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406 Cards in this Set

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What is the most prevalent swallowing disorder in patients with closed head trauma?
Delay triggering the pharyngeal swallow
What is the most prevalent swallowing disorder in patients with stroke?
Delay triggering the pharyngeal swallow
How is the length of coma related to the severity of swallowing problems?
The longer the coma, the more severe the swallowing problems (yeah, that one made you feel good, didn’t it?)
Patients with closed head injury have complex swallowing problems due to the combination of _____________, ____________, and ______________.
Closed head injury, damage to other parts of the body, and nature of emergency care.
Neurogenic damage can be caused by what three forces?
Direct head injury, contra-coup injury, and twisting/shearing of the brainstem
Patients with head trauma may experience other injuries including ____________, _____________, and _______________.
Puncture woulds to the neck, laryngeal fracture, and penetration wounds to the chest (affecting the esophagus)
Patients receiving emergency care may be injured by ____________ or _____________.
Tracheostomy - may be placed to high scarring the larynx. Intubation - forceful intubation can also damage the larynx.
What are four oral swallowing disorders seen in those with closed head injury?
Reduced lip closure, reduced tongue ROM (with poor bolus control), abnormal oral reflexes (including bite reflex), and delayed/absent pharyngeal swallow.
What are eight pharyngeal swallowing disorders seen in those with closed head trauma?
Reduced laryngeal elevation, reduced closure of airway entrance, reduced closure of airway throughout, reduced tongue base motion, reduced CP opening (usually related to reduced laryngeal motion), uni/bilateral pharyngeal wall weakness, tracheoesophageal fistula, reduced velopharyngeal closure.
In patients with closed head injuries, reduced airway closure and reduced CP opening (due to poor laryngeal motion) are generally related to ______________ instead of neurologic damage.
Physical damage to the larynx
What are some patient characteristics which affect swallowing in those with closed head injury?
Impulsiveness, tendency to overstuff mouth, cognitive difficulties, reduced sensation.
True or False: The recovery of swallowing after closed head injury is well documented
False: One study showed recovery over time but it was based on bedside evaluation (Gasp! No radiographic study?!)
True or False: Patients of any age will develop complications from aspirating over a short period of time
False: Younger patients can aspirate (especially on liquids) with no apparent consequences for a year or more.
Why is it important to counsel the family regarding swallowing and dietary changes during the acute phase?
Because if you wait until the rehabilitation stage, the patient and family may not comply with your recommendations.
If a patient with closed head injury has cognitive deficits __________________ will be easier to use than _____________.
Postures and sensory heightening will be easier than voluntary maneuvers.
True or False: Most patients with closed head injury will need to use voluntary maneuvers in order to manage their swallowing disorders.
False: Because the most common disorders are delayed pharyngeal swallow and reduced range/coordination of tongue motion and these can be addressed using other methods.
Initial therapy tasks for patients with cognitive deficits include…
sensory heightening strategies, resistance exercises, range of motion exercises.
When working with family members of patients with closed head injuries, it is crucial to explain the _______________.
Goal of each therapy task and compensatory strategy.
True or False: If you determine that a patient has reached a plateau and dismiss them from therapy while on non-oral or limited oral feeding, that patient will not be able to return to a full oral diet.
False: You should re-evaluate the patient every 6 mos. to 1 year. It is possible that the patient will recover swallowing function after a longer period of time.
In patients with cervical spinal cord injuries, swallowing disorders are usually __________ in nature.
Pharyngeal
Common swallowing disorders in patients with cervical spinal cord injuries include (5):
Delayed triggering of pharyngeal swallow, reduced laryngeal elevation, reduced anterior movement of the larynx (causes reduced UES opening), reduced tongue base motion, and uni/bilateral pharyngeal wall dysfunction.
Damage to CV 4,5, or 6 will often result in…
Poor laryngeal motion leading to poor UES opening
Damage to CV 1 or 2 will result in…
No sensory awareness of swallowing difficulties
True or False: Patients with cervical spinal cord injury may have difficulty closing the airway entrance.
True: This is usually related to poor laryngeal elevation or anterior movement
True or False: Patients with cervical spinal injury don't generally have trouble closing the airway at the vocal folds.
True: This is infrequent in this population. When it does occur, it is generally related to direct laryngeal damage (Intubation, trachostomy placement, prolonged trach)
When patients have SCI damage at or above C3, they may require _______________.
Mechanical ventilation
Name reasons patients with cervical SCI are difficult to assess at bedside
Patients may require mechanical ventilation (cuffed trach) and when the damage is above C5 the swallowing disorders are generall pharyngeal so you can't observe it at bedside.
If a patient is wearing a head/neck brace, during X-Ray you may need to _________________.
Angle the patient 15-30 degrees because the brace may shadow certain parts of the anatomy.
With cervical SCI patients, what procedures will you use during the radiographic study?
Postural changes are often not possible, sensory heightening and voluntary maneuvers are the most helpful.
What are the effects of cervical bracing on the swallow?
Not yet identified in dysphagic patients, but some studies conducted on individuals with normal swallow. These patients report a worsening of the swallow when wearing a brace but the only significant change is LONGER airway closure.
Swallowing becomes more difficult when cervical bracing positions the head in what ways?
If the chin is pulled back / chin or head is retracted on the neck, also if head is extended.
Following an anterior cervical fusion, patients may suffer from what swallowing issues?
Swelling of posterior pharyngeal wall, reduced laryngeal elevation/anterior movement (resulting in reduced closure of airway entrance and reduced CP opening), reduced uni/bilateral pharyngeal wall movement, and possible oral stage problems/delayed triggering of pharyngeal swallow.
Swallowing problems in patients with anterior cervical fusion are caused by…
Trauma to peripheral nerves, swelling, and reactions to hardware in the neck
What is the recovery pattern for swallowing in patients with anterior cervical fusion?
Patients generally recover significantly in 3 months or less. You should determine intervention strategies to allow for oral intake in the meantime.
What are the most helpful techniques for patients with anterior cervical fusion?
Generally compensatory techniques are useful because the swallow is likely to recover spontaneously. Most helpful are: Mendelsohn manuever, supraglottic swallow, super supraglottic swallow. (Remember, postures = ouch!)
Damage to the [part of brainstem] will lead to significant swallowing problems including ____________________.
Medulla / complete inability to trigger pharyngeal swallow
Patients with damage to the medulla may benefit from what techniques?
Sensory heightening because the issue is often a problem triggering the pharyngeal swallow. Try Thermal-Tactile Stim and/or Suck-Swallow technique.
What is the goal of sensory heightening techniques?
To lower the threshold of the swallowing center in the central nervous system
Following removal or acoustic neuroma or other tumor from a cranial nerve, there may be damage to cranial nerves ____, ____, ____, ____, and possibly ____.
VIII, IX, X, XII and VII
Symptoms of cranial nerve damage following neurosurgical procedures will be __________ and may include…
UNILATERAL, facial weakness, pharyngeal wall paresis/paralysis, soft palate weakness, vocal fold adductor paralysis, tongue paresis
Damage to cranial nerve IX will often result in…
Delayed triggering of the pharyngeal swallow
As cranial nerve damage usually results in _________ problems, patients will often benefit from ______________________.
Unilateral / postures: head rotated to the damaged side or chin down to protect the airway during delay.
In addition to compensatory strategies, patients with cranial nerve damage benefit from…
ROM and resistance exercises for lips, oral tongye, tongue base and larynx (Falsetto, effortful swallow, super-supraglottic swallow)
Patients who are cognitively intact should practice exercises ______ times per day for ______.
10 / 5 minutes
Poliomyelitis may lead to disturbances in what stage of the swallow?
Both Oral and Pharyngeal
What oral stage swallowing disturbances may result from poliomyelitis (2)?
Reduced lingual control of bolus, disturbed pattern of bolus propulsion
What pharyngeal stage swallowing disturbances may result from poliomyelitis (3)?
Reduced pharyngeal contraction, Unilateral pharyngeal paralysis, Reduced velopharyngeal closure (leading to nasal regurgitation)
Guillan-Barre is a ____________ causing rapid onset of paresis which may progress to…
Viral-based disease / complete paralysis requiring tracheostomy and mechanical ventilation.
Swallowing difficulty is occasionally the first sign of __________ and is soon followed by general weakness and paralysis.
Guillan-Barre
What will be observed during radiographic study in patients with Guillan-Barre?
Generalized weakness in oral and pharyngeal swallow; reduced ROM of oral tongue, tongue base, and larynx.
Therapy for patients with Guillan-Barre should begin with…
Gentle resistance and ROM exercises, increasing effort as the patient improves.
