THE ASSESSMENT AND MANAGEMENT OF DYSPHAGIA

NEUROGENIC BOWEL

Luh Karunia Wahyuni

Medical Rehabilitation Department
Dr. Cipto Mangunkusumo Hospital
Faculty of Medicine University of Indonesia

Swallowing process

THE NORMAL SWALLOW PROCESS

a. Oral Phase
b. Pharyngeal Phase
c. Esophageal Phase

Swallowing process

Swallowing process

COMPONENT OF SWALLOW
Oral propulsion of the
bolus into the pharynx

Tongue
base

pharyngeal
wall propulsion to
carry
the bolus through the
pharynx and into the
esophagus
Airway closure

Upper
esophageal
sphincter
opening

D y s p h a g i a

DYSPHAGIA
Knowledge
Population
Multidisciplinary approach
Complication

Knowledge in this field is still new and

empirical data are lacking

POPULATION
Diverse patient population
Can result from a broad spectrum of disabilities
Oral & Oropharyngeal cancer
Laryngeal cancer
Neurological impairments (Stroke,TBI, CP etc).
Degenerative disease (Parkinson, ALS,
Myasthenia Gravis etc).

INSIDEN
76,4 % dari 55 pasien palsi serebral mengalami
kesulitan makan.
Penyebab terbanyak adalah disfungsi oromotor
dan kontrol postural yang buruk.

Sjakti HA. Wahyuni LK.Profil Status gizi dan kesulitan makan pada
anak palsi serebral di RS Dr.Ciptomangunkusumo, Jkt, 2006

INCIDENCE
34,7 % of 206 stroke patients had dysphagia
Dysphagia assessed clinically was a significant
variable predicting death and disability at go days

Paciaroni M, Mazzotta G et al. Dysphagia following stroke

Eur Neurol 2004; 51 (3) : 162-7

INCIDENCE
The incidence of dysphagia in stroke patients through a
systematic review of 277 published literature
(1966 May 2005)
Using cursory screening techniques
clinical testing
instrumental
testing

: 37 45 %
: 51 55 %
: 64 78 %

Martino R, Foley N et al. Dysphagia after stroke. Incidence,

Diagnosis and Pulmonary Complications Stroke 2005 ; 36:2756

MULTIDICIPLINARY APPROACH
Require close cooperation of a professional,
multidisciplinary staff, where in each member possesses
particular expertise
The feeding process ..is located at the intersection of
various medical disciplines, but it has not been adequately
addressed by any of them.

Johns Hopkins Swallowing Center

Complications

Aspiration leading to chest infection

Malnutrition
Dehydration
Increased length of hospital stay,
remission to
the hospital and mortality

A S P I R A T I O N

Types of aspiration A, Aspiration before swallow due to reduce tongue

control. B. Aspiration before swallow due to absent swallow response.
C. Aspiration during swallow due to reduce laryngeal closure D. Aspiration
after swallow due to pooled material in swallowing disorders (Logemann
JA, San Diego, 1983, College-Hill Press)

Causes of Aspiration

Reduced
laryngeal closure
Absent/reduced
swallow
response
Pooled material
in pyriform
sinuses

W A R N I N G

S I G N S

Dysarthric speech (slow, labored or slurred

articulation)
Voice (hoarse or breathy)
Excessive drooling (sialorrhea)
Frequent episodes of coughing and choking on
food
and sputum
Prolongation of meals, unexplained weight loss,
effortful
chewing
Difficulty in the oral preparation of a bolus
Pain or obstruction during swallowing

BEDSIDE EVALUATION
Orientation, Language, Visuo-motor perception
Motor Control (ability to mobilization)
Posture (alignment of head, neck,trunk and
extremities)
Quality of respiration
Ability to cough and protect the airway

BEDSIDE EVALUATION
Muscles of facial expression
Muscles of mastication
Dentition
Lingual muscles
Primitive oral reflex (bite
reflex
and tongue thrust)
Articulation (precision and
speed)
Diadochokinetic tasks (pa, ta,
ka)

BEDSIDE EVALUATION

Extrinsic laryngeal muscles

Palatopharyngeal closure

(hyper/hyponasal speech
qualities)
Voice duration :
- Quality
- Pitch
- Intensity

I N S TR U M E N TAL TE C H N I Q U E S

Ultrasound
Videofluoroscopy
Flexible Endoscopic Evaluation of
Swallowing (FEES)
Scintigraphy
Pharangeal Manometry

G O A L S

To prevent aspiration

To maintain an adequate nutritional intake

To reestablish oral eating to the safest optimum

level

To improve motor control at each stages of

swallow through normalization of tone &
facilitation of quality movement

M A N A G E M E N T

What type of nutritional management is

necessary (ORAL vs NON ORAL)

Should therapy be initiated and what type

(compensatory or exercise, direct or
indirect )

What specific therapy strategies should be

used

NON ORAL

ORAL

3-4 weeks
Nasogastric tube syndrome
(chest pain, bilateral cord paresis,
Otalgia, odinophagia)
Protection from aspiration?

NGT

Gastrotomi
Jejenostomi

MEDICAL REHABILITATION
MANAGEMENT

Cognitive stimulation
Feeding modification

Texture
Position/posture
Feeding route
Degree of supervision
Secretion management

MEDICAL REHABILITATION MANAGEMEN

Sensory stimulation
Swallowing reflex modulation
Therapeutic exercise
Compensatory swallowing
manuevers

Nothing by mouth

High risk for aspiration

Because of :
Reduced alertness
Reduced responsiveness to stimulation
Absent swallow and protective cough
Difficulty handling secretions as evidence by
excessive coughing & choking
Wet gurgly voice quality
Significant reduction in the range & strength
of oral, pharyngeal & laryngeal movement
Able to maintain adequate trunk and head
positioning with assistance

Swallow Maneuvers
Swallow Maneuvers

Problem for Which

Maneuver Was Designed

Supraglottic swallow

Reduced or late vocal fold closure

Delayed pharyngeal swallow

Super supraglottic
swallow

Reduced closure of airway

entrance

Effortful swallow

Reduced posterior movement of the

tongue base

Mendelsohn maneuver

Reduced laryngeal movement

Discoordinated swallow

Food chosen dysphagia diets

Be uniform in consistency and texture

Provide sufficient density and volume
Remain cohesive
Provide pleasant taste and temperature
Be easily removed or suctioned when
necessary

Postural Techniques in Eliminating

Aspiration
Disorder Observed

Posture Applied

Inefficient oral transit

Head back

Delay in triggering the

pharyngeal swallow

Chin down

Reduced posterior motion

of tongue base

Chin down

Reduced laryngeal closure

damaged side

Chin down; head rotated to

Reduced pharyngeal contraction

Lying down on one side

Unilateral pharyngeal paresis

side

Head rotated to damaged

Cricopharyngeal dysfunction

Head rotated

Bolus Consistencies
Food Consistencies

Disorders for Which These

Foods Are Most Appropriate

Thin liquids

Oral tongue dysfunction

Reduced tongue base retraction
Reduced pharyngeal wall contraction
Reduced laryngeal elevation
Reduced cricopharyngeal opening

Thickened liquids

Oral tongue dysfunction

Delayed pharyngeal swallow

Purees and thick foods,

Including thickened liquids
entrance

Delayed pharyngeal swallow

Reduced laryngeal closure the
Reduced laryngeal closure throughout