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Feeding and Swallowing Final
Terms in this set (70)
Do pts with neurogenic disorders have reduced sensitivity to aspiration?
Yes, patients with neurogenic disorders typically have reduced sensitivity to aspiration. The patients tend to fatigue easily; therefore: swallowing maneuvers may not be appropriate, smaller meals, other diet changes, and heightening sensory awareness may be more appropriate.
What might be more appropriate compensatory options for neurogenic pts?
smaller meals, other diet changes, and heightening sensory awareness may be more appropriate.
Would you expect improvement in dysphagia from someone whose had a stroke?
Yes, swallowing disorders following a stroke typically are expected to improve.
True or False: Standard Dysphagia treatment is expected to improve dysphagia in someone with ALS.
True of False: Treatment is not expected to improve dysphagia in someone with a TBI.
Where is the major swallowing center located in the brain?
In the medulla
For 1-2 wks. after a medullary stroke, a pt. may experience ____________________.
Wallenberg's Syndrome (ataxia on same side, inability to swallow, hoarse voice), tongue deviation to the side of the stroke
True or False: Pharyngeal Swallow is more likely to return than oral swallow function 1-2 weeks post medullary stroke.
What might exacerbate dysphagia in someone with medullary stroke (or any stroke, really)?
Is it possible for a pt to recover completely from a medullary stroke?
a. Recovery is dependent on severity of swallow problems and medical complications- i.e., more problems and more severe problems, longer recovery
b. Patients with an isolated lesion of the brainstem, may only have a swallowing problem, may recover functional swallow in 3 wks. and resume full oral intake
c. Patients with brainstem lesion(s) and other complications may not recover functional swallow for 6 or more months
What treatment might improve a delayed pharyngeal swallow?
a. thermal-tactile stimulation if delay is longer than 1 sec & can't be managed with posture
b. use of sour bolus
c. supraglottic swallow/breath hold (chin down) - must be tested with VFSS
What impairment may keep a R hemispheric stroke pt. less likely to return to oral intake than a L hemispheric stroke?
because of cognitive disorders, e.g., inattention, may have difficulty using therapy procedures, taking longer to return to oral intake than left CVA
What treatment might be appropriate for someone with Swallow Apraxia?
a. reduce swallow commands
b. allow self-feeding
c. increase oral sensation
-increase bolus volume and viscosity,
-pressure on tongue with spoon
-bolus requiring chewing
What treatments might be appropriate for someone with generalized weakness?
a. falsetto-improve laryngeal elevation
b. effortful swallow-improve tongue base retraction
c. tongue base retraction exercise
d. super-supraglottic swallow & Mendelsohn maneuver to improve overall pharyngeal movement
Recovery is most rapid in first __________ weeks post ictus, following stroke.
Research shows that most stroke pts return to full oral intake after __________ weeks.
Which neurogenic disorder might cause someone to put too much food in their mouth, and eat at a rapid rate?
What 3 neurogenic diseases cause progressive swallowing disorders?
Myasthenia Gravis, Amyotrophic Lateral Sclerosis, Parkinson's Disease
Should you complete regular swallowing evaluations with pts with progressive neuro disease?
a. Regular swallowing evaluations are necessary to set and monitor appropriate goals, including
i. to compensate for deteriorating function as long as possible
ii. to minimize risks of serious aspiration
iii. to maintain optimal nutrition and hydration as long as possible
What is the SLPs role when a pts swallow has become unsafe for oral nutrition?
Our job is to counsel pt./family about risks and advantages of our recommendations and feeding choices they make.
Which neuro disease is known for worsening function with use and improvement with rest?
Which type of ALS will affect swallowing early on?
If bulbar in loci (affecting lower motor neurons in pons and medulla areas) speech and swallowing affected early
Within 18 months of onset, an ALS pt. may require _____________ feeding.