Respiration is originally unstable in patients with Guillan-Barre, so ________________ should be postponed. Later on _____________ are helpful.
Swallowing therapy or maneuvers that prolong airway closure; Supraglottic swallow or Mendelsohn.
Patients with cerebral palsy may exhibit (4 characteristics)…
Inappropriate oral reflexive behaviors; inability to hold cohesive bolus; disorganized lingual movements (bolus not propelled smoothly); pieces of food may spread out during chewing (premature spillage)
Patients with cerebral palsy may be placed into which three categories of swallowing disorders?
Moderate to severe oral function problems; oral function problems + delay triggering pharyngeal swallow; oral function problems + delayed PS + neuromuscular abnormalities during PS
Most children with cerebral palsy fall into the category of swallowing disorders characterized by… This means which consistencies will be challenging?
Oral function problems + Delayed PS / foods requiring chewing will be a challenge due to oral motor issues while thin liquids will also be difficult due to pharyngeal delay
What three oral function problems are commonly observed in patients with cerebral palsy?
Reduced lip closure, tongue thrust, reduced tongue coordination
Patients with cerebral palsy may exhibit what 3 neuromuscular abnormalities once the pharyngeal swallow is triggered?
Reduced tongue base retraction; reduced laryngeal elevation; significant residue after swallow leading to aspiration (this group may aspirate on every consistency)
Management of swallowing disorders in patients with cerebral palsy commonly includes…
Oral motor therapy; thermal tactile stim; diet change to thickened liquids and purees (LAST OPTION)
TRUE or FALSE: Cricopharyngeal dysfunction is rarely a problem in patients with cerebral palsy
TRUE: Myotomy should not be attempted unless other options have been exhausted. As the child grows the larynx will also drop and this may improve opening of the UES.
Do patients with cerebral palsy generally suffer from aspiration DURING the swallow?
No, generally laryngeal closure is adequate
When does aspiration generally occur in patients with cerebral palsy? What causes it?
BEFORE the swallow: reduced tongue control and delayed pharyngeal swallow / AFTER the swallow: residue left due to poor tongue base action and reduced laryngeal elevation.
Dysautonomia is also known as ____________ and is a ____________ disease with widespread effects including…
Riley-Day Syndrome / Inherited / autonomic inbalance, sensory deficits, motor incoordination, certain episodic phenomena
Patients with Riley-Day syndrome suffer from what type of swallowing problems?
Milder problems - reduction of oral tongue control and reduced tongue base and pharyngeal wall motion. More severe problems - oral involvement and delayed triggering of pharyngeal swallow.
Patients with Riley-Day syndrome may require a G-tube because…
1) Delayed PS - patient may not handle thin liquids and G-tube will be needed for hydration. 2) Dysfunctional LES places the patient at risk for reflux. A G-tube decreases this risk.
Swallowing therapy for patients with Riley-Day syndrome may include…
Oral motor therapy to improve toney function, thermal-tactile stim to help with triggering of pharyngeal swallow.
Techniques to design to improve SPECIFIC swallowing disorders include (7):
Surgical reduction of osteophytes; vocal fold medialization; injection of material into the vocal fold to include closure; laryngeal suspension; dilation of scar tissue in CP area; cricopharyngeal myotomy; botox injection into spastic CP
Cervical osteophytes may cause swallowing disorders due to…
1) Displacement of posterior pharyngeal wall which may interrupt bolus flow, 2) pressing on nerves which creates a sense of dysphagia.
Cervical osteophytes may be surgically removed but there are two possible disadvantages
1) Scar tissue will be created, 2) Possilbe surgical trauma to nerves innervating swallowing structures
After a patient with insufficient airway protection attempts exercises, a surgical option to protect the airway is…
To inject the damaged fold with material to improve closure / Vocal fold medialization surgery
_____ % of aspiration is caused by poor vocal fold closure
10% or less
Laryngeal suspension is used for patients with [swallowing disorder]. It is sometimes used in patients with [medical diagnosis] but rarely in _________ patients.
Reduced laryngeal elevation; Head and neck cancer patients; Neurologic patients
__________ are mercury-filled soft rubber tubes used to dilate scar tissue in the CP region.
Bougies
The effects of scar-tissue dilation are ________, lasting __________.
Temporary / 1-3 months
Dilation of the CP region is generally NOT effective when the cause of the CP dysfunction is…
Neurologic damage
Describe the surgical procedure for a CP myotomy
External incision made through the neck (usually left side); CP fibers are slit from top to bottom usually at posterior midline; May extend upward to inferior constrictor and downward into the upper esophageal musculature.
Improvement of the swallow following a CP myotomy is reported in _______& of cases.
60-78%
What is the criteria for candidates for CP myotomy?
1) CP dysfunction must be the predominant problem; 2) Patient must be able to move material through the oral and pharyngeal stages of the swallow; 3) Patient must be able to voluntarily close airway during the swallow.
What effect does a CP myotomy have if performed as a preventative measure at the time of oncologic procedure?
Study found no difference in post-operative swallowing for patients who did/did not receive a preventative myotomy.
When a CP myotomy alone does not fix the swallowing problem, what can be used?
Head-rotation to the unoperated side (helps with opening UES and directs food to more "open" side). Also, Mendelsohn Maneuver can be used to prolong lanrygeal elevation.
CP Myotomy is counterindicated for patients with…
Multiple dysfunctions of the vocal tract - reduced lingual control, delayed pharyngeal swallow, reduced pharyngeal contraction - on top of CP dysfunction.
Complications of a CP myotomy include…
Hemorrhage, recurrent laryngeal nerve damage, complications from surgically opening the neck.
What are two disadvantages of Botulinum Toxin injection for relaxation of the CP?
1) Difficult to accurately place the injection - CP is hidden behind cricoid cartilage, 2) Inaccurate injection can paralyze other muscles in the area worsening the dysphagia.
List six procedures used to control unremitting aspiration
Epiglottic pull-down, suturing vocal folds together, suturing false vocal folds together, laryngeal bypass / tracheoesophageal diversion, tracheostomy, total laryngectomy
What is an advantage and disadvantage to epiglottic pull-down?
AD: It is potentially reversible; DIS: The epiglottis commonly pulls away, making the procedure unsuccessful
What is the procedure and disadvantages for suturing the vocal folds together?
The epethelium is stripped and the vocal folds are sewn shut. They often tear apart making the procedure unsuccessful. Also, it is usually irreversible.
What are some advantages to suturing the false vocal folds together to control unremitting aspiration?
The false folds are less likely to tear apart than the true vocal folds. Also, this procesure is usually reversible.
For a tracheoesophageal diversion, the cut is generally made at ________ and this is a ___________ procedure.
3rd-4th tracheal ring / relatively permanent
A total laryngectomy is only used to control aspiration when…
There is no other solution for aspiration - it is a permanent procedure.
All non-oral feeding types place the patient at higher risk for _______________.
Gastroesophageal Reflux
In patients with NG tubes, each feeding is usually followed by…
120-240 cc of water to cleanse the tube and ensure adequate hydration
What is the name for a smaller-diameter NG tube that can be used to help prevent irritation and reflux?
A Dobhoff tube
Disadvantages of NG tubes include:
1) Physical presence of the tube is irritating; 2) Potential for reflux; and 3) Feedings usually prepared = expensive
True or False: Data indicates that the presence of an NG tube changes the physiology of the swallow.
FALSE
An NG tube is generally temporary, replaced by a more permanent solution in _____ months if the patient can't transition back to oral feeding.
3-4 months
List six options for non-oral feeding:
NG tube, pharyngostomy, esophagostomy, gastrostomy, jejunostomy, and fundoplication
What are the advantages and disadvantages of pharyngostomy / esophagostomy?
AD: No tube through the nose - less irritating and more socially acceptable. DIS: Creation of scar tissue
What are the advantages and disadvantages of gastrostomy?
AD: Patient can take blender-prepped foods through the tube. This is a long-term solution to severe swallowing problems. DIS: Stoma site can leak, become infected/sore.
What are the advantages and disadvantages of jejunostomy?
AD: It reduces the risk of reflux. DIS: Requires prepared feedings which is more expensive.
Children with gastrostomy or jejunostomy require an additional procedure to reinforce the LES by wrapping the top of the stomach around it. What is this procedure called?
Fundoplication
A patient needs non-oral feeding if they aspirate more than ______ of all food consistencies or take longer than ______ seconds to swallow a single bolus of all food types despite therapeutic intervention.
10% / 10
The most common etiology of dysphagia of unknown origin is…
Neurologic disease
Which patients are most at risk for a combination of oropharyngeal and esophageal disorders?
Those over 60 and children with congenital neurologic impairment.
Who is responsible for esophageal assessment?
