LAST EXAM OF COLLEGE

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acquired final

dysphagia

"difficulty eating"

How many Americans are evaluated each year with dysphagia?

10 million

___ of these Americans are over 50 years of age

22%

Phases of swallowing

1. Oral Preparatory phase
2. Oral Transport phase
3. Pharyngeal Transport phase
4. Esopharyngeal Transport phase

Oral Prep phase

manipulation and/or prep of bolus to swallow. Food is manipulated (masticated if solid)
-sensory input from CN V, VII, IX
-motor input from CN V, VII, IX, XII

Oral Transport phase

tongue begins the anterior to posterior propulsion of the bolus. This is accomplished by lingual peristaltic movement of tongue against hard palate.
-sensory input from CN V, VII, IX
-motor input from CN V, VII, IX, XII

Pharyngeal Transport phase

involuntary movement begins. Tongue (base) propels bolus into pharynx. Velum is elevated. Pharyngeal muscles begin contraction from top to bottom, stripping the bolus through pharynx. hyoid bone elevates.

Esophageal Transport phase

upon entry of bolus through sphinctor, phase begins. Continues by peristalsis

Pediatric swallowing

infants - structures smaller, larynx higher in neck, difference in swallowing pattern.
-suckling - 8 mo. gestation to 6 months after birth
-sucking - after 6 months

Elderly swallowing

changes when older -
vertebral thinning, decreased lung elasticity, laryngeal ossification, laryngotosis (abnormal contraction of larynx, weaker), drying of oral mucosa (xerostomia), taste decrement, smell decrement, GERD

Penetration

material enters larynx

Aspiration

material passes through vocal folds into trachea
-strong protective response against = cough

Silent Aspiration

dangerous, cough response absent
-materials entering airway w/o indication

Dysphagia - Stroke

#1 cause of dysphagia in adults. Due to Cerebral Vascular Accident, Iscemic and Hemorrhagic

Dysphagia - TBI

may result in impaired cognition, interfere with treatment

Dysphagia - Amyotropic Lateral Sclerosis

degenerative disease, upper and lower motor neuron systems
-Bulbar type most affects swallowing early in disease process
-feeding tube almost always necessary

Dysphagia - Parkinson disease

weakness, tremor, silent aspiration

Dysphagia - Progressive Supranuclear Palsy (PSP)

weakness, cough present with aspiration

Dysphagia - Myasthenia Gravis

disease affects lower motor neuron system
-neuromotor junction - difficulty with transmission of neurochemicals
-result is progressive weakness with continued use
-assessment may look normal at onset, performance can deteriorate, sometimes in just minutes

Dysphagia - Multiple Sclerosis

demyelinating disease affects brain and spinal cord - dysphagia may be present when symptoms are present

Dysphagia - Huntington's disease

movement disorder, motor system and cognition affected. Involuntary movement and muscle dysfunction, weakness

Dysphagia - Guillain-Barre

auto-immune virus affecting peripheral NS. can be very rapid, feeding tubes may be necessary, long course of recovery, symptoms are weakness and sensory loss of PNS

Dysphagia - Dementia

progressive disease affecting the cortex. cognitive decline, personality change, unaware of food in mouth, loss of desire to eat

Dysphagia - Head and Neck Cancer

medical management may result in a dramatically altered system -
-muscle damage due to surgery/radiation
-structural alternations due to removal of tissue/bone
-can be severely dysphasic

Bedside evaluation

aka clinical swallow evaluation or non instrumental evaluation

Bedside evaluation - why important?

-determine candidacy for a videofluroscopic evaluation
-determine optimal food/liquid recommendations
-monitor progress, determine possibility of upgrading or downgrading diet

warning signs of dysphagia

-decreased mental status
-dysarthria
-drooling
-coughing/choking
-lengthy meal times
-weight loss
-effortful swallow
-decreased oral management

medical chart review

medical history, respiratory conditions/disease, weight loss, disease process, current event, symptoms, CN eval, surgeries, respiratory status, medications

medical staff interview

impression of swallowing, speech, cognition abilities
-oral secretion management

Oral mechanism examination

-face at rest/facial symmetry
-speech sample
-sustained "ah"
-oral mucosa
-dentition
-tongue
-sensation
-reflexes
-swallow on command
-description of symptoms if possible

Instrumental Assessment

-videofluoroscopy
-FEES
-Ultrasound
-electromyography
-cervical auscultation

Fluoroscopy

dynamic xray

Cinefluoroscopy

film, frame by frame analysis

Videofluoroscopy

videotape, immediate playback capabilities, audio recording capability
-assess overall swallow function (4 phases)

Modified Barium Swallow Study

determine presence of aspiration, why aspiration occurring, alleviation of symptoms
-3 consistencies, at least 2 swallows each

MBSS Patient Positioning

can be time consuming
-sitting or standing, 90 degree angle

MBSS measures/observations

-oral transit time, pharyngeal transit time
-stasis/residual material
-penetration
-aspiration (before, during, or after swallow?)

A-P view

front
-asymmetries
-collection of material unilateral or bilateral

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