Chapter 10: Dysphagia Justice Communication Sciences and Disorders: An Introduction Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

Focus Questions What is dysphagia? How is dysphagia classified? 10.1 Focus Questions What is dysphagia? How is dysphagia classified? What are the defining characteristics of dysphagia? How is dysphagia identified? How is dysphagia treated? Justice Communication Sciences and Disorders: An Introduction Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

10.2 Introduction Dysphagia: impairment in the ability to swallow because of neurological or structural problems that alter the normal swallowing process ASHA expanded the Scope of Practice for speech-language pathologists to include swallowing disorders in late 1980s Dysphagia intervention now makes up about 50% of a SLP’s caseload in medical settings (e.g., hospital, nursing homes) Justice Communication Sciences and Disorders: An Introduction Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

Case Study #1: Sylvia Anderson 10.3 Case Study #1: Sylvia Anderson 78-year old with Alzheimer’s dementia living in a nursing home – needs minimal to moderate assistance while eating Lately, hasn’t been finishing meals, has gurgly voice quality during mealtime, and has recently had severe coughing episodes while eating SLP suspects a pharyngeal stage swallowing problem and wants a further instrumental assessment at local hospital Justice Communication Sciences and Disorders: An Introduction Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

10.4 Case Study #1 Questions Transporting Sylvia to the local hospital for an instrumental examination is costly. How can the costs be justified? How might reliance on others for assistance with feeding influence nutritional status and hydration? Justice Communication Sciences and Disorders: An Introduction Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

10.5 Case Study #2: Lee Chin 43-year old bilingual man who has persistent dysphagia following cancer of the right buccal space To treat the cancer, Lee had radiation therapy and neck dissection Currently exhibits pharyngeal dysphagia, aspiration, hoarse vocal quality, and right lower facial weakness Currently receives nutrition through a g-tube Justice Communication Sciences and Disorders: An Introduction Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

10.6 Case Study #2 Questions Is Lee a candidate for dysphagia therapy at this time? Why or why not? What education should be provided to Lee regarding his situation? Justice Communication Sciences and Disorders: An Introduction Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

Case Study #3: Martin Coleman 10.7 Case Study #3: Martin Coleman 45-year old man diagnosed with ALS 18 months ago Unable to work, on a puree diet with thin liquids, has lost 15 pounds in past two months, just recovered from severe aspiration pneumonia MBS shows severe oral and pharyngeal dysphagia with aspiration Martin and his family now need to decide whether or not to resort to feeding tube, and want to consult their priest to make sure decision is in keeping with their religious beliefs Justice Communication Sciences and Disorders: An Introduction Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

10.8 Case Study #3 Questions As the speech-language pathologist, what are your responsibilities to this client and his family in making their decision? What support systems should be provided to this family during their decision-making process? Justice Communication Sciences and Disorders: An Introduction Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

10.9 I. What is Dysphagia? Disorder of swallowing rendering person unable to safely and/or efficiently eat or drink To understand disorder swallowing, must first understand the normal swallowing process Justice Communication Sciences and Disorders: An Introduction Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

10.10 The Normal Swallow Innate ability which is present in the developing fetus Necessary to maintain nutrition and hydration Adults swallow approximately 580 times daily unconsciously Swallowing is a four-phase process: Oral preparatory phase Oral phase Pharyngeal phase Esophageal phase Justice Communication Sciences and Disorders: An Introduction Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

Oral Preparatory Phase 10.11 Oral Preparatory Phase Begins as food or liquid enters the mouth Containing, manipulating, and preparing the food or liquid into a bolus Chewing (mastication) occurs to grind solid bolus into manageable texture Requires coordination of lips, tongue, teeth, mandible, and cheeks Duration: variable depending on substance Respiration: normal through the nose (mouth closed) Justice Communication Sciences and Disorders: An Introduction Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

Oral Phase Bolus is propelled to the back of the mouth 10.12 Oral Phase Bolus is propelled to the back of the mouth “stripping action” by the tongue Tension in the cheeks (buccal muscles) Duration: 1-1.5 seconds Respiration: normal through the nose Justice Communication Sciences and Disorders: An Introduction Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

