Transcript Slide 1

DYSPHAGIA IN THE
NEUROLOGIC AND
HEAD AND NECK
CANCER PATIENT
Karen Ball MPA MS CCC-SLP BCS-S
Speech Language Pathologist
Queens College,
City University of New York (CUNY)
[email protected]

Review normal swallow physiology (oral prep,
oral stage, pharyngeal stage, esophageal stage)

What muscles are involved, neurological input
(supra hyoid muscles, tongue, laryngeal, palatal,
pharyngeal muscles)

Review cortical and peripheral input into the
swallow (CNS/PNS, UMN/LMN)

Role of swelling (larynx post intubation, post
anterior spine surgery, head/neck surgery)
BACK TO BASICS
Pressure generation and bolus transit during the
pharyngeal stage of swallowing
Swallowing mechanism as a closed system
(McConnel)
BACK TO BASICS

Oropharyngeal pressure pump
Tongue (piston)
Pharyngeal wall (chamber)
(tongue base applies pressure to bolus tail,
pharyngeal contraction also applies force to the
bolus, increasing velocity and propulsion of the
bolus through the pharynx)
PRESSURE GENERATION SYSTEM

PE segment pump
Larynx
Hypopharynx
Anterior movement of the larynx opens the PE
segment
Esophageal pressure sub atmospheric, opening PE
segment releases this, bolus is drawn into
esophagus
PRESSURE GENERATION SYSTEM

Acute

Chronic

Progressive

Combination (Patient with PD who is s/p CVA or TBI
secondary to a fall)
Associated diagnoses:

Structural (osteophytes, diverticula, achalasia)

Diabetes

Physiological: (esophageal dysmotility, Gerd, LPR)

Psychological (anxiety, fear of choking)
NEURO DIAGNOSES

Contributing factors that could be present:
Metabolic encephalopathy
Confusion/Lethargy
AGE/Sarcopenia
NEURO DIAGNOSES

Muscle tone: (spasticity, flaccidity)

Muscle weakness/paralysis

Bradykinesia

Major muscles(muscular structures) affected:
Tongue (oral tongue, tongue base)
Cheeks
Velo pharyngeal complex
Pharynx
UES
Vocal folds
Suprahyoid muscles
Intrinsic laryngeal muscles
NEURO INVOLVEMENT

Location

Staging (size)

Treatment (surgery, chemo/radiation, or combo)
and response to treatment.

If surgery, how was the area of the resection
reconstructed?

Presence of G-Tube and timing of placement.
H/N CANCER DIAGNOSES

Can change the mechanics of swallowing by
altering the swallowing structures (surgery)

Can change the physiology of swallowing
secondary to effects of Chemo/RT (fibrosis,)on
the major muscles involved in swallowing.

Can change the desire to eat due to presence
of sensory or taste changes or pain.
Occasionally, fear can also contribute.
H/N CA TREATMENT

A thorough, well thought out clinical exam is
essential.

Clinician style
Conservative? i.e.: “afraid” of aspiration (thickens
everyone’s liquids, recommends NPO continually).
Realistic? (Common sense)
Thoughtful? i.e.: quality of life essential
Empathetic? Involve the patient in the decision
making.
CLINICAL EXAMINATION
The COUGH
Indicative of airway protection
Is cough secondary to ingestion of food or liquid?
Nervous/anxiety provoked? (habit cough)
Secondary to globus?
Secondary to GERD/LPR?
We all cough!!!!
CLINICAL EXAMINATION
LANGMORE, ET AL “PREDICTORS OF ASPIRATION
PNEUMONIA: HOW IMPORTANT IS DYSPHAGIA?”
(DYSPHAGIA, 1998)

189 Elderly subjects recruited from outpatient
clinics, acute care wards, and nursing home
from the VA Medical Center, Ann Arbor, MI

Given an oral/pharyngeal/esophageal
swallowing assessment, feeding assessment,
functional status assessment, medical
assessment, oral/dental assessment.

