1. DYSPHAGIA Assessment, Management and Therapy Options Jennifer Bowers Speech and Language Therapist QEUH

2. Whistle stop tour of Dysphagia What is dysphagia? Dysphagia in neurological disorders Assessment of the swallow - the normal swallow - the abnormal swallow Management of dysphagia Swallowing Therapy / Rehabilitation

3. What is dysphagia? Dysphagia is the blanket term used for difficulty with swallowing An impairment in the ability to chew and/or swallow food/ fluids Dysphagia is often underestimated in neurological disorders Resulting from impairments to the CNS, PNS or local damage to the swallowing mechanisms at any level (oral, pharyngeal, laryngeal).

4. Food glorious food Nutrition and hydration are vital for life Eating and drinking is, for most people, hugely enjoyable Eating is a central part of home life and many social activities Preparation and consumption of food has many cultural components and plays an important role in society We have to eat and we like to eat!

5. Swallowing anatomy

6. Swallowing is an essential function that is carefully regulated by the central nervous system and, in particular, by the cerebral cortex There are many different areas of the cerebral cortex involved in swallowing fMRI shows different areas of the cortex activated for different types of swallow eg. voluntary vs reflexive Input from the peripheral nervous system also vital Damage to, or disease process in CNS/PNS structures associated with swallowing, lead to dysphagia.

7. Cranial nerves involved in swallowing Trigeminal CN V general sensation from face; motor supply to masticatory muscles Facial CN VII taste from anterior 2/3 tongue via chorda tympani; motor supply to muscles of facial expression including lips Glossopharyngeal CN IX general sensation from posterior 1/3 tongue, soft palate, tonsils, fauceal pillars and pharynx; taste from posterior 1/3 tongue; motor supply to pharyngeal constrictors and to stylopharyngeus Vagus CN X general sensation from the larynx; motor supply to palate/pharynx/larynx; autonomic supply to oesophagus Accessory CN XI motor supply, supplementing vagus; motor supply to muscles controlling head position Hypoglossal CN XII motor supply to intrinsic and extrinsic tongue muscles

8. The normal swallow There are 3 stages of the swallowing process Oral stage Pharyngeal stage Oesophageal stage

9. Oral preparatory stage Sensory recognition of food/fluids (sight, smell, texture, temperature) Arousal of appetite Food/fluid in oral cavity Lip seal Chewing and manipulation to form a cohesive bolus drenched in saliva Soft palate is actively lowered to retain food in oral cavity, avoiding naso pharyngeal escape Nasal breathing continues

10. Oral executive stage Tip and blade of tongue rises and presses the bolus against the hard palate Sides of tongue rise, creating central groove for food bolus Increased tension in muscles of cheeks closes off lateral sulci and prevents bolus falling between jaw and cheeks. Sensory feedback is important Bolus arrives on base of tongue and contacts anterior pillars of fauces triggering swallow

11. Pharyngeal stage This stage cannot be voluntarily interrupted and will not happen unless reflex is triggered Breathing is halted during this stage For safe accomplishment there must be efficient protection of airway to avoid aspiration Rapid completion of sequence to allow breathing to resume Soft palate raised to stop food entering nasal cavity

12. Posterior tongue thrust propels bolus into pharynx and pharyngeal peristalsis begins. Epiglottis tips over Hyoid bone moves forward moving larynx to fit under base of tongue Closure of false cords and true vocal cords Pharyngeal peristalsis continues until bolus reaches crico-pharyngeal sphincter Pharyngeal transit time of one second

13. Oesophageal stage Reflexive and involuntary As bolus approaches, crico-pharyngeal sphincter opens Bolus passes into oesophagus and sphincter closes At the bottom of oesophagus, gastro- oesophageal sphincter opens to allow food into stomach Time taken approx two seconds

14. Lateral view of bolus propulsion during the swallow, beginning with the voluntary initiation of the tongue A; the triggering of the swallowing reflex B; the bolus passage through the pharynx C; the entry of the bolus through the cricopharyngeal sphincter into the cervical oesophagus D; and the completion of the pharyngeal stage of the swallow when the entire bolus is in the cervical oesophagus E.

15. Neurological causes of dysphagia CVA (ischemic or hemorrhagic), TBI Hydrocephalus Infective (bacterial or viral) eg. meningitis, encephalitis, TB, cerebral abscess, etc. Tumour eg. malignant or benign Muscular dystrophies, most commonly oculopharyngeal and myotonic Myasthenia Gravis MS MND Neuropathy and myopathy GBS and variants Dementias etc…….

16. Assessment of Oro-pharyngeal dysphagia General observation Oral and peripheral exam 4 finger placement technique Trials of different textures and consistencies Videofluoroscopy Allows detailed examination of a rapid physiological process, completely objective, permanent record, simultaneous voice recording, allows experimentation with position of patient, standard x-ray equipment, low dosage of radiation.

17. Management of dysphagia Compensatory strategies - Texture modification - Bolus control measures eg. bolus placement in mouth, types of cups eg. Drinkrite, Novocup - Posture eg. chin tuck, head turn, head tilt - Positioning Manoeuvres eg. supraglottic swallow, Mendelsohn’s

18. Therapy and Rehabilitation Therapeutic swallowing manoeuvres can mean the difference between a safe and unsafe swallow. Mendelsohn’s Manoeuvre Used to compensate for reduced laryngeal excursion and cricopharyngeal opening Supraglottic swallow Used to compensate for a delayed swallow by aiding closure of the vocal cords and all supraglottic structures, prior to the bolus arrival in the pharynx

19. Exercises for swallow Shaker Used to increase strength for laryngeal excursion, and width and duration of opening of cricopharyngeus Masako Used for pharyngeal strengthening

20. As with any therapeutic intervention, treatment for dysphagia is not one size fits all. While many will cope with texture modification or use of an adapted cup, etc, their underlying condition and current presentation will dictate whether use of manoeuvres, postures or exercises is appropriate.