Transcript
CHAPTER 11:
Disorders of Swallowing
Introduction to Communication Disorders: A Lifespan Evidence-Based Perspective
5th Edition
Owens, Farinella, & Metz
Developed by Sarah A. Dachtyl, Ph.D., CCC/SLP
Chapter Learning Goals
Explain why SLPs are concerned with swallowing
Describe the basic process of human swallowing
Identify some causes of swallowing disorders in children and adults
Describe basic clinical and instrumental assessment techniques
Discuss evidence-based practices in swallowing treatment
Summary
Lifespan Perspectives
The Swallowing Process
Disordered Swallowing
Evaluation for Swallowing
Dysphagia Intervention and Treatment
Prognoses and Outcomes for Swallowing Disorders
Disorders of Swallowing
SLPs who treat dysphagia are part of a team
Swallowing disorders increase risk of choking
May lead to aspiration and pneumonia
Gastroesophageal reflux
Eating is a major social activity
Feeding difficulties in children can stress the parent-child relationship
Among older people, it can lead to isolation, depression, frustration, and diminished quality of life
Lifespan Perspectives
Problems occur in children and adults
Newborns may be unable to suck/ingest nutriment
May refuse food, develop unhealthy habits
Related to diverse conditions
Outcomes of swallowing disorders include
Malnutrition and ill health
Weight loss
Fatigue
Frustration
Respiratory infection
Aspiration
Death
The Swallowing Process
Oral Preparation Phase
The tongue cups to hold fluid in a liquid bolus against the front portion of the hard palate
The tongue and cheeks move the food to the teeth to form a solid bolus
The prepared bolus is held in the mouth by the soft palate, which moves forward and down to touch the back of the tongue and close the passage to the pharynx
The Swallowing Process
Oral Phase
Once the bolus is formed, the oral stage begins
The bolus is moved from the front to the back of the mouth
The pharyngeal swallow reflex is triggered when the bolus reaches the anterior faucial arch
Oral transit usually takes 1-1.5 seconds
The Swallowing Process
Pharyngeal Phase
The velum contacts the rear pharyngeal wall
Base of the tongue and the pharyngeal wall move toward one another to create pressure needed to project the bolus into the pharynx
Pharynx squeezes bolus down
Hyoid bone rises, bringing larynx up and forward
Bocal folds close and epiglottis covers airway
Complete when the pharyngoesophageal segment opens and the food/liquid enters esophagus
Usually takes less than 1 second
The Swallowing Process
Esophageal Phase
Muscles of the esophagus move the bolus in peristaltic contractions into the stomach
Usually takes about 8-20 seconds
Disordered Swallowing
Oral Preparation/Oral Phase
If the lips do not seal properly, drooling can occur
Chewing can be impaired due to poor muscle tone or paralysis involving the mouth or because of missing teeth
Insufficient saliva impedes adequate bolus formation
Muscles of the tongue might not function well
Disordered Swallowing
Pharyngeal Phase
If the swallow is not triggered or is delayed, material may be aspirated
An open velopharyngeal port can lead to substances going into and out of the nose
Poor tongue mobility may result in insufficient pressure in the pharynx
Disordered Swallowing
Esophageal Phase
If peristalsis is slow or absent, the complete bolus might not be transported to the stomach
Residue on the esophageal walls can result in infection and nutritional problems
Disordered Swallowing
Pediatric Dysphagia
Inadequate growth, ill health, fatigue, difficulty learning, poor parent-child relationships
Children with CNS or PNS deficits or neuromuscular disease are vulnerable to feeding and swallowing disorders
Dysphagia may occur at any phase and may range from mild to severe
Disordered Swallowing
Pediatric Dysphagia
Cerebral Palsy
Most common cause of neurogenic pediatric dysphagia
Excessive muscle tone, abnormal posture and movements, possible hyperactive gag
GER is common; ingestion may be painful
Uncoordinated swallowing can lead to aspiration
May require gastrostomy tube feedings
Disordered Swallowing
Pediatric Dysphagia
Spina Bifida: Congenital malformation of the spinal column typically involving associated neural damage, resulting in limited sensation and motor control difficulties