Gastroenterologist
The neurologic evalaluation will focus on ______________________.
Cranial nerves innervating muscles of swallowing and symptoms of neurologic disease which may lead to dysphagia.
Who is responsible for a structural evaluation of the head and neck as well as sensorimotor assessment ofpharynx and larynx?
Otolaryngologist
What team member will be enlisted if a patient has a history of recurrent or recent pneumonia?
Pulmonologist
Which team member is crucial for patients in rehab centers? What does this person do?
Physiatrist - helps fit the dysphagia rehabilitation plan into the patient's overall rehab schedule.
The Gerontologist is responsible for…
Determining REALISTIC goals for the patient as well as monitoring whether combinations of medications are contributing to the dysphagia.
Who makes prosthetic devices?
The Maxillofacial Prosthodontist
The physical therapist assists with…
Optimal positioning of the patient during meals
The occupational therapist can assist with…
Providing assistive devices for eating
What are the responsibilities of the dietician?
Monitoring blood chemistry, weight, and ensuring adequate nutrition.
Which team member decides when to transition the patient back to oral feeding?
Swallowing therapist + Dietician + Attending Physician
Provide an inservice for the respiratory and nursing staff to educate them on _________________.
Signs and symptoms of dysphagia
Provide an inservice for staff members responsible for feeding the patient to educate them on ___________________________.
Complexity of normal swallowing physiology, range of swallowing disorders, and the need for INDIVIDUALIZED feeding plans.
When establishing the radiographic procedure, be prepared to explain what three things?
1) The necessary radiographic procedure; 2) The rationale for all aspects of the procedure; 3) The ways it differs from a standard barium swallow/upper GI exam.
There are generally three fees to factor into the cost of the radiographic procedure. They are…
The room fee, the radiologist's fee, and the swallowing therapist's fee
What have studies shown about the cost and efficiency of dysphagia care using a multidisciplinary approach?
There is not a lot of data in terms of cost OR reduced rates of pneumonia, improved nutrition, and hydration.
Rehabilitation for laryngeal cancer patients became more common in the (decade) when _____________ was introduced as an alternative to _____________.
1950s / partial laryngectomy / total laryngectomy
When considering whether to use laryngeal preservation strategies in the treatment of cancer, Weiss suggests that _______________ is crucial
The patient's perception of quality of life (so, when possible try to preserve the larynx)
Tumors in the larynx may be managed by ____________ or ___________ with ___________ as an adjuvant therapy
Radiation or Surgery / Chemotherapy
For smaller tumors on the vocal folds, ___________ is often the treatment of choice. Cure rates for this treatment when compared to surgery are…
Radiotherapy / usually equal
The larynx is divided into three sections in which tumors may occur. What are these sections and what percentage of laryngeal tumors occur in each?
1) Supraglottis (35% of laryngeal tumors); 2) Glottis (60% of laryngeal tumors); and 3) Subglottic area (5% of laryngeal tumors here)
What does T1N0M0 mean?
A small tumor with no nodal involvment or distal metastasis
Who stages the tumor in head and neck cancer? At what point in the process?
The primary physician (usually otolaryngologist or general surgeon). It is staged prior to treatment.
The TMN staging system allows for comparison of ________________________
Results of therapy across various patients suffering from the same tumor
Will a supraglottic laryngeal tumor spread inferiorly? Why?
Only if it is at the base of the epiglottis / Because of the pattern of lymphatic drainage in the larynx.
True or False: There is not much known about tumors of the larynx
False: these have been studied extensively
In the oral cavity, a margin of 1.5 - 2 cm of normal tissue is the rule when removing tumors. Does this hold true for the larynx as well?
No - more is known about how laryngeal tumors spread so that rule is not always followed in the larynx. A 2-cm margin of normal tissue is always left at the upper end of a laryngeal resection, though.
Smaller supraglottic tumors may involve [list three structures] and are usually treated with ________________________.
Epiglottis, aryepiglottic folds, or false vocal folds / Partial laryngectomy (horizontal AKA supraglottic laryngectomy)
A supraglottic tumor which extends below the false vocal folds may require a resection that includes part or all of the _____________ and ____________ superiorly and the ___________ and ______________ inferiorly.
Hyoid, epiglottis / aryepiglottic folds, false vocal folds
If a supraglottic tumor extends onto the false vocal folds, will the entire ventricle be removed?
No, only the upper half - do not need the 2-cm margin in this case because of pattern of lymphatic drainage (and supraglottic tumors tend to spread laterally not inferiorly)
A standard supraglottic laryngectomy removes the structures which contribute to _____________. These structures are [list three]. Another structure removed is the _________. What is left as a protective mechanism?
Airway protection / epiglottis, aryepiglottic folds, false vocal folds / hyoid bone / base of tongue, arytenoids, and true vocal folds.
During reconstruction following supraglottic laryngectomy, the surgeon will often ________________________________.
Elevate the remaining larynx and tuck it under the tongue base for additional protection during the swallow.
In patients with a supraglottic laryngectomy, what will be different about the swallow? What strategy can be used for both compensation and exercise?
The patient will now close the airway entrance by retracting the tongue base to contact the arytenoids. Laryngeal elevation will also be impaired (because hyoid bone is partially or completely removed)
In patients with a supraglottic laryngectomy, what will happen if the tongue base does not come into complete contact with the posterior pharyngeal wall?
There will be residue left over which will fall directly in the airway after the swallow - the patient has no valleculae anymore and pyriform sinuses will be smaller than usual.
Patients whose supraglottic laryngectomy is extended into the base of the tongue will have what issues? What is a big concern in these patients?
Food and liquid will tend to fall onto the closed airway entrance or on top of the vocal folds. A big concern is whether laryngeal elevation is sufficient to deflect this spillage and direct it into the esophagus.
Patients with laryngeal suspension (following superglottic laryngectomy) may have what two problems? What can be used in rehab?
1) Reduced lingual movement; 2) Reduced control of bolus. You can use ROM and bolus control exercises in therapy.
What are some sensory issues in patients with supraglottic larygectomy?
Sensation of the larynx may be reduced due to sacrifice of one superior laryngeal nerve - reduced cough reflex, patient unaware of aspiration, delayed pharyngeal swallow is also possible
The supraglottic laryngectomy can be extended inferiorly to include _____________ and occasionally ____________. What does this mean about the patient's recovering a normal swallow?
Part of one true vocal fold / part or all of on arytenoid cartilage / This means that the patient has even less tissue with which to protect the airway - changes of recovering normal swallow without chronic aspiration is diminished.
Long term follow-up of patients with standard supraglottic laryngectomy showed what results?
1) Regained normal swallowing with no aspiration during or after the swallow; 2) Able to swallow normal diet at ~ 1 month post; 3) Some patients took 3-6 months to recover oral intake.
Long term follow-up of patients with supraglottic laryngectomy extended to include part or all of one arytenoid revealed what results?
1) Minimum of 2 months (most often 6-12 mos.) attempting rehab; 2) Several never able to drink liquids without significant aspiration and required trach indefinitely
Long term follow-up of patients with supraglottic laryngectomy extended into tongue base revealed what results?
1) Significantly longer to return to oral intake (6 months or longer); 2) Larger resections of tongue may make airway protection impossible - may need to be converted to total laryngectomy
Following supraglottic laryngectomy, patients who do not achieve complete airway entrance closure at first should be put on a program of __________________. This will geneally have an effect within _________ after initiation. Some patients will progress slower but attain airway protection _________ after surgery with continued exercise.
Tongue base and arytenoid ROM exercise / 2-4 weeks / 3-4 months
Following supraglottic laryngectomy, patients with good tongue base action will generally rehabilitate to a normal swallow within ________ postoperatively if they can learn instructions for _________________.
1 month / super-supraglottic swallow
One criteria for selecting a supraglottic laryngectomy is that the patient must __________________
Have the capability of relearning the swallow sequence (those with mental disorders or who cannot follow a sequence of instructions are not good candidates)
Rademaker found that during recovery after a partial laryngectomy, patients who had not attained oral intake before _____________ took significantly longer to do so.
Beginning radiotherapy
In patients with partial laryngectomy (if possible), the onset of radiotherapy should be delayed until _________________.
Oral intake is reinstated
Tumors located on the free margin of one vocal fold with only local extension are generally treated using [three options]
Vertical laryngectomy, hemilaryngectomy, or extended laryngectomy
The hemilaryngectomy involves physical removal of one vertical half of the larynx including [four structures]. The [three structures] are usually left intact.
