Swallowing Exam 2

Front 1

Diet Recommendations are frequently focused on...

Back 1

preventing aspiration and pneumonia

Front 2

aspiration is not always related to development of...

Back 2

pneumonia

Front 3

Best predictors for developing aspiration pneumonia (7)

Back 3

– Dependence for feeding
– Dependence for oral care
– Number of decayed teeth
– Tube feeding
– More than one diagnosis
– Number of medications
– Smoking

Front 4

Dysphagia and aspiration posed some
risks but only if...

Back 4

some other risk factors were present

Front 5

Different Diet Recommendations

Back 5

- Nonoral

- Restricted Diet

- Regular Diet

- Posture adjustment with diet

Front 6

Nonoral - SLPs...

Back 6

do not determine method

Front 7

Types of nonoral diet recommendations

Back 7

– Short-term-nasogastric tube (NGT)
– Long-term-percutaneous esophageal gastrostomy (PEG) tube, gastrostomy tube

Front 8

Restricted Diet

Back 8

– From no liquids to thickened liquids
– From no solids to pureed or chopped solids

Front 9

Diet recommendations decision dependent of...

Back 9

patient, caregivers,
and healthcare professionals

Front 10

Ethical considerations for diet reommendations

Back 10

– Quality of life
– Culture
– Beliefs

Front 11

Free water protocols suggested for:

Back 11

– Patients with liquid aspiration
– Receiving tube feeding or
– Receiving thickened liquids

Front 12

Premise of free water protocols

Back 12

– Water has neutral pH
– Innocuous to lungs if aspirated in small amounts

Front 13

To determine management approach, must consider the patient’s:

Back 13

– Language
– Attention
– Awareness
– Memory
– Visuospatial ability
– Executive function

Front 14

Goals of Management

Back 14

– Rehabilitation of dysfunction
– Prevention of dehydration, malnutrition, and pneumonia
– Return to least restricted diet possible

Front 15

Evidence-based practice

Back 15

– Randomized trials
– Case series studies
– Single subject

Front 16

Compensatory

Back 16

– Attempted during the instrumental exam
• Confirm improvement in safety or efficiency
– Primarily manipulated by the clinician
– Suggested limited cognition required*
– Benefits are immediate, not permanent

Front 17

Rehabilitative

Back 17

– Alter swallowing physiology
– Suggested good cognition required*
– Benefits are permanent

Front 18

Examples of compensatory (5)

Back 18

- Posture

- Volume regulation

- Increased volitional control

- Increased sensory input

- Bolus modification

Front 19

Examples of rehabilitative (7)

Back 19

- Shaker exercise

- Lingual resistance

- Masako maneuver

- Expiratory muscle strength training

- Lee Silverman

- Voice TX

- Neuromuscular electrical stim.

Front 20

Examples of both compensatory and rehabilitative (4)

Back 20

- Effortful swallow

- Mendelsohn maneuver

- Breath-hold

- Increased sensory input - TTA

Front 21

Management typically implements both...

Back 21

both compensation and rehabilitation simultaneously

Front 22

There is frequently ______________ rehab approach

Back 22

more than 1

Front 23

Compensation addresses...

Back 23

swallowing sign

Front 24

Goal for compensation is...

Back 24

safe and/or efficient oral intake

Front 25

Rehabilitation addresses...

Back 25

swallowing physiology (underlying impairment)

Front 26

Goal for rehabilitation is...

Back 26

to improve swallowing physiology (so that compensation is no longer needed)

Front 27

Posture

Back 27

- redirects bolus flow

- changes pharyngeal dimensions

Front 28

#1 culprit for aspiration with tube feeding

Back 28

reflux

Front 29

Chin tuck - what does it accomplish?

Back 29

1. Laryngeal surface of epiglottis closer to PPW

2. Narrows entrance to airway

Front 30

Chin tuck - decreased aspiration for...

Back 30

preswallow pooling to level of the valleculae

Front 31

Chin tuck - no decreased aspiration for...

Back 31

preswallow pooling to level of the pyriform sinuses

Front 32

Chin tuck - increased...

Back 32

duration of laryngeal vestibule closure

Front 33

Head rotation accomplishes...

Back 33

• Facilitates bolus flow
• Increases UES opening
• Decreases pyriform sinus postswallow residual

Front 34

Chin tuck for...

Back 34

• Delayed pharyngeal swallow-vallecular pooling
• Poor oral control-vallecular pooling
• ↓ BOT retraction-vallecular residual
• ↓ supraglottic closure-airway invasion during

Front 35

Head rotation for...

