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Dysphagia evaluation and treatment
BB DYSPHAGIA EVALUATION AND TREATMENT AMANDA C. HEMBREE, MA, CCC-SLP
Dysphagia, or swallowing disorders, has recently become one of the largest growing areas of evaluation and treatment by speech-language pathologists. Many studies have been completed to assist the professional in the diagnosis and treatment of dysphagia. In an acute care setting, the need to assess the patients ability to swallow is extremely important. Evaluation techniques include the bedside examination, the use of cervical auscultation, the blue dye test and the use of videofluroscopic evaluation. Evaluation of such a varied caseload takes extreme skill and knowledge of the anatomy and physiology of the swallow as well as understanding the changes that may occur with various insults to the brain or a change in the anatomy, secondary to head and neck surgeries. Treatment of the disorder is dependent on the disruption to the normal anatomy or physiology that has taken place. Rehabilitation techniques will be discussed with regard to the head and neck patient and the neurologically impaired.
Dysphagia, or swallowing disorders, involves many aspects of the anatomy and physiology of the head and neck. Normal oropharyngeal swallowing physiology is dependent on rapid neuromuscular coordination of structures in the oral cavity, pharynx, and larynx during a brief cessation of respiration. Normal swallowing functions can be separated into four phases: oral preparatory, oral stage, pharyngeal stage, and the esophageal stage. The anatomic areas involved in deglutition include the oral cavity, pharyngeal cavity, larynx, and esophagus. The structures within the oral cavity include the lips, teeth, hard palate, soft palate, uvula, mandible, floor of mouth, tongue, and faucial arches. The structures within the pharyngeal cavity include the tongue base, the epiglottis, the posterior pharyngeal wall, the thyroid, and cricoid cartilage. The opening into the larynx is known as the laryngeal vestibule, which ends at the superior surface of the false vocal folds. There are two distinct spaces formed by these structures within the pharynx which play an important role in swallowing. The space between the base of tongue and the anterior surface of the epiglottis is called the valleculae. The space between the posterior portion of the thyroid cartilage and the posterior pharyngeal wall is called the pyriform sinus. These end inferiorly at the circopharyhgeus muscle. This muscle serves as the valve at the top to the esophagus. The esophagus consists of a hollow muscular tube with a sphincter at each end. The physiology of the swallow takes place in four distinct phases1: The oral preparatory phase, the oral phase or voluntary phase of the swallow, the pharyngeal phase, and the esophageal phase. The frequency of deglutition varies with each activity. Swallowing frequency is the greatest during eating and the least during sleeping. Mean deglutition frequency is approximately 580 swallows per dayJ Swallowing and respiration are reciprocal functions, ie, respiration halts during deglutition. Swallowing has been described as an airway protective reflex because of the reciprocity. 2
From St. Lukes-Roosevelt Hospital, Speech and Hearing Department, New York, NY. Address reprint requests to Amanda C. Hembree, MA, CCC-SLP, St. Lukes-Roosevelt Hospital, 425 W 59th St, Ste 4E, New York, NY 10019. Copyright © 1997 by W.B. Saunders Company 1043-1810/97/0804-0009505.00/0
The oral preparatory phase has various movement patterns which are dependent on the type of bolus consistency that is being swallowed. The oral preparatory phase begins as soon as the bolus enters the mouth and the labial seal is maintained. The labial seal is important, because it prevents food or liquid from falling from the mouth. A liquid bolus has a certain amount of cohesiveness that is maintained during the phase. The bolus is held between the tongue and the anterior hard palate in preparation for the swallow. The tongue may cup around the liquid bolus and seal against the hard palate. The tongue back raises to meet the hard palate, thus providing a seal against leakage into the pharynx. The soft or solid bolus requires mastication and manipulation of the substance to form a cohesive bolus before the initiation of the oral phase. The mandible and tongue are observed to move in a rotary lateral movement. The upper and lower teeth are thus responsible for crushing the material in the oral preparatory phase. This cycle is repeated until a bolus is formed. During the oral preparatory phase, the velum is normally pulled actively anteriorly and rests against the back of the tongue. The larynx and pharynx are at rest during the preparatory phase. The airway is open and nasal breathing may continue until the voluntary swallow is initiated. The oral stage of the swallow is initiated when the tongue begins posterior movement of the bolus by squeezing the bolus posteriorly against the hard palate. The tongue is noted to produce an anterior-posterior movement, rolling the bolus from the anterior portion of the oral cavity to the posterior. At the point when the bolus passes the anterior faucial arches, the oral stage has been completed. The oral stage typically takes less than i second to complete. The pharyngeal stage of the swallow begins with the triggering of the swallow reflex. One is unable to swallow unless there is something in the mouth to swallow, either food, liquid, or saliva. The triggering of the swallow is caused by a sensory input to the brain when food passes the anterior faucial arches. Several events then take place simultaneously. These include (1) the elevation and retraction of the velum and complete closure of the velopharyngeal port to prevent material from entering the nasal cavity; (2) the elevation of the larynx, (3) the retraction of the tongue base, (4) the contraction of the muscles of the posterior pharyngeal wall, and (5) anterior-inferior move-
