Spth 365 Dysphagia and Related Disorders: Diagnosis

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Spth 365 Dysphagia and Related Disorders
Diagnosis

• Lecture Four
• Disordered Swallowing Physiology

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Issues impacting diagnosis of dysphagia

• Symptoms are frequently observable physiology
  frequently is not.
• Ex Wet dysphonia
• Thus, clinical assessment generally gives
  information about symptomotology but requires
  diagnostic assessment to provide information
  about physiology.

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• Symptoms are frequently static physiology is
  frequently dynamic.
• Ex pre-swallow pooling -vs- delayed pharyngeal
  swallow.
• Thus it is easier to evaluate symptoms over a
  period of time, whereas evaluation of physiology
  requires a quick eye

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• Compensatory techniques usually address
  symptomotology rehabilitation addresses
  physiology.
• Ex pyriform sinus residual.head rotation vs
  mendelsohn maneuver.
• Attempting to address clinical symptoms may not
  alleviate the underlying deficit.
• Compensation vs rehabilitation

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Dysphagic Symptoms

• Inadequate bolus preparation
• Anterior leakage
• Post swallow oral residual
• Premature spillage
• Pre-swallow pharyngeal pooling to the level of
  the ____
• Inadequate epiglottic deflection
• Inadequate opening of the UES
• Post swallow vallecular residual
• Post swallow pyriform sinus residual
• Aspiration
• Penetration
• May be both symptom and physiolgoic abnormality

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Dysphagic Physiology

• Oral motor impairment
• Delayed pharyngeal swallow
• Inadequate BOT to PPW approximation
• Weakened pharyngeal contraction/poor stripping
• Inadequate epiglottic to arytenoid deflection
• Inadequate Hyolaryngeal excursion
• Incomplete velopharyngeal closure
• Impaired opening of the UES

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Patient presents ____ phase dysphagia
characterized by symptom secondary to
physiology.
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In the oral phase of swallowing,

• The physiologic abnormality of Poor Oral Control
  can lead to the symptoms of
• Inadequate bolus preparation
• Anterior leakage
• Premature spillage
• Pre-swallow pharyngeal pooling to the level of
  the ...
• Aspiration (usually before the swallow, but may
  be during if contrast fills the pharyngeal
  cavities)
• Penetration (usually before the swallow, but may
  be during if contrast fills the pharyngeal
  cavities)
• Post swallow oral residual

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Clinical Observations

• amount of oral pooling post swallow
• bolus formation and control lingual search
• cohesiveness of bolus
• mastication of texture
• swallows completed volitional or elicited
• estimated transit time onset of swallow (very
  difficult to assess)
• number of swallows to clear bolus
• frequency of reflexive cough
• vocal quality pre and post swallow

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In the oral transit phase of swallowing

• The physiologic abnormality of Delayed
  Pharyngeal Swallow can lead to the symptoms of
• Pre-swallow pharyngeal pooling to the level of
  the ..
• Penetration (usually before the swallow, but may
  be during if contrast fills the pharyngeal
  cavities)
• Aspiration (usually before the swallow, but may
  be during if contrast fills the pharyngeal
  cavities)

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Clinical Observations

• estimated transit time onset of swallow (very
  difficult to assess)
• frequency of reflexive cough
• vocal quality pre and post swallow

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Premature Spill 2o Poor Oral Control -vs-
Delayed Pharyngeal Swallow

• Pre-mature spillage is an impairment of the MOTOR
  system.
• Delayed pharyngeal swallow is an impairment of
  the SENSORY system.
• Is this absolutely positively true? NOPE

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Differential Diagnosis is really really
hard!(not to mention sometimes impossible)

• Delayed Swallow
• Glossopalatal seal intact
• Cohesive bolus for transfers
• More apparent on liquids
• Base of tongue with clear drop/push but latent
  onset

• Premature Spillage
• Glossopalatal seal is poor or absent
• Bolus transfers in bits
• More apparent on solids/heavier textures
• Base of tongue doesnt drop/push

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In the pharyngeal phase of swallowing

• The physiologic abnormality of incomplete
  velopharyngeal closure can lead to the symptoms
  of
• Nasal regurgitation in the case of disorganized
  swallowing response
• Perhaps poor pharyngeal stripping if the pressure
  system is disrupted.

