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DYSPHAGIA CHAPTER 9 What mechanisms are involved in a normal swallow? What causes swallowing disorders? How is swallowing assessed?

What can be done to help people with dysphagia swallow better? DYSPHAGIA (bring books on next Tuesday!) Dont view it from a technical motor problem view.Difficulty or an inability to swallow May be unable to consume enough food and liquids safely (and with pleasure) Also social impact Food social gatherings Aspiration When food enters the airway (NOT A GOOD THING) Swallowing means closing off the airway for breathing and allowing the food to reach the esophagus. Bolus- the term we use for the food thats been chewed Normal eating is both a cognitive act and a motor act. What is the role of food in our society? We use it for energy, nutrition, social (bonding with people), pleasure, cultural identification, social (mannerisms, hosting), love/caring/bonding, occupation, comfort (when youre sick), stress relief, boredom, reward, adventurous (trying new things) COMMUNICATION DISORDERS AND SWALLOWING 50% of SLPs who work in hospitals & extended care facilities do dysphagia assessment or intervention Dysphagia may result in aspiration of food into lungs & gastroesophageal reflux disorder (GERD) Most dysphagic patients also have communication disorders SLPs work with team of professionals and family members LIFE SPAN PERSPECTIVES Problems occur in children (born prematurely or with cerebral palsy) and adults Whatever the etiology or age, outcomes of swallowing disorders include: Malnutrition & ill health Weight loss Frustration Respiratory infection

Aspiration & death

TERMS: Dysphagia: 1.) The inability to stay well-nourished through oral eating. 2.) The inability to stay well-hydrated through regular liquid consumption. 3.) The inability to do it with pleasure. Inability can be congenital or acquired. Aspiration Bolus- the term we use for food thats been chewed Upper Esophageal sphincter (UES)-valve that sits on top of the esophagus. It needs to be open when you eat. If its closed when you breathe, you can possibly choke. Larynx- sits on top of the trachea that has the vocal cords Pharynx- back of the throat Esophagus-path to the stomach Vocal Folds- sit on top of the trachea in the larynx Trachea- path to the lungs Velum- the last part of the palate that goes up CAUSES OF DYSPHAGIA IN ADULTS CVA (Cerebral Vascular Accident-Stroke) Brainstem Stroke Traumatic Brain Injury Dementia Neuromuscular Disease

CAUSES OF DYSPHAGIA IN CHILDREN Cerebral Palsy Premature birth Developmental Disability-Any disorder that affects either or both cognitive or motor functioning

THE NORMAL SWALLOW- FOUR STAGES Anticipatory- the smell, the purpose of the food, and the readiness of eating. People with dementia may not have this cognitive stage. Your knowledge of what food is for and the need to eat is gives the stage the classification as cognitive. Oral- both cognitive and motor stages Oral preparatory Liquid or solid prepared into bolus by tongue and teeth Oral transport Bolus moves from front to back of mouth; pharyngeal reflex triggered

Pharyngeal (have a lot of afferent input-very high sensory input) Soft palate elevates to prevent bolus from entering nasal cavity Hyoid bone brings larynx up and forward (opens the esophagus) Trachea closes with true & false vocal folds, and lowered epiglottis Upper esophageal sphincter opens & bolus moves into esophagus Esophageal ASSESSMENT QUESTIONS Are the muscles of the tongue, lips, and jaw functioning adequately? Can the patient elevate the larynx? Can the patient feed himself? What foods can the patient eat safely? Case History Swallowing problems prior to illness? Preexisting conditions? Medications? Current Medical Status Medically stable/cognitive function? How patient is receiving nutrition (G-tube, NG tube)? Respiratory/cardiac problems? Bedside Clinical Assessment Assess ability to take food off plate (cognitive/motor skills) Level of alertness Oral-motor exam (lips, jaws, tongue, initiation of the pharyngeal swallow) Upward movement of larynx?

Coughing? Gurgly sound? (Gurgly meaning that some of the bolus is on the vocal folds.) Modified Barium Swallow (Part of the SLP practice) Barium-coated food Fluoroscope images taken by radiologist Can visualize pharyngeal stage/aspiration Videoendoscopy Flexible scope via nose to just above epiglottis Patient eats, watch pharyngeal structures via scope DYSPHAGIA IN CHILDREN Prematurity Swallow abilities 30-34 weeks gestation Weak facial muscles, underdeveloped lungs Uncoordinated or weak suck Cerebral Palsy Degree of motor deficit important Cognitive difficulties Inadequate velopharyngeal closure Larynx doesnt elevate, pharyngeal peristalsis Developmental Disabilities