Term
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Definition
| difficulty moving food or liquid from the mouth to the stomach |
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Term
| Infant oral, nasal and pharyngeal cavities |
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Definition
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In infants and children, feeding skills are both in preparation for and in support of speech –inadequate development of feeding and swallowing often directly affects speech development.
Infant the tongue primarily fills the oral cavity, fat pads in cheeks narrows oral cavity, the hyoid and larynx lower in children, velum and uvula hand lower and may cover the epiglottis causing poor airway protection
1st 21 years face elongates
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Term
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Definition
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Anticipatory stage or pre-oral stage (Leopold & Kagel, 2004)
–Respiratory pattern adjusts
–expiration ceases
–Prefeeding respiratory pattern adjusts in response to visual, proprioceptive, olfactory, auditory-verbal stimulus processing
–Salivation and possible preparatory swallow
Oral stage
–Oral preparatory: Food prepared for swallow
–Oral transit or oral transport: Food transmitted to pharynx
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Term
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Definition
Notion of dominant swallowing hemisphere- importance for oropharyngeal dysphagia occurance post unilateral stroke
Neural network composed of multiple levels: Cortical, subcortical, brainstem
Primary regions in swallowing: white matter, primary motor cortex, premotor cortex, supplementary motor area, primary somatosensory cortex, insula, thalamus, basal ganglia, anterior cingulated area.
Swallowing – 2 components; voluntary and involuntary
–Voluntary component – Cortical and subcortical control
–Involuntary components (Px and Esophx) – Brainstem – dorsal and ventral medullary regions and the reticular formation
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Term
| Cranial nerves vital for swallowing |
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Definition
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nCranial CN V -- Trigeminal
Located at the level of the pons. Contains both sensory and motor fibers that innervate the face; important in chewing pharyngeal swallow
nCN VII -- Facial
Contains both sensory and motor fibers; important for sensation of oropharynx & taste to anterior 2/3 of tongue
nCN IX -- Glossopharyngeal
Contains both sensory and motor fibers; important for taste to posterior tongue; sensory and motor functions of the pharynx primary saliva production maker
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Term
| Common conditions associated wtih dysphagia |
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Definition
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Pharyngeal phase dysfuntion seem to occur with right cva
Oral phase dysfunction associatied with left cva
Both hemispheres are involved in swallowing, but one will be more dominant in swallowing
nCortical and brainstem CVAs- left CVA more difficulty with swallowing
nProgressive neurodegenerative diseases – Parkinson’s disease, Huntington’s disease, Alzheimer’s disease, Amyotrophic lateral sclerosis, frontotemporal dementia, progressive supranuclear palsy
nTraumatic brain injury or spinal cord injury
nTumors and cancer of the pharynx or esophagus
nCongenital abnormalities/conditions - Cerebral palsy, spinal muscular dystrophy, cleft lip and palate
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Term
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Definition
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nIntrinsic muscles
Responsible for fine motor mvmts
Superior longitudinal muscle
Inferior longitudinal muscle
Transverse muscle
Vertical muscle
nExtrinsic muscles
Palatoglossus -e
Genioglossus- d
Styloglossus -e
Hyoglossus -d
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Term
| Oral stage – Lip/Face muscle contributions |
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Definition
| Lip/face muscles contribute to pre-oral and oral preparatory stage of swallowing. Examples: Lip seal on a spoon and around a straw, cup, or bottle Blowing a bubble with your bubble gum Sucking up a noodle or sucking through a straw Chewing and L-R mvmt of bolus Keeping bolus contained in the oral cavity Filling your mouth with food or liquid |
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Term
| Palatal and pharyngeal muscles |
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Definition
| Levator veli palatini Tensor veli palatini Uvula Palatoglossus Palatopharyngeus Palatal muscles are vital for oral transport stage of swallowing |
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Term
| Pharyngeal muscle activity |
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Definition
| Pharynx – Nasopharynx + Oropharynx + Laryngopharynx Oropharynx – Posterior to the oral cavity and anterior to the cervical vertebrae Laryngopharynx- Immediately below the OP and extends down to the larynx and the esophagus Pharyngeal muscles – Three constrictors + stylopharyngeus + cricopharyngeus + salpingopharyngeus |