May experience feeding difficulties in all phases
Sensory impairments and dyspraxia can disrupt sucking and food intake
Cranial nerve damage can affect pharyngeal and esophageal stages
Disordered Swallowing
Pediatric Dysphagia
Intellectual Disability and Developmental Delay
Delayed motor coordination in children with ID/DD may interfere with eating and the oral phase of swallowing
Children may be limited in their ability to express food desires and preferences
Disordered Swallowing
Pediatric Dysphagia
Autism Spectrum Disorder
Children with ASD may have significant feeding problems
Behaviors that can interfere with feeding include social withdrawal, impaired communication, stereotypic behaviors, and sensory hypersensitivity
The types of food that are consumed may be restricted, possibly leading to poor nutrition
Disordered Swallowing
Pediatric Dysphagia
HIV/AIDS
Feeding and swallowing disorders are prevalent in children with HIV/AIDS
They have difficulty with oral secretions and exhibit odynophagia (painful swallowing)
HIV-positive children often exhibit developmental delays, language deficits, and poor attention skills
Disordered Swallowing
Pediatric Dysphagia
Structural and Physiological Abnormalities
Children born with cleft palate or lip are impaired in the oral phase
Congenital abnormalities of the jaw, as in Pierre Robin syndrome, or of the face, as in Treacher Collins syndrome, negatively affect oral intake of food
Esophageal atresia prevents normal esophageal swallowing and results in choking
Pyloric stenosis: The pyloric sphincter narrows and prevents food from entering the small intestine
Disordered Swallowing
Dysphagia in Adults
Up to 22% of individuals over age 55 experience swallowing difficulties
Stroke
Dysphagia is a serious problem for 25% to 75% of individuals who suffer stroke
Facial paresis is the primary factor after stroke
All phases of ingestion are likely to be slowed and impaired
Swallowing and breathing are poorly coordinated, increasing risk for aspiration pneumonia
Pneumonia is the cause for about a third of deaths following stroke
Disordered Swallowing
Dysphagia in Adults
Cancer of the Mouth, Throat, or Larynx
Swallowing problems are likely after treatments for cancer
Dysphagia severity related to tumor size/location and the surgical procedure
Radiation may result in diminished salivation, swelling, mouth sores, and reduced swallowing reflex
Chemotherapy can cause nausea, vomiting, and loss of appetite
Disordered Swallowing
Dysphagia in Adults
HIV/AIDS
Susceptible to numerous opportunistic infections
Esophageal ulcers and esophagitis
Multiple Sclerosis
CNS disorder characterized by relapse and remission
Delayed swallowing reflex and reduced pharyngeal peristalsis are the primary symptoms
Disordered Swallowing
Dysphagia in Adults
Amyotrophic Lateral Sclerosis
Poor tongue movement is sometimes an early sign
Reduced tongue mobility may result in spillage into the airway before the pharyngeal swallow has been triggered
The larynx might not elevate and close adequately
Pharyngeal peristalsis is frequently reduced, causing material to remain in the pharynx
All of these may result in aspiration
Disordered Swallowing
Dysphagia in Adults
Parkinson Disease
About 30% of individuals with PD exhibit dysphagia
Oral transport may be impaired by a front-back rolling pattern of the tongue
Pharyngeal swallow may be delayed and laryngeal closure may be impaired
Aspiration can occur when the patient inhales pharyngeal residue
Esophageal motor abnormalities impede swallowing eve early on
Disordered Swallowing
Dysphagia in Adults
Spinal Cord Injury
Higher incidence of esophageal dysphagia
They may experience heartburn, and slow/abnormal esophageal peristalsis
Surgery to the anterior cervical spine may result in dysphagia
Oral preparatory and transport stages are impaired in some post-surgical patients; others experience pharyngeal weakness or upper esophageal sphincter malfunction
Disordered Swallowing
Dysphagia in Adults
Medications and Nonfood Substances
Medication can cause drowsiness/confusion, interfering with anticipation and oral phases