One false fold, one ventricle, one true vocal fold and a portion of the thyroid cartilage on the side of the resection / Hyoid bone, epiglottis, arytenoid
The patient who has undergone a typical hemilaryngectomy should experience _________ swallowing difficulties because…
Few / the unoperated side can attain normal laryngeal closure against the unoperated side because some tissue bulk is reconstructed on the side of the resection following removal of structures.
After a typical hemilaryngectomy, the surgeon will reconstruct by adding tissue to the operated side. In order for the patient to have a normal swallow, the added tissue must be ______________.
At the same level as the normal vocal fold (to achieve closure)
Patients with a hemilaryngectomy sometimes have aspiration during the swallow (temporary). This can be compensated for by ______________. If there is still aspiration, __________ can be attemped or ___________________________. The patient may need to do this for [time] postoperatively.
Chin down / head rotated to operated side / combination of chin down + head rotated which gives the best airway protection / only a few weeks
In some patients with laryngeal tumors, the tumor is located anteriorly so that the ___[structure]____ needs to be included in the resection. In this case, the procedure is known as a ______________ and means that _________[area]________ is removed.
Anterior commissure / frontolateral laryngectomy / Anterior 1/3 of the larynx on both sides (in addition to the entire operated side)
How do surgeons typically reconstruct following a frontolateral laryngectomy?
Bulk of tissue (ie. From strap muscles) placed on the operated side to give the normal side something to contact. The epiglottis, hyoid remain so that larynx can elevate. Both arytenoid cartilages are also present.
Patients who have undergone a frontolateral laryngectomy often recover within ____[time]____ but more of them will require a ____________ initially to prevent aspiration when compared to patients with typical hemilaryngectomy.
2-3 weeks post-operatively / chin-down posture
In a patient needing a hemilaryngectomy, it is possible that the resection will need to include ~ 1/2 of the other side of the larynx. This is called a _____________________.
3/4 laryngectomy
Patients with a 3/4 laryngectomy will generally have sufficient airway protection because [three reasons] but they often need _____________ initially to make eating safe. Also, some will need ____________ to improve airway protection over time.
1) Arytenoids are present; 2) Normal epiglottis and hyoid; 3) Tissue bulk added to the operated side during reconstruction / chin-down and head rotated postures / adduction exercises or super-supraglottic swallow
In patients with hemilaryngectomy, chances of returning to normal swallow without aspiration are greatly decreased if the __________ is included in the resection.
Arytenoid cartilage (ie. When lesion extends more posteriorly)
Long-term study of patients with limited hemilaryngectomy revealed what results?
Normal swallow generally within one week after initiation of oral feeding postoperatively
Long term study of patients with extended hemilaryngectomy (including arytenoid) revealed what results?
Experienced much longer rehabilitation period than those with limited hemilaryngectomy. Some were not able to manage liquids - aspiration during the swallow (needed permanent trach).
Patients with the arytenoid resected as part of an extended hemilaryngectomy generally require _____________ as well as ______________________ to facilitate swallowing without aspiration during the swallow.
Adduction exercises / chin-down + head rotated posture
______________ is a major problem in any extended partial laryngectomy procedure.
Preventing aspiration
Larger laryngeal lesions (T3 or T4) or those involving more than one region of the larynx usually require ________________ or ________________________.
Total laryngectomy; High-dose radiation with or without chemotherapy.
True or False: Patients who have undergone a total laryngectomy are at risk for aspiration after the procedure.
False: there is a physical separation of the GI tract from the respiratory tract.
Swallowing problems following total laryngectomy are related to…
1) Nature of closure (pseudoepiglottis); 2) Tightness of surgical closure; 3) gross anatomical differences (if pharyngectomy or esophagectomy is included)
A pseudoepiglottis is ____________________ following total laryngectomy.
A fold of tissue left at the base of the tongue
What are two explanations for the appearance of a pseudoepiglottis following total laryngectomy?
1) That it is caused by vertical closure of the defect because the base of tongue must be stretched vertically; 2) That the suture line at the base of the tongue breaks down from tension caused by tongue movement
On lateral fluorscopy, the pseudoepiglotts appears as a ____________________________. The greater the struggle, the greater the widening of this pocket.
Pocket at the base of the tongue which collects food and liquid during swallowing
Some total laryngectomees are restricted to _____________ because of a pseudoepiglottis
Liquid consistency
Total laryngectomy patients with lesions in the pyriform sinus or hypopharynx will require extensive resection of ___________. This can lead to a tighter closure forming _________________.
Pharyngeal mucosa / scar tissue in the esopagus
The major treatment for tight closure following total laryngectomy is ____________ but the effects are temporary.
Dilitation - patients asked to swallow increasingly larger mercury-filled rubber catheters to stretch the tissue.
A surgical option for tight closure following total laryngectomy is ___________ (described by Singer and Blom) but may also impact _______________________________.
Pharyngoesophageal myotomy / esophageal voice
Although there are no exercises to improve stricture following total laryngectomy, ________________ may stretch and open the narrowed area if other options are not feasible.
Changing head position (head rotation)
Following total laryngectomy, both a pseudoepiglottis and a stricture can cause _________________ as the patient struggles to swallow.
Backflow of food
Greater swallowing problems will occur if _____________ or _____________ is included along with a total laryngectomy. These problems can sometimes be managed by ___________.
Pharyngectomy / esophagestomy (ie. Backflow of food) / postural changes.
If a patient with total laryngectomy has not returned to full diet after ________, a radiographic procedure is needed to identify _____________.
2 months / structural abnormalities
In terms of treatment, a pseudoepiglottis may be __________ while a stricture may be ____________.
Surgically removed / dilated
If a total laryngectomy patient returns after months or years with swallowing complaints (but were originally eating well) what should you do?
Have them return to their surgeon immediately as this is a sign of possible recurrence
In total laryngectomy patients, a number of surgical and prosthetic devices have been used to try to ______________________________. A major problem with most of these methods is ____________________.
Reconnect the pulmonary outflow to the pharyngoesophagus (for voicing options) / aspiration of food into the trachea from the esophagus
True or False: The Staffieri neoglottis procedure is frequently used to provide voicing options in total laryngectomy patients
FALSE: You want to kill your patients, don't you (This procedure is not used anymore because it resulted in aspiration in most patients)
The most successful surgical method of providing voicing options to total laryngectomees is the ___________________. What does it involve?
Tracheoesophageal Puncture Procedure / involves placing a small prosthesis in a puncture that connects the trachea with the esophagus below vibratory portion. This is a one-way valve so air can be pushed into the esophagus for voicing but food will not flow from the esophagus to the trachea - no aspiration!
True or False: The Panje procedure is similar to using a TEP and is a successful way of restoring voicing to patients with total laryngectomy.
TRUE
In the TEP procedure (Singer and Blom), what can you do if the patient IS aspirating?
Cauterize the puncture site to narrow it and get a better fit for the prosthesis.
Candidates for Singer and Blom's TEP procedure may need a ________________ to prevent pharyngospasm.
Myotomy (much broader than your basic CP myotomy)
Two options for reducing pharyngospasm in patients using a TEP are…
1) Myotomy - pharyngeal muscles are cut which may mean diffuse residue left in the pharynx after the swallow; 2) Neurectomy - nerve supply cut to pharyngeal wall.
After a total laryngectomy, patients may experience minor changes in swallowing including _______________
Increased lingual pressure (to compensate for absence of larynx and reduced pharyngeal wall function)
When treated with radiotherapy for small laryngeal tumors (T1, T2), patients may experience _________ voice change (such as _____________) and changes in _____________.
Temporary / roughness or hoarseness / salivary flow
The radiation field used for high-dose laryngeal exposure extends from ______________________________
The oropharynx to the top of the esophagus
What are the effects of high-dose laryngeal radiation therapy (6,000-7,000 cGy) w/ chemo on swallowing?
Significantly reduced laryngeal elevation and pharyngeal wall motion (advanced laryngeal cancer patients) - laryngeal motion needed for UES opening!!
Issues caused by radiation may not arise until years later and are thought to be caused by…
The process of fibrosis of the tissues resulting from damage to capillaries feeding muscle fibers in the radiated area
Pretreatment counseling is needed for laryngeal cancer patients to ensure the patient is aware of __________________________________.
Possible changes in voice and swallowing that may occur after treatment
For laryngeal cancer patients who will receive radiation, it is generally best for them to begin __________________ exercises before or at the beginning to radiotherapy. These should be done _______ times per day for ________ minutes each and should be continued throughout radiotherapy and after.
ROM exercises for tongue base and laryngeal elevation / 5-10 times / 10 minutes
Two types of neurologic disorders that affect swallowing are:
1) Those that occur suddenly and 2) Those that are degenerative in nature
True or False: In sudden-onset neurologic disorders causing swallowing difficulty (stroke, TBI, etc.), the patient is expected to recover
True (at least in part)
Degenerative neurologic conditions will cause…
Gradual deterioration of swallowing ability over time
In patients who are expected to improve, what three questions should you consider?