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Term
| Swallow Physiology – Oral stage |
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Definition
Oral Preparatory Goal: To reduce food to an appropriate consistency and to place food ready to be transported Tongue positions the food to begin preparing a bolus Reduction phase - Bolus is chewed & mixed with saliva Bolus placement - Bolus is positioned for further transport Oral Transport Goal: To transport the prepared bolus from anterior to posterior oral cavity for passage to the pharynx. This phase occurs as muscles of the lips and cheeks contract followed by tongue contraction against the hard palate. As tongue-hard palate contact occurs, the soft palate elevates as the tensor veli palatini, levator veli palatini and palatophayrngeus muscles contract. The palatal muscle contractions draw the velum superiorly and posteriorly against the nasopharyngeal mucosa and musculature. |
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Term
| Swallow physiology – Pharyngeal phase |
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Definition
This phase is reflexively triggered when bolus approaches the palatoglossal folds Complete closure of velopharyngeal opening. True vocal folds adduct followed by false VFs and aryepiglottic folds adducting Hyoid & larynx begin superior ascent Retroversion of the epiglottis begins. Tongue base and posterior pharyngeal wall contact Top to bottom contractions of pharyngeal constrictor muscles begin Continued elevation of hyoid & larynx towards tongue base Retroversion of the epiglottis complete Anterior movement of hyoid Relaxation of cricopharygeus muscle & opening of upper esophageal sphincter region to allow food into cervical esophagusDuration of typical pharyngeal phase is 1 second Pharyngeal Stage Where the bolus of food/liquid is transferred to the esophagus. Greater than 6 seconds- absent swallow reflex -laryngeal excursion Elevation and retraction of the velum complete closure of the VP 2. Elevation and anterior movement of th ehyoid and larynx 3. Closure of the larynx at three junctures: true vocal folds, false vocal folds, epiglottis 4. Opening of the cricopharyngeal sphincter to allow passage of the food to the esphagus 5. Ramping of the tongue anterior bulging of the posterior wall pharyngeal wall moves posteriorly paristaltic action occurs in the pharynx. 6. Top to bottom pharyngeal contraction (pharyngeal peristalsis. |
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Term
| Swallow physiology – Esophageal phase |
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Definition
| Goal: To carry the bolus through esophagus to the stomach, using peristaltic movements. The lower esophageal sphincter opens to facilitate transport bolus into the stomach. |
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Term
| Dysphagia Team – Medical settings |
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Definition
| Physician (PCP, Neurologist, Radiologist, Gastroenterologist, Otolaryngologist, Surgeon) Registered Nurse (RN), Licensed vocational nurse (LVN) Speech language pathologist Occupational therapist (OT) Respiratory therapist (RT) Physical therapist (PT) Pharmacist Dietitian Certified nurses aides (CNAs) |
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Term
| Dysphagia Team – Educational settings |
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Definition
| Parent Teachers School nurse SLP School dietitian OT School or district administrator |
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Term
| Priorities in dysphagia dx and tx |
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Definition
| Ensuring adequate nutrition and hydration Safety |
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Term
| WHO Model – International Classification of Functioning, Disability, and Health |
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Definition
| Body Functions and Structures -Physiological and psychological functions of body systems, Activity - A: Performance of a task or action by a given person, Participation P: Individual’s involvement in a life situation Environmental Factors - Physical, social, and attitudinal environment in which people live Personal Factors: Age, race/ethnicity, gender, Educational background, Lifestyle |
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Term
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Definition
| Principle 1: Individuals shall honor their responsibility to hold paramount the welfare of persons they serve professionally. Principle 2: Individuals shall honor their responsibility to achieve and maintain the highest level of professional competence. |
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Term
| Principles of Bioethics governing decision making in dysphagia mgmt |
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Definition