Dry mouth is a side effect of more than 300 medications
High doses of steroids may impede pharyngeal swallowing
Antipsychotics may cause tardive dyskinesia: involuntary, repetitive facial, tongue, or lip movements
Smoking and excessive caffeine and alcohol can interfere with normal swallowing
Disordered Swallowing
Dysphagia in Adults
Dementia
The cognitive deficits of dementia may impede attention and orientation to food
Impaired oral preparatory movements may result in poor bolus formation and drooling
Transport of the bolus may be prolonged
Delayed pharyngeal swallow and reduced laryngeal elevation can result in aspiration
Disordered Swallowing
Dysphagia in Adults
Depression and Social Isolation
As people enter old age, they may be lonely or unmotivated to cook for themselves
Mealtime difficulties in one home for the aged were documented in 87% of residents
Depression is associated with diminished interest in food, restlessness, and fatigue
The throat may feel tight
Some may feel too tired to eat and are exhausted after they eat, leading to malnutrition
Evaluation for Swallowing
Silent aspiration: Lack of cough when food or liquid enters the airway
Screening for Dysphagia in Newborns and the Elderly
Primary indication of dysphagia in infants is failure to thrive
Full-term infants not accepting breast or bottle are signaling feeding problems
Observed during mealtimes to evaluate breathing and physical coordination, oral-motor functioning, and techniques that enable quantification of nutritive and non-nutritive sucking
Evaluation for Swallowing
Screening for Dysphagia in Newborns and the Elderly
Checklists for screening for dysphagia in older adults
3-ounce water test identifies 80-98% of patients who are aspirating (but maybe not silent aspiration)
Stroke patients who exhibit a delay in moving food from the front to the rear of the mouth and have incomplete oral clearance signal the likelihood of dysphagic complications
Inappropriate weight may be an indication of poor nutrition due to dysphagia
Evaluation for Swallowing
Case History and Background Information Regarding Dysphagia
Three areas that might result in a referral:
Difficulties have been observed related to feeding and ingestion of food or liquid
The client appears to be at risk for aspirating
The client appears not to be receiving adequate nourishment
Obtain information about the location of the swallowing problem, the kinds of food that are easiest and hardest to swallow, and the nature and severity of the disorder
Evaluation for Swallowing
Clinical Assessment
Caregiver and Environmental Factors
The SLP observed feeding as it occurs normally, paying attention to:
Is the caregiver patient and attentive?
Does feeding take place in a reasonably quiet environment free from distractions?
What position is the individual in when eating or drinking?
How does the client express feeding preference?
Evaluation for Swallowing
Clinical Assessment
Cognitive and Communicative Functioning
Determine alertness/wakefulness, ability to follow directions, and general functioning
Head and Body Posture
Note position of the head and whether the client can position the head given instruction
Not general body posture and tone
Evaluation for Swallowing
Clinical Assessment
Oral Mechanism
Abnormalities of the lips, teeth, tongue, palate, and velum should be noted
Look for facial symmetry and note weaknesses (drooping)
Motor difficulties such as tremor, flaccidity, excessive muscle tone, and poor coordination are noted
Assess motor difficulties and oral reflexes, as well as sensation
Note drooling, gum and tooth infections, or upper airway obstruction
Evaluation for Swallowing
Clinical Assessment
Laryngeal Function
Indirect signs include hoarse, gurgly, or breathy voice quality before/during/after swallow
Other signs
Inability to rabidly repeat /ha/ with a clear voiced vowel sound
Inability to produce vocal tones up and down scales
An s/z ratio greater than 1.3
Inability to produce a strong cough
If difficulties noted, refer to otolaryngologist
Evaluation for Swallowing
Clinical Assessment
Bedside Swallowing Examination
Can be completed if client is alert and does not have a history of aspiration