Back 35

• Pharyngeal hemiparesis-unilateral pharyngeal residual-weaker side
• Unilateral TVF paralysis-aspiration during weaker side
• ↓ UES opening-bilateral pyriform sinus residual either side

Front 36

Chin tuck instructions

Back 36

Patient’s chin should touch the anterior neck. If they cannot accomplish this degree of flexion, maintain maximal flexion

Front 37

Head rotation instructions

Back 37

Turn head as far as you are able toward the ____
shoulder. Keep your head in that position during
each swallow of food or drink

Front 38

Sensory Enhancement

Back 38

– Temperature
– Carbonation
– Taste
– Thermal-Tactile Application

Front 39

Temperature

Back 39

• Little impact

Front 40

Carbonation

Back 40

• Some effects in disordered populations but research methods are suspect
– ↓ residual
– ↓ airway invasion
– ↑ swallow speed through pharynx

Front 41

Taste

Back 41

• Improved effects in healthy and neurogenic populations
• Most studies have focused on sour bolus
– Timing and amplitude of muscle contraction
– Pressure
– Oral preparation time
– In neurogenic patients-faster bolus movement and reduced residual

Front 42

↑ Volitional Control of Oral Transfer

Back 42

– Changing swallow from automatic to more volitional act
– 3-second prep (Huckabee & Pelletier, 1999)
• Patient silently counts to 3 before onset of oral transfer-No empirical evidence
– Self-initiated coordination of button press
(Ludlow et al., 2005)
– Cued swallow (Daniels et al., 2007)

Front 43

Regulating Volume

Back 43

No research using volume regulating cups

Front 44

Changing Consistency

Back 44

– Thickened liquids
– Modifying solids
– Changing consistency order

Front 45

Thickened liquids

Back 45

• Reduced speed
• ↑ cohesion of bolus
• ↓ airway invasion

Front 46

Types of thicknesses

Back 46

– Nectar thick
– Honey thick

Front 47

Thickened liquids can be either...

Back 47

premixed or mixed prior to use

Front 48

Ensure effectiveness of thickened liquids during...

Back 48

instrumental exam

Front 49

When considering thickened liquids, consider:

Back 49

– Patient Satisfaction
– Risk/Benefit Ratio

Front 50

Changing consistency - least restrictive to most restrictive

Back 50

• Adding gravy to moisten dense semi-solids
• Avoiding hard solids, e.g., apples
• Chopped solids
• Pureed solids

Front 51

Changing consistency - consistency order

Back 51

• If postswallow residual is evident w/o patient spontaneously clearing
– Dry swallow after every few swallows
– Cyclic ingestion/Liquid wash: Alternate delivery of liquids/solids
• In instrumental examination:
– 1. see what patient does spontaneously
– 2. have patient dry swallow
– 3. cyclic ingestion

Front 52

Breath-Holding Techniques

Back 52

– Supraglottic swallow-↑ timing and approximation of TVF closure
– Super-supraglottic swallow-↑ laryngeal vestibule closure (Valsalva effect)
• Designed to facilitate airway protection (Logemann 1998)
• Can also facilitate timing and movement of structures (Ohmae et al., 1996; Lazarus et al., 2002)
– Completed during the actual swallow
– Not much research concerning long-term effects

Front 53

Breath-holding techniques are typically for...

Back 53

typically for H&N CA patients-need endurance

Front 54

Breath-holding techniques are not...

Back 54

a quick fix for airway invasion

Front 55

For success with breath-holding techniques, patient needs...

Back 55

• Intact comprehension
• Adequate memory
• Muscular strength
• Endurance

Front 56

Breath-Holding Techniques – Supraglottic swallow-Instructions

Back 56

• Hold breath tight-make sure holding at level of TVF
• Continue to hold your breath tightly while swallowing
• Cough immediately after swallow before breathing in-this clears any residual in airway

Front 57

Breath-Holding Techniques – Super-supraglottic swallow-Instructions

Back 57

• Hold breath very tightly and bear down
• Continue this while swallowing
• Cough immediately after swallow before breathing in-this clears any residual in airway

Front 58

Breath-Holding Techniques – Cardiac effects-Results

Back 58

• 87% of stroke patients demonstrated cardiac
findings during breath-holding training and treatment
• Cardiac findings ended after swallowing TX and
were not evident with other activities
• Ortho patients did not demonstrate cardiac findings

Front 59

Breath-holding techniques may be ___________ for patients with H/O stroke or
CAD

Back 59

contraindicated

Front 60

A treatment is rehabilitative when it attempts to...

Back 60

alter swallowing physiology

Front 61

Rehab targets...