| Principle of Beneficence – ‘Consistently act in patient’s best interests’ Principle of Nonmaleficence – ‘Do no harm’ Principle of Autonomy – ‘Respect individuals as self-determining agents’ and ‘assist people with making decisions consistent with their own values’ Principle of Respect – Provide necessary support and protection to assist those persons whose autonomy is impaired or limited Principle of Justice – Act fairly when dealing with patients |
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Term
| FOOD AND LIQUID CONSISTENCIES: QUICK REFERENCE TABLE |
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Definition
CONSISTENCY INDICATORS SAMPLE FOODS
Regular: Oral, pharyngeal & esophageal skills are normal All food items allowed, no restrictions Mechanical Soft: Chopped/Diced As above, except a rotary chew must be present All items must be chopped or diced; excludes hard meats. No crumbly foods like nuts/popcorn
Mechanical Soft-Ground Mild reduction in oral transit Decreased/absent chewing Poor dental status Reduction in pharyngeal function Soft breads, scrambled eggs, ground meats, pastas with extra gravy, moistened foods that won’t adhere to palate
Pureed Decrease oral propulsion Swallow response delayed Decreased chewing Reduced pharyngeal peristalsis Suspected pharyngeal stasis Non-lumpy strained vegetables or meats, oatmeal, puddings, icecream, porridges (baby-food consistency)
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Term
| What happens when esopx function is impaired? |
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Definition
| Impaired esoPx function can result in retention of food and liquid in the esophagus after swallowing. This retention may result from mechanical obstruction, a motility disorder, or impaired opening of the LES. The body of the esophagus may be obstructed by a web, stricture, or tumor. Esophageal propulsive forces may be reduced due to weakness or incoordination of esophageal musculature. Overactivity of esoPx musculature may result in esophageal spasm, which reduces effectiveness of esoPx food transport. Although not a swallowing disorder per se’, GERD is a closely related problem. Patients with GERD are at risk for reflux esophagitis and peptic strictures, which may obstruct the esophagus and result in dysphagia. |
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Term
| Causes of esophageal stage impairments |
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Definition
| Primary Motility Disorders Achalasia (aperistaltic esoPx, failure of LES to relax), neonatal achalasia Diffuse esoPx spasm Presbyesophagus Webs (Plummer-Vinson Syndrome) Secondary Motility Disorders Scleroderma Reflux esophagitis (peptic) Caustic esophagitis Vagotomy Radiation Myositis Parkinsonism Huntington’s chorea Wilson’s disease Cerebrovascular disease Multiple sclerosis ALS CNS neoplasm Infectious Causes Fungal: moniliasis Bacterial: TB Parasitic: Chagas’ disease Viral: Herpes simplex Metabolic Causes Diabetes ETOH Amyloidosis Serum pH and electrolyte disturbances |
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Term
| Signs and symptoms of esophageal stage dysphagia |
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Definition
| Sensation of food sticking in the chest Food sticking in the throat Drooling Unexplained weight loss Change in dietary habits Chest pain Hoarseness Rarer symptoms: Pneumonia or aspiration, nasopharyngeal regurgitation |
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Term
| In case of suspected esophageal stage dysphagia: |
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Definition
| History should also be directed at eliciting symptoms related to GERD, including heartburn, belching, and sour regurgitation Patient's current medications should be reviewed because some drugs, especially psychotropic medications, can exacerbate dysphagia |
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Term
| Medications that may impair esophageal stage functioning |
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Definition
| Inflammation (resulting from irritation by med) Tetracycline Doxycycline (Vibramycin) Iron preparations Quinidine Nonsteroidal anti-inflammatory drugs (NSAIDS) Potassium Impaired motility or exacerbated gastroesophageal reflux Anticholinergics Calcium channel blockers Theophylline Esophagitis (related to immunosuppression) Corticosteroids Other offenders – Anti-anxiety drugs, Botox, Muscle Relaxants |
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Term
| First lines of evaluation |
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Definition
| Careful history MBS Upper Endoscopy or Esophagoduedonoscopy (EGD; allows you to obtain biopsies and dilate strictures as needed) BUT……… A normal endoscopy and Ba swallow does not adequately rule out a structural esophageal abnormality |
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Term
| Diagnostics for esoPx stage impairments |
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Definition
