swallow poststroke - limitations: Per study, even when pts returned to full oral intake w/in 3 weeks, their temporal measures of swallow physiology, such as _________ and __________ and the relationship btwn. these actions did not return to normal values/
duration of airway closure and cricopharyngeal opening.
p. 312
Recovery of swallow poststroke: Is the swallow ever normal after stroke.
Study indicates no, that the swallowing mechanism is never quite the same poststroke, which may help to explain why it is more severely affected with multiple strokes.
p. 312
Recovery is most rapid in the first _______ poststroke.
3 weeks. Indicating need to evaluate swallowing function in first week and reevaluate in at 3-4 weeks poststroke, especially if nonoral feeding initially inserted, as they may no longer need it 3-4 weeks post.
p. 312
Preliminary data from NU study indicate that the pt's _________ and any complications that arise in the pt's __________ are more important contributors to poststroke swallow function and recovery than previously acknowledged.
prior medical history and poststroke care.
p. 312
Other factors that may impact swallowing function and recovery of stroke pt
1. Tracheostomy 2. Medications 3. Concurrent medical problems 4. Age?
p. 312
Tracheostomy and impact on swallowing function and recovery of stroke pt
Placed during acute stroke phase, may worsen pt's swallowing problem, esp. if cuff inflated (can create tracheal irritation and reduce laryngeal elevation).
p. 312
Tracheostomy in older people and impact on swallowing function and recovery of stroke pt
Particularly in those >80, whose larynges normally rest lower in the neck, tracheostomy may contribute to reducing laryngeal elevation and closure during swallow.
p. 312
Long-Term Tracheostomy and impact on swallowing function and recovery of stroke pt
Trach in place for >6 months can contribute to reduced closure of airway during swallow b/c sensory receptors under the vf's aren't stimulated by airflow. Also, open trach tube doesn't permit buildup of subglottic pressure during swallow, which is thought to facilitate airway closure.
p. 313
Tracheostomy and impact on swallowing function and recovery of stroke pt - swallowing w/ a trach
Lightly cover the external end of the trach tube during swallow to facilitate more normal vf closure and airway protection if the MBS indicates that light coverage of tube improves the swallow.
p. 313
Medications and impact on swallowing function and recovery of stroke pt
Antidepressants may slow swallow coordination and increase severity of disorders. Other meds or interactions of meds may cause xerostomia which makes swallowing more difficult.
p. 313
Concurrent medical problems and impact on swallowing function and recovery of stroke pt - Long-standing insulin dependent diabetes
Can increase severity or prolong recovery of swallowing function b/c of potential for myopathies and neuropathies, which may affect pharyngeal muscle contraction and ROM.
p. 313
Concurrent medical problems and impact on swallowing function and recovery of stroke pt - Hx of TIA's, prior strokes or neurologic damage
May increase chance for significant swallowing problems or worsen severity.
p. 313
How to make patient and family counseling more realistic
Investigate medical hx from chart review and family and/or pt interview to identify factors that may pertain to pt's dysphagia and recovery
p. 313
Does age have an impact on swallowing function and recovery of stroke pt?
No evidence exists that it does.
p. 313
Minor differences in oropharyngeal swallowing functions in older normal subjects include significantly longer _______________ and in males over 80 significant reduction in range of ________ and _________ movement.
phaaryngeal delay time, although difference is only a fraction of a second and no differences in residue are observed; hyoid and laryngeal movement.
p. 313
Changes in Sensory Input via the Bolus for tx of stroke pts - change in bolus volume
Many first time stroke pts have sig. difficulty swallowing small bolus volumes such as saliva (1-3 ml) or large bolus volumes (10-20 ml), as in cup drinking. Provide a range and identify the volume that is most effective for each pt. Larger volumes may provide increased sensory input.
p. 314
Changes in Sensory Input via the Bolus for tx of stroke pts - change in bolus viscosity
Can change speed of bolus flow so some viscosities more easily swallowed in presence of particular swallowing problems.
p. 314
Best bolus viscosity for stroke pt w/ delay in triggering the pharyngeal swallow
Best w/ puddings and purees. Most difficulty on thin liquids b/c they are more likely to splash into the open airway during pharyngeal delay whereas thicket foods tend to stay in the valleculae during the delay, not entering the airway.
p. 314
Best and worst bolus viscosities for pt with brainstem stroke w/ reduced laryngeal elevation and thus reduced CP opening
Greater difficulty w/ thick foods, such as purees. Can easily handle thin liquids (able to drain through even a small CP opening). But, thicker foods could heighten the sensory awareness of food.
p. 314
Changes in Sensory Input via the Bolus for tx of stroke pts - change in bolus taste
Presenting strongly flavored bolus, particularly sour, may improve awareness of bolus, oral onset time and the pharyngea delay time.
p. 314
Care must be taken in presentation of a sour bolus because _________ of an acidic bolus can create more ____________.
aspiration, pulmonary reaction
p. 314
Common active exercises for stroke pts
ROM exercises to improve range and precision of oral tongue and tongue base movement, laryngeal elevation, adduction of vf's, closure of airway entrance and stimulation of pharyngeal swallow.
p. 315
Common problems for stroke pts
Reduction in tongue control of bolus during oral prep for the swallow and disturbed lingual propulsion of bolus during oral transit, unilateral pharyngeal paralysis, reduced pharyngeal wall contraction, residue in pyriform sinus and valleculae on affected side,. reduced laryngeal elevation and airway protection
p. 314
Best to work on motor skills (ROM exercises) ______ in _________ for swallowing before requiring pt to incorporate them into a successful swallowing pattern.
first, in preparation
p. 315