OPERATIVE TECHNIQUES IN OTOLARYNGOLOGY--HEAD AND NECK SURGERY, VOL 8, NO 4 (DEC), 1997: PP 185-190
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ment of the epiglottis. The pressure force of the bolus is responsible for the initiation of this action. Also, by this force, the cricoesophogeal sphincter opens and allows the bolus to pass into the esophagus. The pressure is originally generated during the oral stage of the swallow when the tongue movement pushes the bolus pastthe faucial arches. If one or more of these functions is weak or absent, the swallow mechanism will not function properly. Normally, during this transit through the pharynx, the bolus does not hesitate and a smooth movement is observed. Very little food is left in the pharynx. The esophageal phase begins when the food enters the esophagus at the cricopharyngeal juncture until it passes into the stomach at the gastroesophageal juncture. The esophageal phase of the swallow is not amenable to any kind of therapeutic exercise program; the videofluoroscopic study of the swallow does not tend to involve the examination of the esophagus. A standard barium swallow or upper gastrointestinal series would be more appropriate. The evaluation procedure is varied. Head and neck surgical patients, patients with cerebrovascular accidents, and tracheostomized patients will be discussed in this article. The following assessment measures will be discussed: a bedside examination, cervical auscultation, "blue dye" test, and the modified barium swallow study.
THE
BEDSIDE
EXAMINATION
A careful and complete case history is necessar~ noting the patient's primary diagnosis, neurological status, laryngeal function, respiratory status, nutritional status, and history of any dysphagic symptoms. On initial examination of the patient, structures necessary for a safe and productive swallow are examined. An evaluation of the patient's memory/cognitive status is completed. A screening of the patient's language skills is also completed. Lingual and labial strength and range of motion are assessed. Diadochokinetic speech tasks / pu / / tu / / ku / are useful in assessing the tongue strength and mobility. The / p u / sound indicates the ability to successfully maintain labial closure with adequate breath support to produce a plosive consonant. The / t u / s o u n d allows assessment of the tongue tip movement, and the / k u / sound is an indication of the ability to elevate the back of the tongue. The patient is asked to produce a volitional swallow. Light touch on the thyroid cartilage provides an approximation of laryngeal elevation during the swallow. Abnormal signs such as drooling or coughing on their own secretions are noted. The patient is then given a small bolus to swallow. At an acute care institution, typically water (thin liquid) is at the bedside. Assessment is made of both the oral and pharyngeal stage of the swallow. Oral transit time is noted as well if a delay in the initial of the swallow is present. Overt signs of aspiration are noted at this time, ie, a cou~h reflex, or nasal or oral regurgitation. After the patient has completed the swallow, the patient is asked to phonate a simple / a h / t o assess grossly for laryngeal penetration or possible aspiration. A "wet" vocal quality is indicative of penetration or aspiration. The patient is then given a puree consistency to assess lingual movement necessary for the preparation and propulsion of the bolus into the pharyngeal cavity. Rotary movement of the jaw is observed and digital pressure under the chin assists in assessing tongue movement. Excessive tongue pumping should be noted. The pharyngeal swallow is observed and the examination is complete. It is important to remember that a patient can 186
silently aspirate, and a bedside examination may be normal; however, the patient continues to present with recurrent aspiration pneumonia. This may be indicative of silent aspiration. Recommendations are made on the clinical judgment of the clinician. A diet is recommended and conference with the physician is made. It is at this time that further clinical assessment is decided upon. If the results of the bedside examination are at all indicative of dysphagia, a modified barium swallow (MBS) study is ordered. Signs observed during bedside examination and what they indicate are summarized in Table 1. CERVICAL
AUSCULTATION