1) What therapy should be initiated to normalize swallowing physiology? 2) Will the patient be able to eat a normal diet and when? 3) Is the patient's recovery typical of people with this type of lesion?
For patients with degenerative neurologic conditions, what four questions should you consider?
1) Are there typical changes in swallowing that occur with the onset of this disease? 2) Are there predictable changes in swallowing physiology characteristic of each lesion location? 3) How long can the patient continue to eat by mouth? 4) What techniques can prolong oral feeding?
Patients with neurologic disorders have reduced sensitivity to __________ as evidenced by __________________.
Aspiration / frequent failure to cough in response to aspiration
Neurologic conditions affect sensory feedback regarding the __________ of food in the vocal tract and ________________.
Position / entry of food into the airway
Dysphagic stroke patients exhibit reduced ___________ and ___________ sensation as compared to age-matched controls
Pharyngeal / supraglottic
In patients with neurologic impairment, direct sensory testing is NOT possible because of ________________________.
Cognitive and langauge problems - you can asess it indirectly
How can you assess sensation indirectly in patients with neurologic impairment?
Observe the patients reaction to: aspiration, residual food in the pharynx (a dry swallow to clear it indicates pharyngeal sensory awareness)
In addition to reduced sensation, patients with neurologic impairment may fail to react to aspiration/residue because of…
Chronic presence of aspiration/residue - the patient may have habituated to it
How can you conduct a fatigue test for swallowing?
Complete videofluroscopy just before and after a meal - see if there are changes in the swallow caused by use of the muscles while eating.
What can you do for your neuro patients if fatigue is contributing to swallowing difficulties?
Don't use maneuvers - these are more work and increase fatigue. Try smaller meals, postural changes, sensory heightening (make the swallow easier to trigger), diet changes are appropriate (thinner = easier to move).
Studies indicate it may take up to _________ for the pharyngeal swallow to be triggered normally after extubation
1 week
When evaluating a neuro patient, the evaluation should be postponed if the patient is _____________.
Intubated
What are some techniques for evaluating patients who are comotose or have severe impairments?
Maximize information while putting patient at minimal risk. 1) Evaluate frequency and strength of the swallow by palpating at bedside (5-10 min.); 2) Use surface EMG to assess frequency of swallow; 3) Assess how patient handles his/her own secretions
If you aren't sure how a severely impaired patient is managing his her / own secretions, what can you do?
Open the patients mouth and do thermal tactile stim (observe any muscle contraction that occurs in response); Then place a small amount of cold liquid at the base of the anterior arch. Assess response mechanism (patient should swallow in response)
In the intensive care unit with neuro patients, your full bedside eval should involve giving the patient less than ____________ and should not increase the risk of _________________
1/3 teaspoon of liquid / pulmonary complications
Can you conduct a radiographic study with comatose/very ill patients?
Yes, If they can be positioned on a gurney with back elevated and supported. A nurse or doctor must accompany them
Swallowing problems caused by neurologic lesions from which some recovery can be antipated are caused by _______________________ [list some examples]
Caused by sudden-onset neurologic conditions [stroke, closed head injury, cervical spinal cord injury, anterior cervical fusion, neurosugery affecting brainstem and cranial nerves, poliomyelitis, Guillan-Barre]
Patients with what type of strokes will NOT experience swallowing disorders
Infarcts limited to posterior cortex with no motor component (unless the lesion causes enough edema to affect anterior cortex)
Do stroke patients have sensory loss in the pharynx? What evidence do we have?
Yes, to some degree. On videoflouroscopy, stroke patients do not respond normally to oral/pharyngeal residue [will not report the residue, will not dry swallow in attempt to clear it]
True or False: We have extensive information regarding the location of stroke and subsequent swallowing problems
False - we have some research but there is still a lot that is unclear
When a patient has a lesion in the lower brainstem [medulla], what can you expect from swallowing?
1) Significant oropharyngeal swallowing impairment; 2) Major swallowing centers affected - motor and sensory in medulla (NTS, NA); 3) May include a complete inability to trigger the pharyngeal swallow
With unilateral medullary lesions, oral control will be _____________, the pharyngeal swallow will be _________________, and neuromuscular abnormalities in the pharyngeal swallow will include [list three].
Functional or near normal / absent or significantly delayed / 1) Reduced laryngeal elevation and anterior motion; 2) Unilateral pharyngeal weakness; and 3) Unilateral adductor VF paresis
Patients with unilateral medullary lesions may require non-oral intake for ________ but will generally recover enough to resume oral feeding by _______________.
1-2 weeks post-stroke / week 3
Some patients with medullary strokes will not recover functional swallow for ___________. Helpful techniques will include [list three and their purpose].
4-6 months post-stroke / 1) Thermal tactile stim for delayed or absent pharyngeal swallow; 2) Head rotation to compensate for pharyngeal weakness; 3) Mendelsohn and ROM exercises for laryngeal elevation
When considering CP myotomy for patients with brainstem strokes, what are important factors?
1) This should not be considered for at least 6 months post-stroke (give the patient sufficient time to recover spontaneously and with therapy) 2) Typically, reduction in UES opening is caused by reduced laryngeal lifting/anterior motion, NOT spasticity in the muscle itself. So, myotomy isn't going to help a whole lot.
At 12 and 4 weeks after a medullary stroke, patients whose swallow was functional at 3 weeks post-stroke reveals that…
Swallow is still functional but measures of pharyngeal movement during the swallow are outside the normal range for individuals of their age/gender
A high brainstem stroke (pontine) leaves patients with _____[four characteristics]___.
1) Severe hypertonicity; 2) Absent/delayed pharyngeal swallow; 3) Unilateral spastic pharyngeal wall paresis/paralysis; 4) Reduced laryngeal elevation with severe CP dysfunction.
What are some treatment considerations for patients with pontine stroke?
These patients have absent/delayed pharyngeal swallow, unilateral pharyngeal wall dysfunction and severely reduced CP opening (due to reduced laryngeal elevation) SO: They may not respond to head rotation because of hypertonicity. TTS may be helpful but can also increase oropharyngeal hypertonicity. Recovery is slow and difficult. You can try massage to reduce buccal hypertonicity.
Subcortical strokes may affect motor and sensory pathways to and from the cortex. Swallowing difficulties are generally related to ________ and include [three problems]
Timing / 1) Mild delay (3-5 sec) in oral transit; 2) Mild delay 93-5 sec) triggering pharyngeal swallow; 3) Mild to moderate impairment of timing of neuromuscular components of the pharyngeal swallow.
When patients with subcortical strokes aspirate, it is generally _________ the swallow because of __________________ or ________ the swallow because of ____________.
Before - Delayed pharyngeal swallow / After - impaired neuromuscular control
Patients with subcortical strokes will often resume full oral intake __[when?]_____. Beneficial therapy techniques for this population include ______________________.
3-6 weeks post-stroke if there are no other complications / Techniques to improve triggering of pharyngeal swallow (TTS) and ROM exercises for larynx and tongue base.
Patients with anterior left hemisphere strokes tend to exhibit ____[three swallowing issues]_____.
1) of swallow (mild to severe - usually accompanies some degree of oral apraxia; 2) Mild oral transit delays (3-5 sec); 3) Mild delays triggering pharyngeal swallow (2-3 sec).
True or False: Patients with anterior left hemisphere strokes tend to have motorically normal pharyngeal swallows
True
What are some treatment techniques for patients with anterior left hemisphere strokes?
1) Sensory enhancement - to speed the swallow; 2) May do best when feeding themselves without commands (due to swallow apraxia)
Patients with right hemisphere strokes may exhibit _________[three swallowing issues]____.
1) Mild oral transit delays (2-3 sec); 2) Longer pharyngeal delay (3-5 sec); 3) Laryngeal elevation delayed during swallow (can cause aspiration before or during the swallow)
What are some treatment considerations for patients with right hemisphere strokes? [List 4]
1) Chin down + TTS will be helpful for pharyngeal delay; 2) May use superglottic or supersupraglottic swallow during delay to prevent aspiration; 3) ROM exercises can be used to improve laryngeal elevation; 4) Patient may have attention/cognitive issues which will create difficulty using therapy and compensatory strategies.
Who will return to oral intake faster - a patient with a left hemisphere stroke or one with a right hemisphere stroke?
The patient with the left hemisphere stroke will return to oral intake faster (R. hemi causes more attention and cognitive issues which complicate rehabilitation)
What effects do multiple strokes have on the swallowing in general? In the oral phase? In the pharyngeal phase?