| Barium Esophagogram: Radiographic eval of the esoPx Assesses esoPx bolus transit, esoPx shortening, UES and LES closure and opening Used to rule out neoplasia in patients who complain of thoracic dysphagia or odynophagia Esophageal manometry: Msmt of pressure changes in body of esoPx Indirect measure of contraction and function; no direct obsv. of bolus Intra-esophageal pH monitoring: Prolonged pH recording in the study of GER Laryngopharyngeal reflux (LPR) Globus pharyngeous (Cook, 2007) Appropriate when a motility disorder or GERD is suspected Electromyography - Indicated in patients with motor unit disorders, such as polymyositis, myasthenia gravis, or ALS. Note: These are seldom the first lines of investigation |
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Term
| Treatments for esoPx stage impairments |
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Definition
| PROBLEM Peptic stricture of the esophagus, achalasia of the lower esophageal sphincter Gastroesophageal reflux disease Diffuse esophageal spasm Esophageal cancer Eosinophilic esophagitis TREATMENT Dilatation, myotomy, fundoplication, Botox Dietary modification, no eating at or close to bedtime, remaining upright after eating, pharmacologic therapy, smoking cessation Pharmacologic therapy Esophagectomy Oral steroids, elimination of food allergen |
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Term
| Basic Normal Oral-Motor Reflexes of Newborns & Infants |
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Definition
| rooting suckling sucking swallowing tongue thrusting biting gagging Babkin’s palmomental |
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Term
| Feeding Development and Transitions: Liquids |
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Definition
| bottle/breast birth – 6 months cup drinking 7-12 months (about 1 month after spoon feeding begins) straw drinking 36 months |
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Term
| Feeding Development & Transitions: Solids |
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Definition
| Spoon feeding 4-6 months Munching/chewing 6-7 months Controlled, sustained biting 12+ months Rotary chewing 12-15+ months |
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Term
| Causes of Dysphagia in Children |
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Definition
| Organic (anatomical, neuromuscular) Developmental (dysfunctional, uncoordinated) Functional (conversion, conditioned) |
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Term
| Populations at Risk for Development of Feeding/Swallowing Disorders |
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Definition
| neurological problems congenital anomalies metabolic disorders cognitive or behavioral limitations psychosocial problems chronic illness GI disorders |
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Term
| Common Symptoms for Referral for Feeding/Swallowing Evaluations |
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Definition
| difficulties during feeding pulmonary status general health/GI issues neurological problems structural/anatomical differences |
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Term
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Definition
| Case History Pediatric/developmental History Clinical Bedside Swallowing Evaluation Videofluoroscopic Swallowing Evaluation Video Nasal Endoscopic Swallowing Evaluation |
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Term
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Definition
| pertinent medical history language comprehension alertness nutritional status hydration status respiratory status pulmonary disease neuromuscular integrity method of intake |
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Term
| Pediatric Clinical Bedside Swallowing Evaluation |
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Definition
| environment observation of caregiver oral mechanism examination positioning assessment utensils consistencies deglutitive evaluation communicative issues |
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Term
| Abnormal Reflex Patterns in Children with Feeding Disorders |
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Definition
| jaw thrust tongue thrust lip retraction tonic bite reaction tongue retraction nasal regurgitation |
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Term
| Disorganized vs. Dysfunctional Feeding Patterns |
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Definition
| Disorganized feeder - difficulty initiating movements - inconsistent, uncoordinated, arrhythmic tongue and jaw movements - immature suck pattern - fatigues easily Dysfunctional feeder - movements may be excessive or minimal, if at all present - abnormal tongue postures (humped, retracted, flaccid) - asymmetrical |
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Term
| Radiation Exposure for Children |
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Definition
| Acquire maximum information in a minimal amount of time. no more than 120 seconds of exposure infants should only be exposed for 30-60 seconds total (Arvedson & Christensen, 1993) Only radiate the part of the body that is being examined. |
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Term
| What is the “real” goal of therapy with the child? |
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Definition
| Meeting all nutrition and hydration needs orally? Achieving partial oral feeding – nutrition and hydration? Providing taste stimulation safely and pleasure orally? |
