Introduction to Communication Disorders: A Lifespan Evidence-Based Perspective 5th Edition

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