Dysphagia

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Dysphagia

• Sarah Brincks
• 25 May 2008

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Overview

• Normal swallow
• Disordered swallow
• Evaluation of swallowing
• Treatment of swallowing

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Normal Swallowing
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Phases of Swallowing

• Oral preparatory phase
• Oral transit phase
• Pharyngeal phase
• Esophageal phase

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Phases of swallowing

• Oral Preparatory Phase
• Voluntary
• Introduction of bolus into the mouth
• Mastication
• Oral Transit Phase
• Voluntary
• Peristaltic movement of tongue to propel bolus
  posteriorly

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Phases of Swallowing

• Pharyngeal Phase
• Mostly involuntary
• Airway closure
• Apneic pause of .5 seconds to 3.5 seconds
• Laryngeal elevation
• Contraction of pharyngeal constrictors
• Inversion of epiglottis
• UES relaxes

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Airway Protection

• VITAL to safe swallow
• Three levels of airway protection
• 1. true vocal folds
• 2. ventricular folds
• 3. epiglottis
• Reflexive cough if bolus enters laryngeal
  vestibule

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Disordered Swallowing

• Causes
• CVA (stroke)
• Neurodevelopmental disorders
• E.g. cerebral palsy
• Head and neck cancer
• Obstructive disorders
• E.g. cervical osteophytes
• Psychogenic swallowing disorders

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Disordered Swallowing

• Signs and symptoms
• coughing and choking
• pneumonia
• wet voice
• excessive drooling
• prolonged duration of meals
• weight loss
• globus sensation

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Evaluations of Swallowing

• Bedside exam
• Chart review
• General functional status
• Ask the patient
• Oral mechanism exam
• Dry swallows
• Assess mastication
• Trial swallows

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Evaluations of Swallowing

• Modified barium swallow study
• Use a variety of consistencies
• 2 bites of each consistency
• Begin with VERY small amount of bolus
• If patient does not show signs of aspiration,
  give larger amount
• Begin with consistency least likely to be
  aspirated
• E.g. if patient is suspected to have pharyngeal
  weakness, give thicker consistency to avoid
  aspiration of thin consistencies

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Treatment of Dysphagia

• Bolus manipulation
• Thin liquids oral dysfunction
• reduced UES opening
• Thickened liquids delayed pharyngeal swallow
• reduced lingua-velar contact
• Purees delayed pharyngeal swallow
• reduced laryngeal closure
• reduced mastication
• Allow patient least restrictive diet that is safe
  for him or her to swallow
• modified from Logemann, J. (1998) Evaluation and
  Treatment of Swallowing Disorders, Pro-Ed,
  Austin, TX, U.S.A, p. 203.

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Treatment of Dysphagia

• Behavioral therapy
• Swallowing postures
• Chin down
• Chin up
• Head turn
• Head tilt

• Swallow maneuvers
• Supraglottic swallow
• Super-supraglottic swallow
• Effortful swallow
• Mendelsohn maneuver

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Treatment of Dysphagia

• Behavioral therapy
• Oral motor exercises
• Useful to increase strength, range of movement,
  and coordination of muscles
• Use exercises that target the weak or deficient
  muscles
• See next slide for a list of oral motor exercises

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Treatment of Dysphagia

• Lips
• Puff cheeks and hold
• Alternate smiling and puckering lips
• Tongue
• Protrusion/retraction
• Alternativng lateral movement
• Press tongue tip to roof of mouth and hold
• Press tongue dorsum to roof of mouth and hold
• Press tongue against resistance, such as a tongue
  blade
• Use a toothette or rolled gauze to move in mouth
• Pharynx
• Dry swallow using swallow maneuvers
• Larynx
• Hard-onset vocalizations
• Falsetto exercise glide up pitch scale and hold
  at highest possible note

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Treatment of Dysphagia

• Other useful tricks and tips
• Pressing down with a spoon on the tongue
  encourages
• Prohibit drinking through straws
• Alternate bites of food with sips of liquid or
  thickened liquid
• Encourage the patient to feed himself when
• Laryngeal massage or tapping

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References

• http//www.ckha.on.ca/rehab/images/dysphagia.gif
• Karnell, M. (2008) Class Notes. 003-236
  Swallowing Disorders, Department of Speech
  Pathology and Audiology, University of Iowa, IA,
  U.S.A.
• Logemann, J. (1998) Evaluation and Treatment of
  Swallowing Disorders, Pro-Ed, Austin, TX, U.S.A.