Followed for up to 4 years for an outcome of
verified “aspiration pneumonia”
Results
Best predictors:
 Dependent for feeding
 Dependent for oral care
 Number of decayed teeth
 Tube feeding
 >1 medical diagnosis
 Number of Medications
 Smoking
LANGMORE, ET AL “PREDICTORS OF
ASPIRATION PNEUMONIA: HOW IMPORTANT
IS DYSPHAGIA?”
(DYSPHAGIA, 1998)
“Dysphagia was concluded to be an important risk
for aspiration pneumonia, but generally not
sufficient to cause pneumonia unless other risk
factors were present as well”
LANGMORE, ET AL “PREDICTORS OF
ASPIRATION PNEUMONIA: HOW IMPORTANT
IS DYSPHAGIA?”
(DYSPHAGIA, 1998)

Ambulation Status

Activity Level/Spunk

Nutritional Status

Independence with ADL’s i.e.: feeding
CLINICAL EXAMINATION:
LET’S THINK ABOUT:
ACTIVITY LEVEL AND ATTITUDE

Support System

Permanent Residence
CLINICAL EXAMINATION:
SOCIAL/CAREGIVER / LIVING
SITUATION
Does aspiration of food lead to aspiration
pneumonia???
J. Robbins has found that aspiration of thickened
fluids is much more difficult to clear from the lungs
than aspiration of thin liquids.
MD thoughts essential at this juncture. How tolerant
are they of aspiration. How much is too much?
PS: we all aspirate/penetrate occasionally..does
this mean we need to place ourselves NPO???
ASPIRATION

Nectar thick

Honey thick

Thickeners available: natural foods (i.e.:
applesauce)
Corn starch type: Thick it
Xanthan gum type (gel)(simply thick)
THICK LIQUIDS
You like?
Hydration needs generally considered 64 oz.. fluid
per day
Do most of us attain this???
Probably not with normal liquids
Can we assume that patients will consume 64 oz. of
thick liquids? (rarely)
THICK LIQUIDS

You like?
Hard sell to those who are cognitively intact….
We need to strive to maximize a patient’s desire
when we recommend a diet level.
Consider taste, texture, caloric content.
How thick is it?
This can be a challenge if the patient is in the
hospital or nursing facility. OR if the patient is not a
cook!
PUREED FOOD

MBS: Gold standard, able to evaluate all stages
of swallow

FEES: View before and after the swallow. Views
structures best, can assess secretion
management
THE INSTRUMENTAL EXAM

Logemann:
Instrumental Exam indicated when pharyngeal
stage dysphagia is suspected
What happens when access to Instrumental
examinations is limited?
THE INSTRUMENTAL EXAM

Careful, thoughtful clinical examinations can
work!

Need to acknowledge some issues will not be
able to be identified: (i.e.: Zenkers, osteophytes,
esophageal motility, UES function)

You proceed as best you can with your excellent
clinical judgement!
THE INSTRUMENTAL EXAM

Mendlesohn Maneuver

Shaker Exercises

Masako Maneuver

Supraglottic Swallow

Effortful Swallow

Huck and Spit
TREATMENT/TECHNIQUES

Head turn to weak side

Chin tuck (cut out cup, straw)

Lean to strong side
TREATMENT/POSITIONS

Alternate liquids/solids (liquid flush)

Double swallow (dry swallow)

Add texture

Extra sauces and gravies (moisteners)

Caloric enhancement
TREATMENT/MISC.
Exercise Physiology

EMST (Expiratory Muscle Strength Training)
Sapienza (Aspire Products LLC) emst150.com

IPRO (Isometric Progressive Resistance
Oropharyngeal Therapy) Robbins
(Swallowsolutions.com) (lots of info on website)
(relation of IOPI, MOST) Targets effects of
Sarcopenia. Importance of understanding
resistance training in the context of functional
reserve
TRENDS ON THE HORIZON

The best exercise for swallowing is SWALLOWING!

AND

SWALLOWING SOMETHING!

QUALITY OF LIFE AS WELL AS PATIENT SAFETY ARE
KEY
AND REMEMBER!

PATIENT’S RIGHTS

RIGHT TO SAY NO

CLOSE COOPERATION WITH MEDICAL TEAM

PATIENT ADVOCACY
AND REMEMBER!