1) These patients will exhibit more severe swallowing problems; 2) The oral function will be slowed and patient will make repetitive tongue motions; OTT and pharyngeal delay may both be over 5 seconds; 2) Once swallow triggers, patient may have reduced laryngeal elevation, reduced airway entrance closure, and unilateral weakness of pharyngeal wall.
What effects do multiple strokes have on swallowing therapy?
Attention is usually affected in these patients and the ability to use therapy strategies and focus on tasks is impaired.
True or False: Little data exists on recover of swallow post-stroke
TRUE
Research suggests that in patients with first-time ischemic strokes, 95% of the returned to full oral intake within _________ weeks regardless of ___________________.
9 weeks / site of lesion (all of these patients had swallowing therapy)
True or False: 95% of first-time ischemic stroke patients will recover a normal swallow within 9 weeks post-stroke
False: They return to oral intake by nine weeks because their swallow is FUNCTIONAL (they don't aspirate) but timing of the swallow is still abnormal - for example they may still exhibit a pharyngeal delay. The swallowing mechanism is NEVER quite the same following a stroke.
Following a stroke, when is recovery most rapid? What does this mean about scheduling your evaluations?
1) Within the first two weeks / 2) You should evaluate the patient's swallow in the first week and then again at 3-4 weeks (especially if the patient is initially on non-oral feeding
What four factors may affect swallowing function and recovery in stroke patients?
1) Tracheostomy during acute phase; 2) Medications; 3) Long-standing insulin dependent diabetes; 4) History of TIAs, prior strokes, or other neuro damage
How can medications affect the function and recovery of swallowing after a stoke?
Antidepressants may slow swallowing coordination and increase the severity of the swallowing disorder. Also, some medications cause xerostomia.
How can long-standing insulin-dependent diabetes affect swallowing function and recovery following a stroke?
It can increase the severity of the swallowing disorder or prolong recovery because of the potential for myopathies and neuropathies. This may affect pharyngeal coordination and ROM.
What effects does age have on swallowing function and recovery after a stroke?
1) No age effects have been identified but remember that older patients have normal changes in swallow (60-80 year olds have longer pharyngeal delay time and older men have reduction in range of hyoid and laryngeal movement -reserve)
In general, what treatment strategies are used for stroke patients?
Postural changes, sensory heightening (including altering bolus characteristics) and active exercises
What effects are seen in stroke patients when you change bolus volume?
Many first time stroke patients have difficulty with small (1-3 ml) or large (10-20 ml) volumes. There is evidence that a larger bolus may increase the sensory input to facilitate triggering the swallow during MBS.
What effects of bolus viscosity have been observed with stroke patients?
Patients with delayed pharyngeal swallow will do better with puddings and purees. Patients with brainstem stroke affecting CP function will have more trouble with thicker foods.
What effects of bolus taste have been observed with stroke patients?
Presenting a strongly flavored (esp. SOUR) bolus may improve awareness, oral onset and pharyngeal delay. Be careful because aspiration of more acidic material may create respiratory issues.
What are the two primary treatment modalities for malignant tumors in the oral cavity?
Surgical resection and radiotherapy (with or without chemotherapy)
Three means of delivering radiotherapy in the oral cavity are…
1) Implant into gross tumor; 2) External beam methods; 3) Combination of both
What are organ preservation protocols?
Means of treatmeant designed to reduce the functional impact of the tumor treatment by preserving the patient's oropharyngeal structures and (hopefully) function
If a patient has a combination of surgery and radiotherapy to eradicate an oral tumor, when is radiotherapy given?
Usually 4-6 weeks after the surgery to allow the patient some time to heal
A full course of radiotherapy for oral tumors usually includes a full dose of ________ spread over _______ weeks. The exposed field usually includes _____________.
6,000-7,000 cGy / 5-6 weeks / all the lymph nodes in the area
True or False: Chemotherapy is commonly used to eradicate tumors in head and neck cancer patients
False: Chemo is experimental in these patients and is used as an adjuvant treatment at this time. Tumor shrinkage may occur after chemo but is usually short-lived.
The general rule for surgical removal of tumors in the oral cavity is…
That the tumor is removed along with a 1.5-2 cm margin of normal tissue all the way around.
A resection is called simple when…
Only one structure is affected
What is a composite resection?
When more than one structure or parts of more than one structure are included in the resection
True or False: The rule of oral cancer surgery is that you will always remove the tumor with necessary margins without considering postoperative function.
True - reconstruction and rehabilitation are secondary concerns
Why do patients need dental assessment prior to initiating radiotherapy?
Because radiotherapy disrupts salivary glands and this increases the risk of dental disease. If the patient has diseased teeth, they need to be removed prior to radiation.
What is osteoradionecrosis of the mandible?
A condition caused by radiotherapy in which pieces of the mandible become infected and start to break off. These pieces can then protrude through the skin and soft tissue. This condition should be avoided at all costs which is why a pretreatment dental assessment is crucial.
Describe the TNM system
A system of staging oral/laryngeal tumors. T stands for tumor and is followed by a number (1-4) denoting size of the tumor. N indicates the number of affected lymph nodes, and M indicates the number of sites of distant metastasis. This allows comparison of treatement outcomes across different patients with the same tumor.
Six oral regions where tumors frequently develop are:
1) Anterior floor of mouth or lower alveolar ridge in the anterior floor of mouth; 2) tongue (laterally or anteriorly); 3) Lateral floor of mouth or lateral alveolar ridge; 4) Tonsil (between faucial pillars); 5) Base of tongue area; 6) Hard or soft palate
When there is a large tumor in the anterior floor of the mouth, tissues are removed as a unit because…
This will help prevent the spread of the cancer
What is primary closure? This is commonly done for resections of parts of what two structures?
When smaller lesions are resected, the surgeon will simply pull the tissue back together and suture it. / Common for tongue and soft palate
What is a flap?
A piece of tissue that has been elevated or raised away from it's normal site. One portion is left attached to allow for continued blood supply
What are myocutaneous flaps? When are these used? What are some typical donor sites for oral cavity reconstruction?
A flap that is used when more amounts of tissue are needed at the surgery site. These flaps include muscle and over lying skin - generally passed under the skin to the reconstruction site. / Typical donor sites include: Pectoralis major, platysma, and trapezius m.
What is a graft? What are the disadvantages of using a graft to reconstruct in the oral cavity?
A graft (or Microvascular free tissue transfer) involves moving tissue from distant parts of the body to reconstruction sites. The veins and arteries are then anastamosed to those at the reconstruction site. / Disadvantages: time consuming, more difficult surgically (read: more costly), and an infection in the oral cavity is a possible complication.
What are sensate / innervated grafts?
These are being used more recently to attempt to bring more normal sensation to the reconstruction site. They include nerve fibers from the donor site which are attached to those at the new site. Research is still needed to determine how this will affect speech/swallowing.
Oral cancer patients may suffer from changes in [three areas]
Salivary flow, speech, swallowing
Radiotherapy may lead to swallowing disorders related to [four things]
Reduced salivary flow, intraoral sensory loss, fibrosis/reduced ROM, mucositis
What will lead to optimal function in the oral cavity - primary closure or distal flaps?
Primary closure appears to result in better function because no foreign material is introduced and oral sensation will be more normal (but in class, Dr. L. didn't seem like a huge fan of primary closure - check your class notes on this!)
How does radiotherapy work AGAINST rehabilitation?
Typically, the patient will start post-surgical rehab. Before beginning radiotherapy. The patient will start to see improvements in the swallow. Then, when radiotherapy begins swallowing will worsen again (radiation effects begin about 4 weeks in to radiotherapy) - the patient may withdraw from therapy and not return.
Patients with resection of ________ or more of the tongue will benefit from a palatal augmentation prosthesis
50%
Treatment of cancer in the oropharyngeal area will affect ___________ and/or ___________ (structures).
Tongue base / pharyngeal wall
What techniques should be used for rehabilitation following oropharyngeal cancer treatment? What else can be useful?
Exercises to improve tongue base function - this will improve swallow safety and efficiency / Intraoral prosthesis may also be useful to address VP deficits
Following oral cancer surgery, you can generally begin rehabilitation once _________________. In most patients, this will be _________ after surgery.
The patient's suture lines have healed enough to withstand aggressive exercises / 10-14 days post-op
In H/N cancer patients, differing effects on speech and swallowing occur as a result of various extents of _____________, ____________, and _____________.
1) Surgical resection; 2) Surgical reconstruction techniques; 3) Radiation
Rehabilitation begins with _____________. It is necessary to identify the best way to treat the tumor while maintaining as much function as possible. The best way to accomplish this is __________________.