The client’s reaction to the appearance of food and drink is evaluated
Oral mechanism function is observed throughout the swallow
Pharyngeal phase swallowing efficiency can be judged in part by noting specific behaviors during food or drink intake
Evaluation for Swallowing
Clinical Assessment
Bedside Swallowing Examination
A small amount (1 tsp.) of thin or thick liquid may be placed in the mouth, and the client is encouraged to swallow
Inability to cough may suggest difficulty closing the larynx to protect the airway
Nasal regurgitation reflects inadequate VP closure
Observe the movement of the hyoid bone and thyroid cartilage
Evaluation for Swallowing
Clinical Assessment
Bedside Swallowing Examination
Record the number of times the client swallows for each amount of food or drink
If vocal quality changes after swallowing, this may indicate pooling of liquid
Note difficult and safe food consistencies
Determine preferential placement in the mouth for food and liquid
Evaluation for Swallowing
Clinical Assessment
Managing a Tracheostomy Tube
Some clients have a tracheostomy tube for breathing
A swallowing evaluation may still be conducted with physician approval
The cuff is deflated and secretions from the mouth and above the cuff are suctioned
The patient covers the tube before each swallow to normalize tracheal pressure
Evaluation for Swallowing
Instrumentation
Modified Barium Swallow Study
AKA: Videofluoroscopy: An X-ray procedure used for suspected dysphagia and/or aspiration
Barium is coated onto or mixed into food or liquid
SLP determines size, texture, and consistency of the food/liquid and head/body position
Radiologist or X-ray tech observes movement of barium
Video recorded for later analysis
Useful in determining whether the client should be fed orally or nonorally, what food textures are safest, and what types of therapy are appropriate
Evaluation for Swallowing
Instrumentation
Fiberoptic Endoscopic Evaluation of Swallowing
For adults too ill for MBSS
Flexible laryngoscope through nose into pharynx
Coughs, holds breath, and swallows dyed food
May reveal premature spillage, airway closure
Provides information about desirable posture, preferred food types, aspiration
Evaluation for Swallowing
Instrumentation
Scintigraphy
Computerized technique
Measure amount of aspiration
Radioactive tracer mixed with food
Radioactive markers placed externally
SLP positions, suggests swallow procedures, interprets results
Provides insight regarding esophageal function and may help determine whether oral feedings are safe
Evaluation for Swallowing
Instrumentation
Ultrasound/Ultrasonography
Imaging technique using inaudible sound waves
Transducer that generates and receives sound waves is placed below the chin for views of the oral cavity and on the thyroid notch for visualizing the laryngeal area
Acoustic images are taped
Assesses oral phase duration and the structure/movement of the tongue and hyoid bone
Dysphagia Intervention and Treatment
Feeding Environment
Minimize distraction
Relaxed and unhurried
Develop self-feeding skills if possible
Appropriate utensils
Dysphagia Intervention and Treatment
Body and Head Positioning
Upright, 90 degree hip angle, symmetrical
Reduce extraneous movement
Chin tuck
Head back
Head tilt and head rotation
May lie on one side if pharyngeal residue is present
Dysphagia Intervention and Treatment
Modification of Foods and Beverages
Textures, Quantities, and Temperatures
Foods that are hard to chew, small or slick when wet, or are thick and sticky are not recommended for children under 5 with neuromotor difficulties
NDD Level 1: Dysphagia – pureed
NDD Level 2: Dysphagia – mechanical soft
NDD Level 3: Dysphagia – advanced
NDD Level 4: Regular
Levels of liquids: thin, nectar-like, honey-like, and spoon-thick
Dysphagia Intervention and Treatment
Modification of Foods and Beverages
Textures, Quantities, and Temperatures
Straws can allow too much fluid in the mouth
Spoons with shallow bowls limit food amounts
Avoid placing food in the mouth until the previous bolus has been swallowed
Patients are encouraged to swallow twice per bite or sip
Foods of varying temperatures may increase the sensory awareness of food
Dysphagia Intervention and Treatment