Back 61

the underlying impairment

Front 62

Rehab benefits are...

Back 62

permanant

Front 63

Rehab requires good...

Back 63

cognition

Front 64

Most patients should receive at least an attempt at rehabilitative treatment, unless:

Back 64

– Obtunded
– Unable to attend and/or follow directions

Front 65

For frail or acute onset cognitive impairment:

Back 65

– Gradually build-up endurance
– Work on attention and comprehension
• SLPS not just swallowing therapists

Front 66

Remember, if both compensation and rehabilitation are needed, address them...

Back 66

simultaneously

Front 67

Generally multiple rehab options to
address a specific swallowing impairment
– For most patients, you want to work on...

Back 67

them all

Front 68

Swallowing Treatment - Research
Typical to start with...

Back 68

Healthy

Front 69

Sensory Enhancement -

Thermal-Tactile Application suggested to...

Back 69

facilitate elicitation of the pharyngeal swallow

Front 70

Thermal-Tactile Application - Immediate but temporary...

Back 70

increase in swallowing evocation

Front 71

What are you doing with Thermal-Tactile application?

Back 71

Rubbing the chilled mirror on anterior faucial arch

Front 72

Use what for Thermal-tactile application?

Back 72

Use 00 laryngeal mirror chilled in ice or ice stick but NOT lemon glycerin swabs

Front 73

How often for Thermal-tactile application?

Back 73

Suggestion of 4-5, 10-15 minute sessions daily, but need further research to confirm

Front 74

What is the overall goal of air-pulse stimulation?

Back 74

Improve onset of pharyngeal swallow and frequency of the swallow

Front 75

The air-pulse stimulation device is not yet...

Back 75

approved by the FDA

Front 76

What is purpose of Lingual resistance?

Back 76

Lingual strengthening

Front 77

What do you do with lingual resistance?

Back 77

• Compressing IOPI between tongue and hard
palate
• Identify one repetition maximum value
– Press your tongue as hard as you can against the IOPI bulb
– Complete 2 sets of 3 reps

Front 78

Isometric progressive oropharyngeal (I-PRO)
protocol

Back 78

– Work at 60% maximum first week and 80%
maximum remainder of time
» Readjust 80% maximum every 2 weeks
– Regime: 30 reps, 3X/day, 3days/week for 8 weeks
» Anterior tongue
» Posterior tongue

Front 79

SwallowSTRONG® Device

Back 79

• Sensors at 5 locations embedded
into a custom molded mouthpiece
• Improve swallow function, lingual
muscle stamina

Front 80

Results of lingual resistance

Back 80

– ↑ tongue volume
– ↑ isometric and swallowing pressures
– ↓ OTT
– ↓ P-A Scale score

Front 81

Use lingual resistance for...

Back 81

– Use for impairment of poor orolingual
control resulting in inadequate bolus
preparation and/or formation, oral residue.
– Use for impairment of reduced base of
tongue retraction resulting in valleculae
residue

Front 82

Masako Maneuver initially documented in...

Back 82

patients S/P BOT resection

Front 83

Masako Maneuver - what do you do?

Back 83

• Protrude tongue maximally but comfortably, holding between central incisors while swallowing
• Individual swallows saliva, not bolus-Not a
compensatory strategy as ↑ vallecular residue due to immobilizing tongue

Front 84

Masako Maneuver

Results in healthy adults

Back 84

• ↑ anterior bulging of PPW
• Inhibits tongue movement- ↑ vallecular residue

Front 85

Masako Maneuver

Results in patients with BOT resection

Back 85

• ↑ pharyngeal pressure

Front 86

Use Masako Maneuver with patients...

Back 86

with vallecular residue due to ↓ BOT retraction

Front 87

Gargling requires study to determine...

Back 87

if improvement in swallowing following exercise program of gargling

Front 88

Greatest BOT retraction during movement for
___________ as compared to tongue pull-back or yawn

Back 88

gargle

Front 89

Positive results of effortful swallow

Back 89

• ↑ oral and pharyngeal pressure, particularly distal pharynx
• ↑ tongue to palate contact
• ↑ superior movement of hyoid
• ↑ duration of UES opening, anterior hyoid movement, and laryngeal vestibule closure

Front 90

Negative results of effortful swallow

Back 90

• ↓ hyoid movement
• No change in airway invasion
• No change in pharyngeal pressure

Front 91

Effortful swallow can be either _____________ or ___________

Back 91

compensatory or rehabilitative

Front 92

Which patients for effortful swallow?