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Term
| Goal of Oral-Motor Treatment |
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Definition
| the development of appropriate use of the mouth, respiratory and phonatory systems in exploration, sound play, and as much oral feeding as possible. oral-feeding is the by-product of the program, not its major goal. |
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Term
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Definition
| oral feeding improving the mechanisms of swallowing and sucking works toward the use of food and liquid in the program feeding is both a long-term and short-term goal |
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Term
| Phagophobia: What it is & Symptoms |
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Definition
| fear and avoidance of swallowing food, fluid, or pills sensation of foreign body in throat throat pressure or constriction of throat difficulty initiating the swallow weight loss secondary to decreased oral intake avoidance of eating in public malnutrition |
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Term
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Definition
| Most patients acquire after episode of choking on food (McNally, 1994) May develop into a preoccupation with choking (Chatoor, Conley & Dickson, 1988) |
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Term
| Speech-Language Pathology Evaluation for Phagophobia |
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Definition
| Duration of symptoms Sensation or occurrence of bolus sticking Localization of where bolus feels stuck Maneuvers required to move bolus Sensation of aspiration Weight loss or dietary modification Symptoms of eating disorder Relevant antecedent event or stressors Family history of dysphagia Related symptoms: odynophagia, globus, nasal regurgitation, ptosis, diplopia, dysarthria, dysphonia, diffuse muscle weakness, heartburn |
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Term
| Inservicing Ideas/Suggestions Purpose: |
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Definition
| The main purpose of any clinical educational inservice is to educate and /or train medical professionals, caregivers/families, and even the patient, in their area of disorder and the techniques which will assist them in their recovery. Tailor your inservice in terms of the amount of professional lingo, layman terminology, and facility setting. Keep in mind that most inservice presentations typically last about 30 minutes in duration. Possible goals of the inservice may be to: a) help co-workers identify speech/swallowing problems so that referrals can be made to the SLP; b) train those caregivers working with the specified population; c) help prepare the patient to be more independent & safe d) educate parents of their child’s communication, swallowing, hearing impairment and helpful compensatory strategies. |
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Term
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Definition
| 1) Instructional Inservice: Medical Setting: You may speak about a certain disorder and may include examples of patients that medical personnel are familiar with to demonstrate the type of disorder you’re describing. You should include a definition, list of symptoms, what they can do when working with residents with these problems, and tips for communicating/assisting with their swallowing for that population. School Setting: You may start by describing recent diagnostic results and discuss the data, and give examples of normative performance and compare it with their child’s current performance. It is helpful to give examples of the areas that were tested and also to distribute user-friendly, short handouts on that particular disorder; i.e., Asperger’s syndrome, swallowing, oro-myofunctional disorders, etc |
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Term
| For all inservices: Here are our top recommendations! |
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Definition
Always bring a sign-in sheet so you have a record of the number of people attending, disciplines represented (or not represented) ! Make inservices interesting so participants feel they are walking away with useful information ! Always distribute a single page handout with useful techniques, important resources (websites etc) and with information on how they can contact you for questions or information (give out business cards for parent inservices) ! Whenever possible, bring tangible items to the inservice (for example, if demonstrating oral care –bring all supplies), or if demonstrating use of special feeders, cups, straws etc – bring these items to the inservice. Also, by the same token, bringing charts or pictures is also a great idea. ! Always keep in mind WHO is in your audience: FAMILIES? DOCTORS? PATIENT? NURSES? STUDENT? PARENTS? AIDES? HIRED CAREGIVERS? ! Be very clear about your goals for doing an inservice – it is important to keep this in sight and let participants know what you (as an SLP) are hoping will be the outcomes of the inservice presentation !