Clinical examination alone is unreliable in the detection of aspiration, planning a diet, or managing dysphagia. A bedside examination may not show overt signs of difficulty; however, the patient continues to present with aspiration pneumonia. 3 In this case, the patient may be silently aspirating. Cervical auscultation is a method used to assess the pharyngeal phase of the swallow. Cervical auscultation is a general term that describes several techniques. Auscultation with a laryngeal microphone provides a broader spectrum sound of muscle and fluid movement and breath exchanges, whereas a stethoscope narrows the spectral range of sound for enhanced detection of low frequency breath sounds. The use of the stethoscope provides adequate transmission of sound frequencies up to 1,000 Hz. Studies have shown that with the normal adult, respiratory apnea occurs during pharyngeal swallows, usually during the expiatory phase of breathing. Expiration usually follows the swallow apnea, and the length of expiration after the swallow varies. 4 It has been found that respiratory patterning is more variable, swallow apnea is less consistent, and inspiration occurs more frequently after the swallow with dysphagic adults. The breath sounds in dysphagic patients are different, often characterized by respiratory bubbling, throat clearing, and vocal stridor. The use of cervical auscultation is used to further assess the patient's pharyngeal stage of swallowing and to assist in distinguishing those who aspirate. Cervical auscultation has a variety of limitations. Currentl~ there is a lack of agreement on nomenclature, and no data exist to support the correlation of acoustic sounds with specific swallowing events. However, cervical auscultation is believed to be helpful in the further assessment of patients at the bedside examination. THE
'BLUE
DYE' TEST
This evaluation measure is done with those patients who have undergone a tracheotomy. The most common indication for a tracheotomy is airway obstruction, which can be either chronic or acute. Acute airway obstruction may be TABLE 1. Signs Observed During Bedside Examination and What They Indicate Bedside signs of dysphagia Coughing, choking during or after swallow with thin liquid "Gurgley" vocal quality Sticking in the back of the throat Regurgitation Long time to initiate swallow Food accumulates in mouth
Indication Upper airway penetration/aspiration Material on the vocal folds Residual in the valleculae/pyriform sinus Reduced velopharyngeal competency Decreased sensation in pharynx Poor lingual movement
DYSPHAGIA EVALUATIONAND TREATMENT
due to an infectious process, such as obstructive adenotonsillitis, acute epiglottisis, or any deep neck space infection that could cause airway compromise by swelling of or extension to surrounding tissues. Chronic airway obstruction is usually due to the presence of a mass, sometimes benign but most often malignant, and may occur at any level from the oropharynx to the larynx, including the subglottic area. Chronic or acute airway obstruction may also result from vocal cord paralysis, particularly bilateral adductor paralysis. A tracheotomy may also be performed in patients who require prolonged ventilator support. It also facilitates pulmonary toilet in patients who cannot clear their own secretions adequately. The major swallowing disorder associated with tracheotomy is aspiration. A tracheotomy may cause desensitization of the larynx so that the patient may be unaware of aspiration, and the protective cough mechanism that would ordinarily clear the airway may be blunted. The tracheotomy also reduced laryngeal elevation. Also observed is the uncoordinated laryngeal closure due to chronic upper airway bypass. The blue dye test is used with those patients who present with a tracheotomy. The patient participates in all the aspects of the bedside examination, and cervical auscultation is used. However, when the presentation of food is done, the food is saturated with blue food coloring. The reason for the color blue is so that it can be detected if suctioned from the trachea. Because the tracheotomy creates decreased intrapharyngeal air pressure, the tracheostomy tube is covered during the swallow in an attempt to increase pressure within the pharynx during the swallow. Also, this may increase subglottic sensory receptors before the swallow and may improve the vocal fold closure, s Most swallows occur during the exhalatory phase of the respiratory cycle, with exhalation temporarily stopped by the swallow. 6 Exhalation usually resumes after the swallow. Thus, if the patient's tracheostomy is occluded during and immediately after the swallow, the exhalatory airflow after the swallow potentially contributes to clearance of residual food away from the top of the airway, lessening the risk of aspiration after the swallow. It is also best that the cuff is deflated before attempting any swallows. An inflated cuff may irritate the trachea as the larynx elevates during the swallow. Or, the inflated cuff may restrict laryngeal elevation. The patient is then observed for 8 hours after feeds. If the presence of blue is noted when suctioning the patient or on the outside of the tracheotomy tube, it is suggestive of aspiration. However, this does not completely answer our question. It is not sufficient to note that the patient is in fact aspirating, but as a clinician, one must find out why.