Back 92

• Vallecular residue due to ↓ BOT to PPW contact-YES
• Vallecular residue due to ↓ hyolaryngeal elevation yielding ↓ epiglottic deflection–??
– Need to ensure no negative effect on hyolaryngeal movement

Front 93

How do you do the Mendelsohn Maneuver?

Back 93

Individual initiates swallow and at peak of hyolaryngeal excursion, maintain suprahyoid contraction before relaxing and completing the swallow

Front 94

Mendelsohn maneuver initially designed as...

Back 94

a compensatory strategy to facilitate bolus flow through the UES

Front 95

What is notion of Mendelsohn maneuver?

Back 95

Notion is that prolonging suprahyoid contraction prolongs UES opening

Front 96

Rehabilitative thought of Mendelsohn Maneuver is that...

Back 96

repetitive performance ↑ UES compliance and bolus flow

Front 97

Which impairments for Mendelson maneuver?

Back 97

• Pyriform sinus residual due to anterior hyolaryngeal movement
• Vallecular residue due to ↓ hyolaryngeal movement yielding ↓ epiglottic deflection

Front 98

Mendelsohn maneuver is difficult to...

Back 98

master

Front 99

Shaker exercise designed to...

Back 99

increase UES opening by targeting anterior hyoid movement

Front 100

Use Shaker exercise with...

Back 100

patients with pyriform sinus postswallow residual due to UES opening caused by ↓ anterior hyoid movement

Front 101

Shaker exercise completed with individual in ____________ position

Back 101

supine

Front 102

Isotonic Shaker exercise

Back 102

• Individual lifts head “high enough to observe toes”
• Maintains for maximum of 1 minute
• Completes 3X

Front 103

Isokinetic Shaker exercise

Back 103

• 30 repetitions raising and lowering head

Front 104

Shaker exercise should be completed how often?

Back 104

3X/day for 6 weeks

Front 105

Shaker is designed to be performed...

Back 105

independently, but compliance issues-have patients return for follow-ups to check on progress

Front 106

Variations on Shaker exercise

Back 106

- Jaw opening

- Chin tuck against resistance - CTAR

Front 107

Jaw opening

Back 107

• Hold mandible in maximally opened position for 10s, rest 10s
• Two sets of 5 reps completed daily X 4 weeks
• Individuals with dysphagia
– ↑ superior hyoid movement and width of UES opening
– No improvement in anterior hyoid movement
– No decrease in residual

Front 108

CTAR

Back 108

• Compress ball between chin and sternum for 10s
• 10 consecutive reps of ball compression
• Healthy adults
– Greater SMG activation of suprahyoids compared to Shaker exercise

Front 109

EMST

Back 109

Expiratory Muscle Strength Training

Front 110

EMST initially used to...

Back 110

to ↑ voice and speech but findings showing positive effects on swallowing and cough

Front 111

EMST - increase...

Back 111

forced output of the expiratory muscles

Front 112

Neuromuscular Electrical Stimulation
(NMES)

Back 112

– Intramuscular-motor
– Transcutaneous (VitalStim)-motor
– Peripheral stimulation of the faucial archessensory
– Peripheral stimulation of the pharynx-sensory

Front 113

NMES is designed to...

Back 113

augment the motor pattern

Front 114

NMES should be used for specific...

Back 114

swallowing pathophysiology, not applied randomly

Front 115

Pharyngeal electrical stimulation does...

Back 115

Sensory input to the pharynx to expands the
cortical swallowing area of the ipsilesional hemisphere

Front 116

Pharyngeal electrical stimulation procedure...

Back 116

– Intraluminal catheter inserted into pharynx
• 5 Hz for 10 min increased cortical excitability and expansion of cortical area
• Improvement in swallowing function on VFSS
• Results persisted for 30 minutes

Front 117

Peripheral Neuromuscular Stimulation

Back 117

Stimulation of anterior faucial arches
• Less effect on placticity
• Stimulation at 5 Hz inhibited cortical response
• Stimulation at 0.2 Hz facilitated cortical response but had no effect on functional swallow

Front 118

Cricopharyngeal bar

Back 118

Prominent extrinsic defect on the posterior
aspect of the cervical esophagus

Front 119

Cricopharyngeal bar is seen around where?

Back 119

C5-C6

Front 120

_____________________ of cricopharyngeal bar is debatable

Back 120

Functional significance

Front 121

Prevalence of cricopharyngeal bar

Back 121

5-11% - generally and incidental finding

Front 122

Cricopharyngeal bar may be due to... (2)

Back 122

1. Neuromuscular Disease

2. GERD

Front 123

some neuromuscular diseases that can cause bar

Back 123

polio

stroke

MD

Front 124

Cricopharyngeal bar can be a factor for development of...