Modification of Foods and Beverages
Placement
Should be where there is intact sensation and adequate muscle strength
This can be affected by oral surgery, radiation, or neurological problems
Dysphagia Intervention and Treatment
Behavioral Swallowing Treatments
Strengthening exercises
Swallowing physiology and range of motion
Bite blocks for lowering mandible
Flavored gauze or toothettes
Placement of the hand at the level of the hyoid bone to facilitate awareness of laryngeal movement
Hold tongue depressor with lips for lip seal and strength
Push tongue against tongue depressor for tongue strength
Moving tongue in various ways for coordination
Head lift exercises for pharyngeal muscle strength
Dysphagia Intervention and Treatment
Behavioral Swallowing Treatments
Effortful and Double Swallows
Effortful: Used when tongue does not retract enough
Double or multiple: When there is pharyngeal or oral residue
Supraglottic Swallow
Do not fully close the glottis or close the glottis late
Breath and hold breath
Put a small amount of food/liquid in mouth
Swallow
Cough or clear throat while exhaling
Swallow again
Dysphagia Intervention and Treatment
Behavioral Swallowing Treatments
Super-Supraglottic Swallow
Like the supraglottic swallow
Requires an effortful breath hold
Ensures complete glottal closure
Dysphagia Intervention and Treatment
Behavioral Swallowing Treatments
Mendelsohn Maneuver
Clients who do not have adequate laryngeal elevation
Place small amount of food/liquid in mouth
Chew if necessary
Swallow while placing thumb and forefinger on sides of the larynx
Manually hold larynx high for 3-5 seconds during and after swallowing
Let go of larynx and let it drop
Dysphagia Intervention and Treatment
Medical and Pharmacological Approaches
Drug Treatments
Neurological patients benefit from being medicated before eating
Atropine can control drooling
Nifedipine may be useful in managing dysphagia after stroke
Botox can improve swallowing in cricopharyngeal muscle spasticity/hypertonicity
Some medications cause or contribute to swallowing disorders
Dysphagia Intervention and Treatment
Medical and Pharmacological Approaches
Prostheses and Surgical Procedures
Palatal obturator for VP closure
Intraoral appliances for children with CP
Growths on the cervical spine that displace the rear pharyngeal wall can be removed
The dimensions of the vocal folds can be increased
The larynx can be elevated
The vocal folds can be sutured closed and breathing will occur through a tracheostomy
Injection of botox for esophageal dysphagia
Dysphagia Intervention and Treatment
Medical and Pharmacological Approaches
Nonoral Feeding
Clients who require more than 10 seconds to swallow a bolus or who aspirate more than 10% will likely require at least some nonoral feeding
Nasogastric tube: Feeding tube is place through the nose and into the stomach
Pharyngostomy: Feeding tube is inserted into the stoma
Esophagostomy: Feeding tube is placed in the esophagus through a hole in the chest
Percutaneous endoscopic gastrostomy: Feeding tube is placed in the stomach through a hold in the abdomen
Prognoses and Outcomes for Swallowing Disorders
Objectives
Improve food and drink intake
Prevent aspiration
Success determined by cause, severity, and onset of treatment
Treatment beneficial at least 80% of the time
Sometimes preventable
Can be related to poor dentition
Avoid certain substances
Summary
SLPs can work with infants who are unable to nurse adequately, children with feeding problems, and older people who have dysphagia.
Swallowing affects nutrition and health, as well as social and personal aspects of life
A team approach is needed for assessment and intervention
Treatments address the feeding environment, posture, food textures and temperatures, oral motor mobility, and specific swallowing techniques
Non-oral feeding may be required in severe cases
Online Resources
Information on dysphagia diets: http://www.dysphagia-diet.com/
Swallowing treatment: http://www.entandallergy.com/vas/services/swallowing_treatment.php
Aaron’s Tracheostomy Page: www.tracheostomy.com
Video examples of FEES: www.asha.org, search “Endoscopic Evaluation of Swallowing”
iSwallow app: www.ucdvoice.org