Overview of Ch. 7

* Hard palate * Soft palage * Alveolus, floor of the mouth, tonsil, and anterior faucial pillar * Lateral tongue * Base of tongue

* Primary treatment modalities * Surgical resection * Radiotherapy with or without chemotherapy

* Oral cancer patient experience changes in * Salivary flow * Speech, swallowing post-treatment * Intraoral sensory loss * Decreased tongue and jaw range of motion

* Oralpharyngeal Cancer patients experience changes in * Reduced Tongue base movement * Pharyngeal wall motion * Velopharyngeal function

* After Radiotherapy to the Oral cavity and Orpharynx patients will experience either immediately or within a year after radiotherapy * Reduced saliva flow- these are permanent * Swelling in the mouth * Sores in the mouth * Reduced speed of tongue movement * Delay in oral transit time * Delay in triggering the swallow * Can benefit from the Super-supraglottic swallow and Mendelsohn maneuver

* Counseling before treatment * Patient education before treatment * Start preparatory oral motor exercises to build strength * Direct therapy when cleared by surgeon * Usually start with a nasogastric tube * Videofluroscopic swallow examination * Begin oral feedings with appropriate diet

Overview of Ch. 8

* Tumor Staging * TNM classification system * 60% occur in the glottic area * 35% occur in the supraglottic area * 5% occur in the subglottic area * Tumor management * Surgical * Radiotherapy * With or without chemotherapy follow up

* After Radiotherapy, patients may experience * Hoarseness- temporary * Minimal Saliva flow changes * Rarely report swallowing problems immediately * With high doses of radiotherapy and chemotherapy patients may experience significantly reduced laryngeal elevation and reduced pharyngeal wall motion * Sometimes these changes may not be noticed until years later

* Counseling prior to treatment * Patient education prior to treatment * For radiation management- can begin tongue range of motion, tongue base and laryngeal elevation exercises before treatment * Postoperative treatment will depend on patient’s functional capacity after surgery and the extent of the surgery

* Direct treatment and exercises can begin postoperatively when cleared by the surgeon * Videofluoroscopic swallowing examination should be completed before feeding orally. * Begin appropriate diet as patient progresses

Overview of Ch. 9 and 10

* Significant oropharyngeal swallow impairment * Medulla houses the major swallowing centers * Unilateral lesions- * functional oral control, * delayed trigger of swallow * weak pharyngeal swallow * Reduced laryngeal elevation * Reduced opening of upper esophageal sphincter * Residue in pyriform sinus and pharyngeal wall

* Thermal-tactile stimulation to improve the trigger of the swallow * Head rotation to the damaged side * Mendelsohn maneuver * Range of motion exercises for laryngeal elevation * Cricopharyngeal myotomy

* Affect motor and sensory pathways to and from the cortex * Mild delays in oral transit time * Mild delays in triggering pharyngeal swallow * Aspiration before the swallow * Treatment to focus on * Thermal tactile stimulation for trigger of swallow * Range of motion of larynx and tongue base

* Anterior left hemisphere * Apraxia of swallow * Delay in initiating the oral swallow * No tongue motion in response to presentation of food * Mild oral transit delays * Mild delays in triggering pharyngeal swallow * Treatment can focus on * Increasing bolus taste * Increasing pressure of the spoon on tongue * Thermal-tactile stimulation * Allowing them to feed themselves

* Right Hemisphere * Mild oral transit delays * Moderately delay in triggering pharyngeal swallow * Delayed laryngeal elevation * Aspiration before the swallow * Therapy can focus on * Chin down posture * Thermal tactile stimulation * Supraglottic or super-supraglottic maneuver * Range of motion exercises to improve laryngeal elevation

* Can be complex due to various types of neurologic injuries the patient sustained during the accident * Delay in triggering pharyngeal swallow is most common * Can present with multiple oral and pharyngeal disorders * Cognitive difficulties such as impulsiveness and inability to recall or follow compensatory strategies can impact treatment

* Treatment * Are responsive to postural changes * Range of motion exercises * Enhanced sensory input * Swallowing maneuvers may be too difficult * Can work with family members and caregivers in providing cueing and thermal tactile stimulation * Can progress very slowly or quickly depending on brain function

* Without a head injury * Delay in triggering pharyngeal swallow * Reduced laryngeal elevation and anterior movement * Reduced upper esophageal sphincter opening * Reduced tongue base motion * Unilateral or bilateral pharyngeal wall dysfunction * Many require a tracheostomy tube for airway management

* Treatment * Cervical Bracing and Anterior Cervical fusion can impact swallow function and ability to use exercises, compensatory strategies, or postural changes

* Oral dysfunctions * Inability to hold material in a cohesive bolus * Difficulty with mastication * Disorganized lingual movements * Treatments include * Oral motor exercises * Thermal-tactile stimulation * Diet changes

* Initially- agnosia for food- they cannot visually recognize food as food * As it progresses- apraxia for both feeding and swallowing- difficult using utensils to feed themselves- difficult to initiate the oral stage of swallowing * Holding food in mouth and not swallowing * Decreased tongue motion for chewing * Delay in triggering pharyngeal swallow * Reduced laryngeal elevation

* Reduced oral intake which significantly impacts nutrition and hydration * Treatment * Sensory enhancement prior to placing food in mouth * Diet changes * Modify volume/rate of food

* Progressive disease * Predominantly corticobulbar involvement * Begins with reduced tongue mobility * Decreased mastication * Lip closure is reduced * Delayed triggering of pharyngeal swallow * Treatment * Thermal tactile stimulation * Diet changes

* Oral Phase * Repetitive anterior-posterior rolling pattern in lingual propulsion of bolus * Decreased mastication and management of bolus * Pharyngeal Phase * Delay in triggering pharyngeal swallow * Tongue base motion reduced * Pharyngeal wall contraction reduced * Laryngeal elevation and closure are reduced * Aspiration after the swallow

* Treatment * Medication management * Active range of motion exercises for tongue, lips * Laryngeal elevation exercises * Effortful swallow * Mendelsohn maneuver * Effortful breath-hold * Falsetto exercises

* Lesions from the cortex to the brainstem to the cranial nerves * Can present with various swallowing disorders * Hypoglossal nerve- lingual control of bolus, chewing, and oral transit time is reduced * Vagus nerve-reduced tongue base movement, pharyngeal wall movement and delayed trigger of the swallow * Treatment * Medication management * Enhanced sensory input * Thermal-tactile stimulation

* Biochemical changes in the myoneural junction * Fatiguing of involved musculature with repeated use * Tongue musculature or velar function affected * Backflow of food into the nasal cavity * Decreased mastication * Treatment * Compensatory swallow management strategies * Exercises may only contribute to fatigue * Diet changes

* Prolonged contraction and difficulty in relaxation of involved muscles * Muscles of mastication * Upper esophageal sphincter opening * Aspiration due to inability to pass through upper esophageal sphincter

* Affects cricoarytenoid joint * Restricts arytenoid movements which adduct vocal folds * Residue collects in airway entrance * Aspiration after the swallow * Treatment * Medication * Introduce compensatory strategies * May need diet changes until inflammation is eliminated

* Poor Respiratory and Swallowing coordination * Difficulty with airway closure * Aspiration during the swallow * Treatment * Compensatory strategies to conserve energy * Postural changes * Diet changes * Sensory enhancement procedures