Back 124

Zenker's diverticulum

Front 125

Treatment for cricopharyngeal bar

Back 125

Botox, possibly myotomy

Front 126

Diverticulum

Back 126

Out-pouching of a structure

Front 127

Which diverticulum is superior to the UES?

Back 127

Zenker's

Front 128

Which diverticulum in inferior to the UES?

Back 128

Killian-Jamieson

Front 129

Diverticulum results from...

Back 129

repeated failure of UES to remain open for bolus clearance that leads to prolonged pressure

Front 130

What will patient report if they have a diverticulum?

Back 130

• Patient will report regurgitation of undigested food

Front 131

Treatment for diverticulum is...

Back 131

surgical

Front 132

Osteophyte

Back 132

Bony outgrowth from
vertebrae

Front 133

If osteophyte too large, may...

Back 133

interfere with swallowing, e.g., epiglottic deflection, width of UES opening

Front 134

Osteophyte treatment is...

Back 134

surgical, but questionable if this
helps

Front 135

Tumor staging parameters

Back 135

– Location, Size, Nodes, and Metastasis

Front 136

Tumor size

Back 136

1-4

Front 137

Nodes

Back 137

Number of lymph nodes involved

Front 138

Metastasis

Back 138

Presence of tumor outside the region

Front 139

Example of tumor staging notation

Back 139

T2N1M1 (subscripts)

Front 140

Treatment for head and neck cancer (3)

Back 140

1. Surgical resection

2. Radiation therapy (XRT)

3. Both

Front 141

Head and neck cancer surgical treatments (3)

Back 141

1. Structure(s) resected

2. Closure technique

3. Neck dissection

Front 142

Closure technique is particularly critical in ____________

Back 142

oral cavity

Front 143

Neck dissection options (2)

Back 143

• Modified (MND) or Radical (RND)

Front 144

If person requires both surgery and XRT, XRT
generally completed...

Back 144

post-surgery

Front 145

Devascularization

Back 145

decreased healing

Front 146

XRT length

Back 146

5-6 weeks

Front 147

Frequently tooth extraction prior to XRT - causes what for speech/swallowing?

Back 147

decreased salivary flow

increased dental disease

Front 148

Xerostomia

Back 148

decreased saliva

Front 149

Xerostomia causes what?

Back 149

decreased bolus manipulation and transfer

Changes in tongue motion that may affect evocation of the pharyngeal swallow

Front 150

Fibrosis

Back 150

change in muscle fibers due to ↓ blood flow-progressive

Front 151

Fibrosis affects what?

Back 151

– Bolus manipulation and transfer
– Affects all aspects of pharyngeal stage

Front 152

Mucositis

Back 152

injury to mucosa characterized by erythema and ulcerative lesions

Front 153

Mucositis occurs where?

Back 153

– Oral cavity but can also occur in pharynx and esophagus

Front 154

Stricture

Back 154

Narrowing or closure of the pharynx or esophagus

Front 155

Suspected cause of stricture

Back 155

» Ulceration from severe mucositis
» Immobile larynx 2° radiation fibrosis and limited swallowing attempts

Front 156

– Goal is to keep a person ________________ during XRT

Back 156

receiving oral intake

Front 157

Initiate ROM exercises prior to, during, and
maintain throughout lifetime

What do they target?

Back 157

- Tongue

- Mandible

- Hyolaryngeal complex

Front 158

Oral cancer tumor locations

Back 158

• FOM-anterior, lateral
• Tongue-anterior, lateral, base
• Tonsil
• Faucial pillar
• Hard palate
• Soft palate
• Mandible

Front 159

Tumors involving posterior oral cavity (faucial
pillar, tonsil, BOT) also impact...

Back 159

pharyngeal stage of swallowing

Front 160

Oral Cancer
– Composite resection
• Involves...

Back 160

removal of more than 1 structure

Front 161

Oral Cancer

– Surgical closure techniques

Back 161

• Primary-suture soft tissue
• Skin grafts-transplantation of superficial skin from
one site to the area of the resection
• Flap-tissue elevated from normal site
– Pedicle flap-tissue from one site with continued
connection of blood supply to the area of resection
– Microvascular free flap-tissue along with blood supply

Front 162

For oral cancer dysphagia, pay attention to these three things...