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Term
| Checklist for Medical Chart Review |
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Definition
| Advance Directive for Health Care Admission Records (demographic data, current diagnoses, relevant ICD-9 codes, insurance information) History and Physical Physician’s Orders (or Requests for Physician’s Orders) Progress Notes (SOPA note format) Labs Radiology or Special Reports (either of these could contain a VFSS report) Rehab and Therapy (will include PT, OT, ST documentation if no such titled tab, place all documentation under Progress Notes) Multidisciplinary care plan (long, pull-out sheet which must be filled in by all disciplines treating the client) Other Tabs that may contain relevant information GI/Dietary Audiology and Opt/Opth Psych/psychosocial reports (Neuropsych reports, social worker evals may be found here) |
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Term
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Definition
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Term
| Medications Associated with Dysphagia |
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Definition
| Medications that can cause direct esophageal mucosal injury10 Antibiotics Doxycycline (Vibramycin) Tetracycline Clindamycin (Cleocin) Trimethoprim-sulfamethoxazole (Bactrim, Septra) Nonsteroidal anti-inflammatory drugs Alendronate (Fosamax) Zidovudine (Retrovir) Ascorbic acid Potassium chloride tablets (Slow-K)* Theophylline Quinidine gluconate Ferrous sulfate Medications, hormones and foods associated with reduced lower esophageal sphincter tone and reflux11 Butylscopolamine Theophylline Nitrates Calcium antagonists Alcohol, fat, chocolate Medications associated with xerostomia11 Anticholinergics: atropine, scopolamine (Transderm Scop) Alpha adrenergic blockers Angiotensin-converting enzyme inhibitors Angiotensin II receptor blockers Antiarrhythmics Disopyramide (Norpace) Mexiletine (Mexitil) Ipratropium bromide (Atrovent) Antihistamines Diuretics Opiates Antipsychotics |
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Term
| stages of swallowing cont'd |
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Definition
Pharyngeal stage: Bolus transmitted to esophagus
Esophageal stage: Food transmitted from upper esophageal region to stomach |
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Term
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Definition
| Try to leave a few minutes for questions (not possible in your 10-minute presentation!) but when you do a real inservice, be sure to set aside some time to answer questions –often times you may get referrals on the spot (“You know the patient in ICU 4 has been coughing a lot....”, “my son’s been spitting up a lot since last week”...... Etc) ! Get feedback from your participants after the inservice - this could be done formally or informally ! When you do your first inservice, invite someone you trust to observe and give you comments on your delivery style, pluses and minuses of your presentation so you can continually improve upon your presentation skills. Also, it is an equally good idea to ask to attend an OT or PT’s inservice when you are new out there, so you learn about their work but also get to observe the kinds of inservices they do. |
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Term
| Neurology of Swallowing cont'd |
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Definition
Swallowing is a centrally mediated phenomenon with two loci of control:
–Frontal cortex- Anterior to the sensorimotor cortex
–Brainstem areas – Dorsal BS: Nucleus of Tractus Solitarius-receives input from the trigeminal sensory nucleus receives infro from the pons. Involved in the muscles of the pharynx and esophagus; Ventral BS: Nucleus Ambiguus- all sensory information is integrated and motor response is Allows for a safe swallow for a variety of foods, taste, temperature and bite sizes. |
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Term
| FOOD AND LIQUID CONSISTENCIES: QUICK REFERENCE TABLE cont'd |
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Definition
| Thin: Oral, pharyngeal & esophageal skills are normal Juice, water, clear soups, coffee, tea, sodas Nectar-thick:Decreased oral propulsion Cricopharyngeal dysfunction Adequate swallow reflex Nectar, vegetable juices, cream soups, milkshakes TEST: (If a spoon is dipped, does it coat the spoon and drip off???) Honey-thick: Decreased oral propulsion Reduced pharyngeal peristalsis Cricopharyngeal dysfunction Decreased/absent chewing Milkshakes, or thickened juices TEST: if a spoon is able to stand up in it |
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Term
| types of inservices cont'd |
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Definition
| . 2) Practical Inservice: For this type of inservice, develop simple exercises and make up scenarios so that your audience can “experience” the disorder and the treatment techniques that you plan to implement. Some professionals refer to this as “an empathy inservice”. Again, be sure to include a definition of the disorder, you may assign certain disorders to participants in the audience, and go around the room and demonstrate w/ the participants. Ahead of time, each participant has a script on how they are to demonstrate the disorder so that it can be portrayed accurately. It is recommended to usually pair up participants so that one acts as a patient and the other acts as a caregiver/observer. |
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