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Clinical Observations

• Patient reports /clinician observes food in nose
• Ability to expectorate post swallow pharyngeal
  residual

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In the pharyngeal phase of swallowing

• The physiologic abnormality of inadequate BOT to
  PPW approximation can lead to the symptoms of
• Post swallow vallecular residual
• Aspiration (usually post swallow)
• Penetration (usually post swallow)

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Clinical Observations

• Ability to expectorate residual
• Frequency of reflexive cough
• Vocal quality pre and post swallow

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In the pharyngeal phase of swallowing

• The physiologic abnormality of inadequate
  epiglottic deflection can lead to the symptoms
  of
• Inadequate epiglottic deflection
• Aspiration (usually during the swallow)
• Post swallow vallecular residual
• Penetration (usually during the swallow)
• nb inadequate epiglottic deflection can also be
  a symptom of another physiologic abnormality

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Clinical Observations

• Ability to expectorate residual
• frequency of reflexive cough
• vocal quality pre and post swallow

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In the pharyngeal phase of swallowing

• The physiologic abnormality of Inadequate
  Hyolaryngeal Excursion can lead to the symptoms
  of
• Inadequate epiglottic deflection which in turn
  leads to
• Post swallow vallecular residual
• Aspiration (usually during the swallow)
• Penetration (usually during the swallow)
• Inadequate UES opening which in turn leads to
• Post swallow pyriform sinus residual

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Clinical Observations

• onset of swallow (very difficult to assess)
• height of laryngeal elevation (very difficult to
  assess)
• duration of laryngeal elevation
• ability to expectorate post swallow residual
• multiple reflexive swallow pattern
• frequency of reflexive cough
• vocal quality pre and post swallow

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In the pharyngeal phase of swallowing

• The physiologic abnormality of Pharyngeal
  Weakness can lead to the symptoms of
• Post swallow vallecular residual
• Decreased pharyngeal stripping
• Post swallow pyriform sinus residual
• Post swallow diffuse pharyngeal residual
• Aspiration (during or after the swallow)
• Penetration (during or after the swallow)

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Clinical Observations

• Ability to expectorate post swallow residual
• Altered vocal resonance post swallow
• frequency of reflexive cough
• vocal quality pre and post swallow

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In the crico-oesophageal phase of swallowing

• The physiologic abnormality of inadequate
  opening of the upper esophageal sphincter can
  lead to the symptoms of
• Post swallow pyriform sinus residual
• Aspiration (usually after the swallow or during
  subsequent swallows from residual)
• Penetration (usually after the swallow or during
  subsequent swallows from residual)

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Clinical Observations

• Ability to expectorate post swallow residual
• Multiple reflexive swallow pattern
• Discomfort in swallow
• Change in vocal resonance post swallow
• frequency of reflexive cough
• vocal quality pre and post swallow

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Documentation
The patient presents______________
_________________dysphagia characterized by
________________resulting in ________________
(severity)
(phase)
(Physiologic abnormality)
(symptoms)

There is ____________ __________________
aspiration of ______________ that is
_________________________.

(severity)
(time of)
(texture) (response
to aspirate)




Reflexive cough that clears


Reflexive cough that does
1.

Thin liquids
not clear
2.

All liquids


Altered respiratory rate


None


Oral phase
3.
Puree

that does not clear


Mild


(Oral transit)
4.

Solids


No response



Mild to Moderate

Pharyngeal phase
Etc


Moderate


Cricoesophageal


Moderate to Severe


Esophageal


deflection


Severe


Severe to Profound



Profound


1.
Poor oral control


Pre-swallow




During the swallow
Premature spillage 2º poor oral
2.

control


Post-swallow

Delayed Pharyngeal Swallow
3.

4.
Inadequate BOT to PPW
approximation
5.
Decreased pharyngeal stripping

Inadequate Hyolaryngeal excursion
6.

7.
Inadequate epiglottic to arytenoid
8.
Inadequate opening of the UES
Etc.
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Summary

• Swallowing is a very complex process
• More information about management technique
  highlights the need to understand the physiology
• Use symptoms for orientation to the problem
• Evaluate the physiology