Back 162

– Structure(s) resected
– Amount of structure resected (particularly in reference to tongue)
– Nature of Reconstruction

Front 163

– Anterior tongue resection

Back 163

• Difficulty moving tongue
• Initially delayed onset of pharyngeal swallow

Front 164

– Anterior FOM

Back 164

• Some initial difficulty with oral transfer but
swallowing is generally okay

Front 165

– Anterior composite resection involving tongue

Back 165

• ↑ severity of deficits
• ↓ mastication

Front 166

– BOT resection/Posterior composite resection

Back 166

• Oral and pharyngeal stage problems
– ↓ oral prep, mastication, transfer
– Delayed pharyngeal swallow
– BOT resection affects BOT retraction
– Possibly ↓ hyolaryngeal anterior and superior movement

Front 167

• Oral Cancer-Swallowing Treatment

Back 167

– Pre-operative counseling
– If possible, particularly before XRT, start ROM
exercises
– May require speech therapy
– TX initiated 10-14 days post-op

Front 168

Oral Cancer-Swallowing Treatment
– Prosthesis

Back 168

fill in palate or defect

Front 169

Maxillary reshaping prosthesis

Back 169

facilitates tongue to palate contact

Front 170

Oral Cancer-Swallowing Treatment

– Swallowing TX

Back 170

• Consistency
• Posture-head back
• ROM and muscular strengthening exercises
• TTS
• Other rehabilitative exercises depending of problem

Front 171

• Laryngeal Cancer
– Tumor location

Back 171

• Supraglottic
• Glottic
• Subglottic

Front 172

• Supraglottic Laryngectomy
– Tumor involves:

Back 172

• Epiglottis
• Aryepiglottic fold OR
• FVF

Front 173

• Supraglottic Laryngectomy
– Resection includes:

Back 173

• Epiglottis
• Aryepiglottic folds
• FVF
• Hyoid
• Possibly BOT resection-even worse swallowing function
• Possibly 1 TVF or 1 arytenoid may be removed significant risk of aspiration

Front 174

• Supraglottic Laryngectomy
– Surgery involves...

Back 174

laryngeal suspension for improved airway protection

Front 175

Supraglottic Laryngectomy

– Long recovery

Back 175

• ↑ time to recovery: BOT < TVF < arytenoid
• Possible need for total laryngectomy or trach

Front 176

• Supraglottic Laryngectomy-Swallowing
– Aspiration...

Back 176

during swallow

Front 177

Supraglottic Laryngectomy-Swallowing
– If BOT...

Back 177

↓ BOT retraction

Front 178

Supraglottic Laryngectomy-Treatment

Back 178

– ↑ Consistency
– Super-supraglottic swallow
• Ability to learn swallowing sequence criteria to performing surgery
– BOT exercises
– ↑ time to swallowing recovery if patient unable to tolerate oral intake prior to XRT

Front 179

Hemilaryngectomy

Back 179

Removal of one vertical half of the larynx

Front 180

Options for hemilaryngectomy (what can be removed)

Back 180

• 1 FVF
• 1 TVF (usually excluding arytenoid)
• Part of thyroid cartilage

Front 181

Hemilaryngectomy-Swallowing
– Frequently no...

Back 181

dysphagia

Front 182

Hemilaryngectomy-Swallowing
– Immediately post-op, may need...

Back 182

• Chin tuck
• Head turn

Front 183

Hemilaryngectomy-Swallowing

– Arytenoid involvement yields...

Back 183

significant dysphagia with difficulty with airway protection

Front 184

Total Laryngectomy

Back 184

Entire larynx and thyroid cartilage removed

Front 185

Total Laryngectomy
– No aspiration, unless...

Back 185

a TE fistula

Front 186

Total Laryngectomy

– Swallowing problems can occur post-op or
years later... (2)

Back 186

• Pseudoepiglottis
• Stricture

Front 187

Laryngeal Cancer
– All patients require...

Back 187

pre-op counseling

Front 188

For total laryngectomy, communication
options are a focus of...

Back 188

counseling

Front 189

Neurogenic dysphagia: prevalence

Back 189

>500,000 worldwide

Front 190

Neurogenic dysphagia occurs in ____% of acute stroke patient

Back 190

~55%

Front 191

Stroke

_______% demonstrate aspiration on instrumental exam

Back 191

40%

Front 192

Stroke

______% demonstrate silent aspiration

Back 192

40%-70%

Front 193

Unilateral supratentorial stroke

Back 193

• RHD or LHD
• Anterior > posterior
• Cortical or subcortical (↑ incidence with corticalsubcortical involvement)
• ↑ incidence with subcortical white matter vs gray matter lesioning

Front 194

Stroke-supratentorial
– Differences between RHD and LHD
(according to some)