What are the major signs of Parkinson's?
a. shuffling gait (slow, stooped-over, shuffling)
b. tremor, pill-rolling type
c. rigidity, especially thoracic
d. masked facies
e. rough, breathy voice (glottal fry)-often an early sign/symptom
Tongue pumping is a typical presentation in _______________.
At the end stage of Parkinson's, what can reduce a pts ability to follow swallowing strategies?
At the end stage of Parkinson's, person may have dementia, making use of swallowing strategies difficult or impossible
What is the primary cause of head/neck cancer?
a. Tobacco and alcohol make up 75%
b. HPV- Human Papillomavirus
c. Growing in incidence
d. Paan (southeast Asian immigrants), preservatives, oral health, occupational exposure, radiation exposure, etc.
True or False: A flap is a type of surgical resection for head/neck cancer.
FALSE- Surgical reconstruction in order to improve function following resection
What 2 side effects of radiation impact swallowing?
a. Causes fibrosis (pharynx particularly sensitive)
-Radiation "burns" the soft tissue, which builds scar tissue
b. Causes xerostomia (dry mouth)
True or False: If less than 50% of the tongue is resected in a partial glossectomy there is usually a temporary swallowing disorder.
More than 50% tongue resection in a glossectomy may require treatment that includes ____________.
a. Primarily liquids/liquidized solids
b. tilt head back (dump swallow)
c. range of tongue-motion exercises
d. palatal augmentation (reshaping) prosthesis
What is the purpose of a palatal augmentation?
An intraoral prosthesis which reshapes the contour of the patient's hard palate so that it can more effectively interact with the remaining tongue tissue and movement
Who creates the palatal prosthesis?
What effect might a palatal resection have on the soft palate?
nasal regurgitation, (severe hypernasality and nasal emission)
What can be done to significantly reduce speech/swallowing disorders at the time of a palatectomy?
placement of palatal obturator at time of surgery, usually significantly reducing swallowing and speech problems
What major surgical resection in head/neck cancer would cause severe dysphagia?
Hypopharyngeal tumors often invade several structures, perhaps spreading to the larynx and neck (lymph nodes), requiring a laryngopharyngectomy and resulting in severe dysphagia
Which laryngectomy type involves resection of the hyoid bone, epiglottis, aryepiglottic folds, and the false folds?
Supraglottic Laryngectomy (Horizontal Laryngectomy)
What problems will you see with supraglottic laryngectomy?
a. Aspiration during swallow due to reduced laryngeal closure
b. Aspiration after swallow due to reduced pharyngeal contraction
c. Pts with typical supraglottic laryngectomy and good tongue base action usually have functional swallow within 1 month, if they learn to use supraglottic or super-supraglottic swallow
What is resected during a hemilaryngectomy?
Resection of 1 false fold, 1 ventricle, 1 true fold and portion of thyroid cartilage
Which laryngectomy type has the least effect on swallowing?
Which laryngectomy type involves a tracheostomy?
What treatments may be effective for strictures/narrowing after a total laryngectomy?
a. head rotation (sometimes helps to stretch and open PE segment)
b. double swallows per bolus
c. alternating liquid and solid swallows
e. cricopharyngeal (or P-E) myotomy
What is the only thing that can cause aspiration in someone with a total laryngectomy?
This is impossible after a total laryngectomy because the trachea is sewn to the skin of the neck, so there is no connection between the mouth and the lungs to allow for aspiration
Is an infant an anatomical miniature of the adult?
No- The infant is not an anatomical miniature of the adult
What totally fills the oral cavity of an infant?
Where is an infants pharyngeal swallow triggered?
In the vallecula (young adults- triggered in the anterior faucial pillars)
How long does a bolus take to pass through the esophagus in an infant?
3-10 seconds (8-20 in adults)
When should a typically developing infant begin rotary chewing?