Treatment planning (prior to any surgery, radiation, etc.) / A tumor conference with the entire team so that everyone can give their input.
Who are members of the team present at a tumor conference?
The radiation oncologist, medical oncologist, surgeon, swallowing therapist, maxillofacial prosthodontist, social worker. The patient should also be consulted on treatment decisions.
What patient characteristics are crucial in planning treatment for H/N cancer?
emotional status, financial resources, medical history, strong preference for a particular type of treatment
What does swallowing pretreatment counseling involve for patients with H/N cancer?
A swallowing screening is conducted (and then possible MBS) to identify any disorders already present. Then, the SLP will inform the patient of possible changes to speech/swallowing as a result of treatment. Rehabilitation options will also be discuss. It is important to stress the patient's responsibility in their own rehabiliation.
When a patient has surgery for H/N cancer, you should provide ____________ with in 2-3 days.
Post-operative counseling.
___________ status is critical for possible prosthetic intervention. A pre-treatment consultation should be conducted to ensure that ________________ for stabilization of the prosthetic device after surgery.
Dental / crucial teeth are spared
The ideal case in H/N cancer swallowing rehabilitation will the that the _________________ takes place during radiographic assessment.
First attempted swallow after surgery
When patients undergo radiation, what should happen in terms of rehab/exercise?
Therapy should be continued during radiation and after when possible. If therapy must be post-poned, patients should be encouraged with continue ROM/flexibility exercises on their own.
True or False: 65% of H/N cancer patients receive speech and swallowing rehabilitation
False: only about 50%
________ % of patients with H/N cancer receive maxillofacial prosthetic intervention
Less than 10%
When planning rehabilitation for H/N cancer patients, what are the two most important pieces of information you need from the surgeon?
1) The exact nature and extent of the resection; 2) The exact nature of reconstruction
What swallowing problems are seen in patients with small (50% or less) resection of the tongue + primary closure?
They are relatively temporary issues as the patient recovers: 1) Delayed triggering of Pharyngeal swallow (caused by edema, tongue mov't changes, etc); 2) Bolus control may be affected
What treatment techniques would you use for patients with primary closure of a small tongue resection (50% or less)?
1) TTS for delayed pharyngeal swallow (maybe only a few days of this); 2) ROM and bolus control exercises to help them adjust to changes (3-4 weeks)
In patients with 50% or more of the tongue resected, _________________ will be affected. What consistency might work well? Is pharyngeal swallow affected? Finally, what maneuver might be useful?
Bolus control and propulsion / liquids/thin pastes can be managed with head tilted back / Pharyngeal swallow is generally normal / May use supraglottic swallow to protect airway prior to swallow
What rehabilitation techniques will be used in patients with 50% or more of the tongue resected?
ROM exercises and intraoral prosthesis to allow the patient to manage all consistencies (except those requiring chewing)
The _____ of the esophagus is smooth while the ______ is striated.
Bottom 2/3
Top 1/3
The inner layer of the esophagus is ______ while the outer layer is ______. What will happen if you contract each layer?
Circular muscle (contraction will constrict the esophagus); Longitudinal muscle (contraction will shorten the esophagus)
What are the four layers of the esophagus?
Mucosa, submucosa, circular m., longitudinal m.
What is the resting pressure of the LES? Why is this important?
20-30 mm Hg (25 generally); This is crucial because it needs to be higher than the gradient between intraabdominal and intrathoracic pressure to prevent food from being sucked back up into the esophagus.
How is the esophagus controlled?
The top 1/3 - direct control (Vagus)
The bottom 2/3 - indirect control (Vagus via neurons in ENS)
What is the ENS?
The Enteric Nervous system or "second brain" consists of 100 million neurons embedded in the walls of the GI tract. It is separate from the CNS and ANS.
The GI system is under what three levels of control?
CNS, ANS, ENS
Once the swallow triggers, about how long does the bolus take to get into the stomach?
8-9 seconds
What are seven major groups of esophageal dysfunction?
Structural, motility, infectious, neoplastic, inflammatory, congenital, iatrogenic
The most common cause of esophageal dysphagia is...
Structural abnormalities
List 4-5 structural abnormalities that cause esophageal dysphagia
Schatzki's ring, Easinophilic esophagitis, peptic stricture, hiatal hernia, esophageal diverticula, CP bar, esophageal web, blah, blah, blah
What is Schatzki's ring?
A circumferential lip of tissue circling the inside junction between esophagus and stomach. It is the second most common cause of ED.
What is the most common cause of esophageal dysphagia now?
Easinophilic Esophagitis
What is a peptic stricture?
An esophageal structural abnormality which presents as an hourglass-shaped point in the esophagus due to collagen/fibrous tissue formation
What percentage of those with esophagitis develop complcations?
10-20%
What is Zenker's diverticulum?
A pocket with the opening situated above the UES - food can collect there. Mostly in older patients. May see Boyce's sign (focal, gurgly neck swelling often on the left)
Name four esophageal motility disorders
Achalasia
Diffuse esophageal spasm
Scleroderma
Polymyositis
What is an esophageal motility disorder?
Disorders arising from abnormal muscle/nerve activity which causes abnormal peristalsis or valving.
What is achalasia
Failure of the LES to relax (problems in Enteric NS...botox may be used!)
What is diffuse esophageal spasm?
Disorganized peristalsis caused by simultaneous contraction at different levels of the esophagus (AKA corkscrew esophagus or tertiary contraction)
What is the most common GI manifestation, occuring in over 90% of cases?
Esophageal dysmotility
List iatrogenic causes of esophageal dysphagia
caustic/pill, post surgery, radiation, chemotherapy, sclerotherapy, fundoplication, NG tube
What is the clinical term for pain during swallowing?
Odynophagia
True or False: Neoplastic disorders are common causes of esophageal dysphagia
False
What are the local complications of reflux esophagtis?
Erosive esophagitis, bleeding, esophageal ulceration, esophageal stricture, Barrett's esophagus, esophageal adenocarcinoma.
List four infectious causes of esophageal dysphagia
Candida, Herpes simplex virus, cytomegalovirus (CMG), HIV
Tests for esophageal dysphagia may include:
Barium swallow, video swallow, upper endoscopy, esophageal manometry, scintigraphy, CT scan, endoscopic ultrasound
Treatment for esophageal dysphagia may include:
Medical, endoscopic, and surgical treatments
What medical treatments are used for esophageal dysphagia?
smooth muscle relaxants, prokinetic agents, antimicrobials, steroids
What endoscopic treatments are used for esophageal dysphagia?
Botox, pneumatic dilation, bougie dilation, TTS balloons, PEG placement
What surgical treatments are used for esophageal dysphagia?
Myotomy, esophagectomy, thoracotomy, laparotomy (Latin, anyone?)
What is ventilation?
The movement of air back and forth between the outside atmosphere and the inner spaces of the lungs
What is external respiration?
The exchange of gases between walls of the lung spaces and the transporting blood
What is internal respiration?
Gases exchanged between blood and cells of the body
What is the physiologic heirarchy?
Respiration, swallowing, speech
The _________ houses the pulmonary system which includes [3 things]
Thorax / trachea, bronchi, lung structures
The respiratory tract starts anteriorly with the _________ and _________. The mouth is also sometimes used to conduct air into the pharynx.
Left nasal passage, right nasal passage (just want to make sure I get this right on the quiz, you know)
What is the conducting zone? What structures are included?
The parts of the respiratory system that get air in and out of the lungs. Includes: Trachea, bronchi, and bronchioles.
What is the respiratory zone? What structures are included?
The parts of the respiratory system that are involved in gas exchange. Includes: Respiratory bronchioles, alveolar ducts, alveolar sacs.
Where does the trachea bifurcate?
Around T5
Each bronchus enters the lungs through its ______. How many divisions take place?
Hilus / 20 divisions
At blind ends of respiratory tubes, you will find...
A pulmonary alveolus
Alveoli are ____________. Each alveolus shares a wall ___________ with vascular capillaries.
Pouch-like evaginations of the walls of respiratory bronchioles, alveolar ducts, and alveolar sacs / one-cell thick
Alveoli have large ________ which is important because oxygen-carbon dioxide exchange occurs via _________.
Surface area / diffusion
What is the law of LaPlace? Why do we care?
P = 2T/r (where p = pressure on the alveolus, T= surface tension, and r= radius of alveolus). We care because it means that alveoli are at risk of collapsing because of surface tension and their small size.
What is the word for collapse of an alveolus? What keeps this from happening?
Atelectasis / surfactant
What is surfactant?