Back 194

• ↑ oral stage dysfunction with LHD
• ↑ pharyngeal stage dysfunction and aspiration with RHD

Front 195

Stroke-supratentorial
– No differences in swallowing dysmotility
between hemispheres (according to others, like Dr. Daniels)

Back 195

• Equal incidence of oral and pharyngeal stage
problems, and aspiration between RHD and LHD
• ? if cognitive deficits generally associated w/ RHD contribute to notion of more impaired swallowing

Front 196

? if cognitive deficits generally associated w/ RHD
contribute to notion of more impaired swallowing

Back 196

– Neglect-spatial, sensory, awareness of deficits
– Attention, Impulsive
– More apt to be more conservative in recommendations?

Front 197

Apraxia of swallowing-(questionable terminology)

Back 197

• Disorganized lingual movements resulting in
extended oral transfer OR hesitation in initiation of oral movement
• More evident in artificial environments (e.g.,
instrumental examination) and with cue to swallow
• Not evident in natural environment with no weight loss in patients

Front 198

Stroke-Lateral Medulla
AKA...

Back 198

Stroke-Lateral Medulla

Front 199

Stroke-Lateral Medulla

Back 199

– Cluster of symptoms including dysphagia
– Severe pharyngeal dysphagia-even saliva
– All aspects of pharyngeal stage involved
• Initially, frequently severely delayed or absent
swallow. Once evoked, weak
• ↓ superior, anterior hyolaryngeal movement with ↓
UES opening
• Oral stage generally intact
• Good sensation
• Good cognition

Front 200

Stroke recovery timeframes

Back 200

– If single supratentorial stroke-recovery within
3-4 weeks-(functional, but may not be “normal”)
– Much longer period of recovery for LMS

Front 201

Neurogenic Dysphagia
• Movement Disorders

Back 201

– Parkinson disease-ideopathic
– Parkinson plus diseases (atypical PD)
• Progressive Supranuclear Palsy
• Olivopontocerebellar Atrophy (multisystems
atrophy)
– Huntington disease
– Wilson disease

Front 202

Parkinson disease
_____% experience dysphagia, particularly as
the disease advances

Back 202

~70%

Front 203

Onset of Parkinson disease

Back 203

approx 55-65 y/o

Front 204

Parkinson is slowly __________

Back 204

progressive

Front 205

Parkinson disease
– Dysphagia characteristics (6)

Back 205

• Repetitive anterior-posterior (rolling) lingual gestures
• Delayed onset of the pharyngeal swallow
• ↓ BOT retraction
• ↓ pharyngeal contraction
• ↓ anterior and superior hyolaryngeal movement
• Can frequently see tremor of tongue on CSE and tremor of laryngeal and pharyngeal structures on VFSS

Front 206

Huntington Disease
Cause

Back 206

– Diffuse atrophy of caudate and putamen

Front 207

Huntington - Onset

Back 207

30-50 y/o

Front 208

Huntington - Neurologic Symptoms (4)

Back 208

• Gait disturbance
• Dysarthria
• Dysphonia
• Dysphagia

Front 209

Huntington Disease
– Dysphagia characteristics (5)

Back 209

• Lingual chorea
• Poor coordination of breathing and swallowing
• Eructation
• Uncontrollable posture-affects oral and pharyngeal motility
• Tachyphagia-rapid, unregulated swallowing

Front 210

Dementia disorders (4)

Back 210

– Alzheimer disease
– Vascular dementia
– Lewy body dementia
– Frontotemporal dementia

Front 211

Dementia
– Alzheimer disease

Back 211

• Decline in one or more major cognitive domains

Front 212

Alzheimer onset

Back 212

• Onset generally after 65 years

Front 213

Dementia
– Alzheimer disease

• Dysphagia characteristics (4)

Back 213

– ↓ oral transfer (some suggest cue negatively impacts swallowing and ↑ performance w/o cue)
– Delayed pharyngeal swallow
– Aspiration as disease progressive
– ? agnosia

Front 214

• Multiple Sclerosis

Back 214

– Multiple CNS white matter tracts
– Remitting/relapsing pattern of symptoms

Front 215

Multiple Sclerosis

– Onset

Back 215

25-30 to middle age

Front 216

Multiple Sclerosis

– Symptoms-multifocal CNS involvement (5)

Back 216

• Ataxia
• Weakness
• Spacticity
• Fatigue
• Cognitive problems

Front 217

Multiple Sclerosis
– Dysphagia is not...