10.13 Pharyngeal Phase Begins as the bolus reaches the tonsils (faucial pillars) Pharygeal swallow reflex is triggered: Pharyngeal wall and back of tongue move together and pharyngeal muscles squeeze to move bolus down through the pharynx Upper esophageal sphincter opens to allow passage of bolus into esophagus Time: 1 second Respiration: briefly halted (apneic moment) During bolus transit, risk of food or liquid entering the airway Justice Communication Sciences and Disorders: An Introduction Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

Pharyngeal Phase – Protective Mechanisms 10.14 Pharyngeal Phase – Protective Mechanisms Soft palate elevates to stop bolus from flowing upward into nasal area Larynx moves forward and higher in the neck to reduce risk of entrance into airway Epiglottis forms a cover over the larynx Vocal folds come together to close the entrance into the larynx If material does enter the larynx, reflexive cough to expel it will occur Justice Communication Sciences and Disorders: An Introduction Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

10.15 Esophageal Phase Bolus is propelled through the esophagus by an involuntary wave or contraction Moves from the upper esophageal sphincter through the lower esophageal sphincter and into the stomach Time: 8-20 seconds, can be influenced by age (often increase in duration in elderly population) Respiration: normal through nose and mouth Justice Communication Sciences and Disorders: An Introduction Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

Disordered Swallow: Dysphagia 10.16 Disordered Swallow: Dysphagia Impairment can occur in one, some, or all of the four phases of swallowing Some persons have impairments that result in aspiration (food or liquid moves below the level of vocal folds into the airway) Some persons have to alter their diet to control the consistencies, but this can cause difficulty maintaining hydration and nutrition Some persons require an enteral feeding tube for nutritional maintenance Justice Communication Sciences and Disorders: An Introduction Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

Additional Considerations 10.17 Additional Considerations Dysphagia should not be confused with a disruption in feeding, but it is one subgroup of feeding disorders Dysphagia is not a disease but a symptom of several etiologies (e.g., neurological injuries, progressive brain diseases) Social and psychological impacts of dysphagia: changes in eating routines and food choices, decreased personal independence, and challenge to participating in community activities Justice Communication Sciences and Disorders: An Introduction Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

Prevalence and Incidence 10.18 Prevalence and Incidence Statistics on who experiences dysphagia: 14% of acutely hospitalized patients 30-35% of patients in rehabilitation facilities 50% of residents in nursing home environments Justice Communication Sciences and Disorders: An Introduction Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

II. How is Dysphagia Classified? 10.19 II. How is Dysphagia Classified? No universally accepted system, but usually based on etiology, manifestation, and severity Some available instruments: Penetration-Aspiration Scale: 8-point scale to describe degree of airway protection during the swallow (1 = no material enters airway, 8 = aspiration) New Zealand Index for Multidisciplinary Evaluation of Swallowing: rates swallowing performance on a scale from 0 to 4 (0 = no significant impairment, 4 = profound impairment) Justice Communication Sciences and Disorders: An Introduction Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

III. Defining Characteristics of Dysphagia 10.20 III. Defining Characteristics of Dysphagia Structural abnormalities or physiological deficits for each of the phases of swallowing: Oral preparatory Oral Pharyngeal Esophageal SLP manages oral preparatory, oral, and pharyngeal dysphagias (i.e., oropharyngeal dysphagia); gastroenterologist manages esophageal dysphagia Justice Communication Sciences and Disorders: An Introduction Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

Oral Preparatory Phase Dysphagia 10.21 Oral Preparatory Phase Dysphagia Likely causes: head and neck cancers, stroke, Parkinson’s disease Characteristics: Decreased lip closure Problems controlling ingested materials Problems biting or chewing Inefficient oral preparation (long duration) Justice Communication Sciences and Disorders: An Introduction Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

10.22 Oral Phase Dysphagia Likely causes: stroke, progressive neurological diseases Characteristics: Difficulty moving bolus to the back of mouth Inability to control bolus flow Delayed initiation of bolus movement Justice Communication Sciences and Disorders: An Introduction Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

Pharyngeal Phase Dysphagia 10.23 Pharyngeal Phase Dysphagia Likely causes: head and neck cancers, neurological disorders Characteristics: Incomplete palatal elevation (nasal reflux) Delayed initiation of pharyngeal swallow reflex Weak tongue and pharyngeal muscle forces Reduced laryngeal elevation (more prone to aspiration) Inadequate opening of the upper esophageal sphincter (bolus cannot move into the esophagus) Justice Communication Sciences and Disorders: An Introduction Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