What are some diagnoses that are often associated with dysphagia in children?
b. Neurologic conditions (e.g., cerebral palsy, brain injury)
c. Complex medical conditions (e.g., gastrointestinal, cardiac and respiratory conditions)
d. Craniofacial anomalies (e.g., cleft lip and cleft palate, often associated with other problems in a variety of syndromes)
e. Developmental disabilities (e.g., Down Syndrome)
f. Autism Spectrum Disorders
What are the 4 primary areas involved in feeding/swallowing disorders in infants?
a. Oral Issues
b. Pharyngeal Issues
c. Gastrointestinal Issues
d. Respiratory/Airway Issues
Can constipation have an impact on a child's desire to eat?
a. May cause GER
b. Impact on a child's desire to eat
c. May reduce overall food and liquid intake
What types of things might trigger a pediatrician to refer to SLP?
a. Sucking, swallowing and breathing incoordination
b. Weak suck
c. Breathing disruptions or apnea during feeding
d. Excessive gagging or recurrent cough with feeds
e. New onset of feeding difficulty
f. Diagnosis of disorders associated with dysphagia
g. Weight loss or lack of weight gain for 2-3 months
Know the feeding development at each stage.
a. Bottle/breast: birth-6 months
b. Cup drinking: 7-12 months (about 1 month after spoon feeding begins)
i. 1-2 months after spoon
ii. Wide-lipped, open cup
iii. Spout cup not desirable
iv. Single sip at first
v. Thicker liquids initially
vi. Straw introduced gradually
c. Straw drinking: 12 months
d. Spoon feeding: 4-6 months
i. Readiness 4-6 months developmental skills
ii. Upright position, head control
iii. Flat spoon
iv. Child should open mouth independently
v. Spoon at mid-tongue, slight downward pressure
vi. No scraping mouth after every bite
e. Munching/chewing: 6-7 months
f. Controlled, sustained biting: 12+ months
g. Rotary chewing: 12-15 months
h. Feeding development
i. 7-9 months
1. Gag reflex becomes protective
2. Mouth used to investigate environment
3. Coordinated lip, tongue, jaw movements
4. Drooling only with teething
5. Cup drinking, lower lip as stabilizer at 9 mos.
6. Mouth closure around cup rim
7. Moving lateral tongue to touch solids while upper lip cleans off spoon
ii. 10-12 months
1. Self finger-feeding
2. Increasing coordinated jaw, tongue, lip movements in all positions
3. Weaning from bottle as cup drinking continues
4. Closes lip on spoon and uses lips to remove food from spoon
iii. 13-18 months
1. All textures taken
2. Finger foods
3. Scoops food to mouth
4. Well-coordinated phonating, swallowing, and breathing
5. Lateral tongue motion
6. Straw drinking
iv. 19-24 months
1. Swallows with lip closure
2. Up-down tongue movements precise
3. Self-feeding predominates
4. Chewable foods
5. Rotary chewing
6. Independent food intake
v. 24-36 months
1. Lip closure while chewing
2. Circular jaw rotations
3. One-handed cup holding and open cup drinking without spillage
4. Fills spoon with use of fingers
5. Takes wide range of solid foods
6. Total self-feeding; uses fork
What might you see in "food refusal"?
a. Hyperextending head and neck
b. Turning head away
c. Spitting food out of the mouth
d. Closing mouth tightly so food can't get in
e. Pushing at sides of neck (Pharyngeal residue?)
Is being a "picky eater" always a sign of a disorder?
Know the treatment and facilitation techniques used to improve feeding/swallowing in infant/small children.