A mixture of phospholipids that line the alveoli and reduce their surface tension
In addition to preventng atelectasis, surfactant increases _____________
Lung compliance - the amount the lungs can expand
What are the two surfaces of the lungs?
Costal (rib) and Mediastinal (medial)
How many lobes are in the lungs?
three right pulmonary lobes, two left pulmonary lobes
The lungs are covered by the _________ and ________ pleura (it's not left and right, I promise!!). The pressure in he intrapleural space is usually _________.
Pulmonary and pareital / negative
What is lung compliance?
Distensibility of the system, or how lung volume changes as a result of pressure change
There is an inverse relationship between the compliance of the lungs and chest wall and their _________
Elastic properties (Elastance)
What happens during forced inhalation?
Muscles are employed to enlarge the volume of the thorax and decrease pressure to draw air in
What are two ways of decreasing thoracic air pressure?
Thoracic (chest wall) enlargement and increasing the vertical dimension of the thorax
Two major muscles of inspiration are __________ and __________. List three others that help...
Diaphragm, external intercostals / scalenes, pectoralis major, pectoralis minor
What is the major muscle of exhalation? And two others?
Internal intercostals / transverse thoracic, quadratus lumborum
List four abdominal muscles involved in respiration
Rectus abdominus, external obliques, internal obliques, transverse abdominus
What happens during active inspiration?
Scalenes and sternocleidomastoid are employed in addition to major inspiratory muscles to help elevate the thorax. Pectoralis major and minor can also help.
What happens during forced exhalation?
Internal intercostals depress rib cage to decrease thoracic volume, quadratus lumborum ad transverse thoracic muscles kick in. Abdominal muscles may increase pressure on viscera to help push the diaphragm up.
Inspiratory capacity =
Tidal volume + inspiratory reserve volume
Functional residual capacity =
Expiratory reserve volume + residual volume
Vital capacity =
Inspiratory capacity + expiratory reserve volume
What systems are important in swallowing?
Neurologic, sensory, respiratory, pharyngeal/laryngeal, oral/nasal
What is the upper airway vs. lower airway? Where is the boundary between the two?
Upper airway = oral, nasal, pharyngeal, laryngeal areas.
Lower airway = trachea, bronchi, lungs.
LARYNX is the boundary
What are the main valves in the upper airway?
Oral (lip closure), nasal (VP closure), pharyngeal (only closes when tongue base contacts pharyngeal wall), laryngeal (VF and airway entrance)
What is the setting of valves for speech breathing?
Lips open, VP closed, larynx in rapid movement
Wha is the setting of valves for exerted breathing?
lips open, VP closed, glottis open
The patient should breathe nasally and ____________ as opposed to clavicular or abdominal
Diaphragmatically
What are the normal respiratory rates?
Young - 16 / min
Old - 20 / min
Pressure in the respiratory system is dependent on _________, _________, and __________
Muscle control, exhalatory forces, valving
Early infants and those over 70 show what differences in respiration compared to the rest of us?
Less consistent coordination of respiration and swallowing. More frequent interuption of inhalation to swallow - greater risk!!
When do babies stabilize the respiratory swallowing pattern?
By about three months
Closing the airway for the swallow should be ______ and begins when ____________. Some patients over 60 tend to...
Rapid
Head of bolus reaches top of airway
Close the airway entrance earlier
A patient should NOT have _________ of swallows interrupting inhalation
More than half
Information about respiration that is critical for swallowing includes:
1) Focal points of breathing
2) Rate of respiration and swallowing
3) Drooling or saliva build-up in the mouth
4) Resp-Swallow pattern
5) Efficiency of swallow
6) Coughing, gurgly voice, throat clearing
7) Pneumonia history
8) Chronic bronchial secretions (bronchorrhea)
9) Dietary intake
10) Medical Dx placing patient at risk?
Excessive discharge of mucus form the air passages of the lungs is lovingly called _______. It is a sign of ________.
Bronchorrhea / pneumonia
What are some causes of respiratory disease?
Expansion of lungs impeded - paralysis, pain, alveolar noncompliance;
airway diameters reduced - asthma
(Patient may have increase respiratory and ventilatory rates)
List some restrictive pulmonary conditions
pneumothorax, atelectasis, pleural effusion, pulmonary edema, asthma, sepsis (leads to Adult Respiratory Distress), paralysis, pulmonary fibrosis
List some obstructive pulmonary conditions
COPD - Chronic obstructive pulmonary disease: Emphysema, chronic bronchitis
What is the difference between aspiration pneumonia and pneumonitis?
Aspiration pneumonia is caused by foreign material entering from upper airway while pneumonitis is caused by acidic gastric contents (GERD!!)
Aspiration pneumonia is fatal in _____ of cases
20-50%
What is bronchospasm?
An abnormal contraction of smooth muscle of the bronchi (usually associated with asthma)
What is cyanosis?
blue-grey color - purplish discoloration of mucus membranes (occurs when you have < 5 gr. hemoglobin)
What is dyspnea?
The feeling of having difficulty breathing
What is hemoptysis?
Coughing up blood - generally GI issues!
What is hyperpnea?
Rapid/deep breathing
What is hypoxemia?
Deficient oxygenation of the blood
What is rhonchi?
Whistling/snoring sounds int he lungs
If a patient has less than ________ swallows in 5 minutes, it is considered abnormal
2-3
What treatments should be done to improve respiratory support for swallowing?
1) Increase length of breath hold
2) Coordination - inhale, exhale, swallow, exhale more
3) Do not work on swallows until it is rapid enough to fit in maximum comfortable breath hold.
4) Make sure paitent is holding his/her breath at the larynx!
What is a head injury AKA?
Acquired brain injury, traumatic brain injury
Head injury can happen when __________ or __________
1) When head suddenly/violently hits an object
2)When an object pierces skull and enters brain tissue
According to the CDC, ______ people suffer TBI each year. ______ of these people die. The cost of TBI in the US is ________.
100 out of every 100,000
52,000
$48.3 billion annually
The risk of head injury is especially high in ________, ________, and _________
Adolescents, young adults (esp. 15-24), those over 75 (Children under age 5 also at higher risk)
The risk of head injury is higher in __________ in all age groups
Males (twice as high!)
_________ of all TBIs involve alcohol either by the victim or the person causing the injury
Half
The three most common causes of TBI are...
1) Motor vehicle, bike, or vehicle-pedestrian mishaps (50%)
2) Falls (25%)
3) Violence (nearly 20%)
Common GENERAL symptoms of TBI include:
1) Anxiety, nervousness, depression
2)Behavioral changes - disinhibition, impulsiveness, emotional extremes
3) Blurry/double vision (diplopia)
4) Attention and memory issues
5) Aphasia, dysarthria, dysphagia
6) Balance and coordination issues
7) Muscle stiffness/spasms
8) Sleep difficulties
9) Weakness (usually hemi-paresis)
________ is a loss of conciousness while ___________ is a brief loss of conciousness caused by a blow to the head.
Coma / Concussion
Post-traumatic amnesia is...
A state following TBI in which the patient is not oriented (acute confusion)
After TBI, recovery is characterized by...
Progressive improvement in cognitive and behavioral functions (usually rapid at first and then slows to a plateau after months/years)
The Glascow Coma Scale can be used to assess...
Degree of conciousness
The difference between a closed-HI and open-HI is...
In an open HI, the skull is penetrated and the brain is exposed to air
What are diffuse injuries?
Microscopic damage throughout many areas of the brain. Shearing of large nerve fibers ad stretching of blood vessels in many areas (frontal and temporal lobes are particulary susceptible)
What are hypoxic-ischemic injuries?
They cause swelling in the brain which restricts the flow of blood-borne oxygen, glucose, and other nutrients
What is a focal brain injury?
One confined to a specific area of the brain that causes localized damage that can often be detectd on CT or X-ray
What are contusions?
Bruises that cause swelling, bleeding, and destruction of brain tissue. (Frontal and temporal lobes!!)
A small amount of bleeding that spreads thinly over the surface of the brain is characteristic of...
A subarachnoid hemotoma
The most common late secondary complications fo TBI are...
Hydrocephalus and chronic subdural hemotoma
What is chronic subdural hemotoma?
A focal brain injury characterized by an accumulation of blood or spinal fluid on the surface of the brain that exerts pressure on brain tissue
A slow bleeding that occurs outside the brain (usually over surface of frontal or parietal lobe)
Subdural hemotoma
Bleeding outside the brain generally caused by damaged artery
Epidural hemotoma
The three stages of medical treatment for TBI are...
Acute, subacute, chronic
Acute treatment focuses on...
Saving the victims life. Airway, breathing, blood supply. Surgery may be needed within days (ie. to decrease cranial pressure). Seizures may occur. Monitor swelling in the brain.