Esophageal Phase Dysphagia 10.24 Esophageal Phase Dysphagia Likely causes: reflux, certain cancers Characteristics: Structural abnormalities in esophagus Decreased esophageal motility or contraction Inadequate opening of lower esophageal sphincter (bolus cannot move into stomach) Excessive opening of the lower esophageal sphincter, allowing backward flow of contents from stomach to esophagus (reflux) Justice Communication Sciences and Disorders: An Introduction Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

Dysphagia Causes: Neurological Disease 10.25 Dysphagia Causes: Neurological Disease Stroke Interruption in blood supply to brain, resulting in brain damage Frequency of dysphagia is about 50% Increases risk for malnutrition, aspiration, and pneumonia Traumatic brain injury Dysphagia is common complication of neurological damage (from 26 – 71%) Delay in pharyngeal swallow reflex, decreased pharyngeal constriction, and oral motor problems Justice Communication Sciences and Disorders: An Introduction Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

Dysphagia Causes: Progressive Neurological Disease 10.26 Dysphagia Causes: Progressive Neurological Disease Parkinson’s disease: Incidence of dysphagia from 50% to 92% Drooling, problems in bolus preparation and transport, delayed swallowing reflex, aspiration, residual materials in pharynx Amyotrophic lateral sclerosis: Also known as Lou Gehrig’s disease, patients will experience oropharyngeal dysphagia at some point in their disease process Dementia: Dysphagia is common feature in moderate and severe impairment levels Justice Communication Sciences and Disorders: An Introduction Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

Dysphagia Causes: Head and Neck Cancers 10.27 Dysphagia Causes: Head and Neck Cancers Many patients with cancers of the mouth, pharynx, and larynx experience dysphagia prior to medical management of the cancer, but treatments can cause dysphagia or make the already existing case more severe The extent of the medical intervention to combat the cancer influences the swallowing profile Justice Communication Sciences and Disorders: An Introduction Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

Dysphagia Causes: Medical Interventions 10.28 Dysphagia Causes: Medical Interventions Surgical management: full or partial removal of components of swallowing Radiation therapy: reduced saliva production, edema, tooth decay, and pain Chemotherapy treatment: nausea, vomiting, and fatigue Tracheotomy: tube alters normal air exchange, interfering with swallowing performance Justice Communication Sciences and Disorders: An Introduction Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

IV. How is Dysphagia Identified? 10.29 IV. How is Dysphagia Identified? SLP is responsible for these tasks: Determine presence or absence of dysphagia Determine underlying causes Assess severity Make recommendations Design and implement rehabilitation plan Share information with other professionals Need to achieve a balance between concern for safety issues and quality of life Justice Communication Sciences and Disorders: An Introduction Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

Consultation with the SLP 10.30 Consultation with the SLP Referral from physician or nurse who suspects swallowing impairment Interdisciplinary approach to screening at hospitals, rehabilitation centers, and clinics: Health care staff members should be trained to recognize possible signs of dysphagia, and then make referral to SLP for further evaluation Justice Communication Sciences and Disorders: An Introduction Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

Clinical Swallowing Examination 10.31 Clinical Swallowing Examination Also called Bedside Swallow Examination: Review of medical records Comprehensive interview with client Oral mechanism examination Trial feedings observation Feeding recommendations Referrals for either: Further instrumental assessment (need physician’s prescription to be covered by insurance) Specialized testing by other professionals Justice Communication Sciences and Disorders: An Introduction Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

Instrumental Dysphagia Exam 10.32 Instrumental Dysphagia Exam More objective, quantifiable measure of swallowing function Commonly used approaches: Fiberoptic Endoscopic Examination of Swallowing: visualization of swallowing through flexible tube with recordable camera Ultrasonography: uses sound waves to recreate a picture of structures (most beneficial in oral phase evaluation Videofluorscopy: same as a modified barium swallow (most commonly used; “gold standard”) Justice Communication Sciences and Disorders: An Introduction Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

V. How is Dysphagia Treated? 10.33 V. How is Dysphagia Treated? SLP works to remediate oropharyngeal dysphagia Compensatory approaches Restorative approaches To maintain nutrition, dietary modifications and/or alternative nutrition via a feeding tube Nasogastric, gastrostomy, jejunostomy Include ongoing assessment of client’s response to intervention, and adjust goals and approaches to fit evolving needs Justice Communication Sciences and Disorders: An Introduction Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.