Back 217

common

Front 218

Multiple Sclerosis

– Dysphagia characteristics (4)

Back 218

• ↓ bolus formation
• Delayed pharyngeal swallow
• ↓ BOT retraction and PPW contraction
• ↓ UES relaxation

Front 219

• Peripheral Nervous System - 3 disorders

Back 219

– ALS
– Myasthenia Gravis
– Guillain-Barre Syndrome

Front 220

Peripheral Nervous System
– Myopathies
• Muscular dystrophies (2)

Back 220

– Oculopharyngeal
– Myotonic

Front 221

Peripheral Nervous System
– Myopathies

• Imflammatory Myopathies (3)

Back 221

– Dermatomyositis
– Polymyositis
– Inclusion body myositis

Front 222

Amyotrophic Lateral Sclerosis (ALS)

Back 222

– UMN and LMN degeneration

Front 223

Amyotrophic Lateral Sclerosis (ALS)

– Bulbar presentation (5)

Back 223

• Dysphagia
• Dysarthria
• Fasciculations
• Muscle atrophy
• Sialorrhea

Front 224

• Amyotrophic Lateral Sclerosis (ALS)
– Spinal (limb) presentation (3)

Back 224

• Reduced dexterity
• Limb weakness
• Spasticity

Front 225

ALS onset

Back 225

@ 60 y/o

Front 226

ALS

FTD in _____%

Back 226

~5%

Front 227

ALS

Death within ______ of ________

Back 227

2 years

bulbar Dx

Front 228

• Amyotrophic Lateral Sclerosis (ALS)
– Dysphagia characteristics (5)

Back 228

• ↓ lingual movement-yields problems with oral transfer, mastication, premature spillage, and oral residual
• ↓ velopalatal seal
• ↓ BOT retraction
• ↓ laryngeal elevation
• ↓ UES opening

Front 229

ALS

Decline in _____ parallels decline in
swallowing

Back 229

speech

Front 230

ALS

↑ dysphagia with ___________ regardless of
type of ALS

Back 230

↓ vital capacity

Front 231

ALS

AAN recommends vital capacity >___% before
PEG tube placement

Back 231

50

Front 232

ALS

Treatment generally is...

Back 232

compensatory as active exercise fatigues muscles

Front 233

• Myasthenia Gravis onset

Back 233

5th decade

Front 234

• Myasthenia Gravis

Neurologic symptoms (5)

Back 234

• Fatigue with sustained exertion
• Ptosis
• Dyplopia
• Dysphagia
• Dysarthria

Front 235

Myasthenia Gravis
– Dysphagia Characteristics (5)

Back 235

• Worsening swallowing as meal progresses need to test for fatigue*
• Poor bolus formation
• Slow oral transfer
• Delayed pharyngeal swallow
• ↓ BOT retraction

Front 236

Myasthenia Gravis
- Treatment

Back 236

medication, compensatory strategies as active exercise yields fatigue

Front 237

Iatrogenic Dysphagia

- Results from...

Back 237

medication or surgery

Front 238

– Medication-induced Iatrogenic Dysphagia (1)

Back 238

• Tardive Dyskinesia

Front 239

– Surgery-induced iatrogenic dysphagia: manipulation of CN (2)

Back 239

• Cervical spine
• Carotid endarterectomy (CEA)

Front 240

Tardive Dyskinesia

Back 240

– Chronic blockade of dopamine receptors
• Associated with neuroleptic drugs
• 20% of patients

Front 241

• Tardive Dyskinesia

– Neurologic Symptoms (2)

Back 241

• Orobuccolingual dyskinesia
• Movement of trunk and pelvis

Front 242

Tardive Dyskinesia
– Dysphagia Characteristics (2)

Back 242

• Tongue thrust
• Disorganized lingual movements

Front 243

• Cervical Spine Surgery

Back 243

– Anterior approach yields greater incidence of dysphagia than posterior
– Damage to pharyngeal plexus
– Also associated dysphonia

Front 244

Cervical Spine Surgery
– Dysphagia Characteristics (6)

Back 244

• Post-operative edema contributes to dysphagia
• ↓ PPW contraction
• ↓ anterior and superior hyolaryngeal movement
• ↓ epiglottic inversion
• ↓ UES opening
• TVF paresis

Front 245

• Carotid Endarterectomy (CEA)

Back 245

– Surgery to remove plaque from carotid
arteries
– Injury to CN VII, X, XII as close to carotid
bifurcation

Front 246

• Carotid Endarterectomy (CEA)
– Dysphagia Characteristics (2)

Back 246

• Post-operative edema
• Same as with cervical spine surgery but also
lingual motility problems if CN XII is involved and
buccal stasis if CN VII is involved