a. Treating Problems with Swallowing/feeding processes
i. facilitating a normal sucking pattern
ii. facilitating mature oral movements during spoon feeding of soft foods
iii. facilitating mature oral movements during cup drinking
iv. facilitating a mature swallowing pattern
v. facilitating normal controlled biting and mature chewing
b. Facilitating a Normal Sucking Pattern
i. place child in prone
ii. maintain tongue in mouth with chin/jaw support; firm pressure to base of tongue
iii. use music and rhythm (1 beat/sec)
iv. establish suckle of liquids from fingertip and spoon
v. massage body of tongue rhythmically with upward-downward motion 1x/sec
vi. provide cheek support while introducing thicker consistencies
c. Facilitating Mature Oral Movements During Spoon Feedings of Soft Foods
i. teach that the mouth can be "quiet" and ready as the spoon approaches
ii. use gentle pressure on the tongue with the spoon
iii. allow food to remain on the child's lower lip
d. Facilitating Mature Oral Movements During Cup Drinking
i. teach that the mouth can be "quiet" and ready as the cup approaches
ii. maintain stable degree of jaw opening
iii. maintain constant contact of cup and lower lip
iv. encourage child to hold onto the edge of cup with teeth
v. thicken liquids
e. Facilitating a Mature Swallowing Pattern
i. explore positioning during VFSS
ii. explore compensatory strategies
iii. explore different food placements
f. Facilitating Normal Controlled Biting and Mature Chewing
i. teach that the mouth can be "quiet" and ready before food enters for biting and chewing
ii. hold cookie between teeth and break off outside piece
iii. ensure stable jaw opening and closing
iv. thicken and add lumpy soft foods
v. increase awareness of teeth through rhythmical biting
vi. wrap food in gauze and tie it to a string
Might you see a communication problem later in life if feeding problems present early in life?
What is suckling?
a. Characterized by in-out tongue movements and some jaw opening and closing
b. Only movement pattern that can be utilized by neonates because the tongue completely fills the oral cavity
What might indicate "readiness to feed" in an infant?
a. Infants should be able to maintain an alert or quiet awake state for 5 minutes prior to feeding - this often ensures a higher volume of intake
b. Ready to feed babies will root for the nipple when presented, organize the tongue and orient the body to midline with arms coming forward to assist
What might happen if an infant is taking in too much fluid that the tongue cannot hold?
a. If the amount of fluid is larger than the tongue can hold, infants frequently reduce seal on the nipple resulting in anterior spillage
b. Fast fluid rate may also spill into the nasopharynx or the hypopharynx, creating wet/congested sounds
Can a poor parental bond alone cause reduced feeding abilities?
a. Caregiver/parent involvement must be encouraged as it will be essential, especially during mealtime and other daily carryover activities
What facial characteristics are considered "normal"?
a. Horizontal width across the eye area is approximately the width of one eye times five
b. Center corners of the eye line up with the widest part of the nose
c. Lip line straight across horizontally at rest
d. Nose is not too tipped up
What are the 11 newborn mouth and throat characteristics that may be different than an adult?
a. Limited open space within mouth and throat
b. Mouth and throat structures close together
c. Small, slightly retruded lower jaw
d. Palate has wide U shape
e. Hard palate is flexible and movable
f. Nose breathing
g. Tongue fills the mouth at rest
h. Tongue is deeply cupped when suckling
i. Gums enlarge to assist with latch
j. Sucking pads in cheeks
k. Eustachian tubes horizontal
Why are sucking pads important?
a. Crucial for effective feeding
b. Exist from birth until 6 months
c. Create intraoral pressure in the mouth for nippling
d. Shrink when baby begins using in the mouth for chewing
e. Full term babies are born with them - don't develop if baby isn't born with them
Where should the mandible line up in the infant?
a. Lower jaw grows forward during the first 6 months if the mouth is developing well
b. Mandible lines up with the philtrum and bridge of nose
What percentage of preemies have some degree of GERD?
85% of preemies have some degree of GERD compared to 10-20% of full-term babies
What types of issues are seen in infants with reflux?
a. Poor trunk control and underdevelopment of abdominal muscles in the 1st month of life
b. Stomach lacks flexibility/stretch- doesn't expand
c. Infants eats too large a volume for stomach size with liquid diet
d. Shortened esophagus
e. LES relaxation
f. Poor motility
g. Immature neurologic system
h. Hiatal hernia
i. Delayed gastric emptying
Does oral motor development have a direct correlation on speech development?
Yes- oral motor development has a direct correlation on speech development
What is a normal suck:swallow ratio?
What is a normal sucking burst pattern?
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