THE MODIFIED BARIUM SWALLOW STUDY (ass) The modified barium swallow study is designed to study the anatomy and physiology of the oral preparatory, oral, pharyngeal and cervical esophageal stages of deglutition, 7 and to define management and treatment strategies that will improve the oropharyngeal dysphagic patient's swallowing safety or efficiency. The MBS study uses fluoroscopy, which is a radiographic technique permitting observation of movement. The use of videofluoroscopy allows for permanent recording of the study. The patient is brought into the fluoroscopy suite and positioned in their usual feeding position. This is AMANDA C. HEMBREE
important because it allows the clinician to mimic the atmosphere with which the patient is currently having problems. A lateral view is initially obtained. The patient is given four bolus consistencies: thin and thick liquid, puree and solid, all saturated with barium. Initially, a small amount of each consistency is used to fully assess the anatomy and physiology of the oral cavity and pharynx. The patient is given larger amounts as the study continues to tax the anatomy, thus revealing any difficulty with the swallow. The view is obtained before during and after the swallow. It is important to note any residual that may be present after the initial swallow has been triggered. The patient may not aspirate before or during the swallowing. It has been noted that the patient may aspirate after the swallow on residual material s After the lateral view is obtained, the patient is turned so that a posterior-anterior view can be obtained. It is in this view that the symmetry of the swallow can be assessed. During this time, vocal fold function can be observed. A major purpose of the MBS is to identify treatment strategies that will improve the safety or efficiency of the patient's swallow. Treatment strategies should be introduced when a significant swallowing disorder is observed, that is, one that causes aspiration or a highly inefficient swallow with a great deal of oral or pharyngeal residual. The radiographic study should not always be terminated when a patient aspirates. Instead, a treatment strategy should be introduced that is selected based on the nature of the patient's disorder. In general, treatment strategies are introduced in the radiographic study in the following order: (1) postural technique, (2) increased sensory input, (3) treatment strategies, (4) volume changes, and (5) changes in diet or food consistency.7 The goal of the radiographic study is to maintain oral intake of foods that are safe and can be swallowed efficiently, even if it is under limited circumstances such as while using a particular postural technique or a particular swallowing maneuver. It is very helpful to be able to assess the effectiveness of therapy procedures radiographically. In the standard protocol, liquid volume is increased as long as no aspiration occurs. If aspiration occurs, the study should not be stopped. Instead, the clinician should examine the patient's swallowing physiology to determine the reason for the aspiration. The clinician should then introduce a change in the patient's posture. If the particular posture is not effective, a swallowing maneuver may be introduced alone or in combination with a postural change. Postural variation may change pharyngeal dimensions or the gravitational flow of food through the oral cavity and pharynx that may, therefore, reduce the patient's aspiration and increase the amount of material entering the esophagus. These compensatory techniques are used as temporary measure to improve food intake while the patient recovers or undergoes swallowing therapy. Not every postural change will assist in the decrease or elimination of aspiration. It is important to understand the physiological changes that each particular postural change produces. Head tilting forward/chin tuck: This pushes the anterior wall of the pharynx posteriorly significantly narrowing the airway entrance and pushing the tongue base and the epiglottis significantly farther backward toward the posterior pharyngeal wall. In some patients, the chin tuck posture results in a widened vallecular space as the tongue falls forward and the epiglottis falls somewhat backward. The chin tuck posture is often helpful for the patient with a 187
elayed swallow, reduced laryngeal closure, and reduced rogue base retraction. 9 Tilting head backward: This facilitates gravitational drain~e of food out of the oral cavity and thus improves the ~eed of the oral transit time used with those patients with oor tongue control or with part of the tongue surgically ~moved. Rotating the head to the damaged side: This closes the yriform sinus on that side. Thus, patients with unilateral haryngeal weakness or paralysis can benefit from directLg the food down the opposite or stronger side. In all lses, the patient's head should be turned toward the amaged side. The external pressure on the damaged vocal ~rd moves the cord to midline, thus improving airway osure. All of these postures can be used in combination with ae another. These postures are used as a compensatory rategy and do not change the patient's physiological lpability or neuromuscular control. 1° Various swallowing maneuvers can be introduced durtg the radiographic study. These maneuvers are used in :tempt to assist the patient in improving swallow safely if Lepostural changes are not helpful. Supraglottic swallow: This is used to close the vocal folds ffore and during the swallow, thus protecting the trachea om aspiration. The patient must be alert, relatively ;laxed, and able to follow simple directions without _~comingupset or confused. 9 Extended supraglottic swallow: This is used with those ~tients who have severe reductions in the tongue mobility r severely reduced tongue bulk because of surgical proceures or oral cancer with little or no oral transit. Supersupraglottic swallow: This is designed to close the ltrance to the airway voluntarily by tilting the arytenoid ~rtilage anteriorly to the base of the epiglottis before and aring the swallow. Laryngeal elevation brings the aryte~id cartilage closer to the posterior surface of the epiglot3, so that the arytenoid does not have to move as far ~teriorly. The extra effort involved in the supersupraglot: swallow increases the anterior tilt of the arytenoid to ose the entrance of the airway early, both before and aring the swallow. This maneuver is partially helpful in rose patients with a supraglottic laryngectomy, thus aproving the tongue base reaction as well as the anterior It of the arytenoid. Mendelsohn maneuver: This uses information on the omechanics of cricopharyngeal opening to improve laryn.~al elevation and cricopharyngeal opening during the vallow, n The Mendelsohn maneuver is designed to imrove laryngeal elevation and the duration and width of icopharyngeal opening during the swallow. Voluntary maneuvers: These are used to clear any residual )lus within the pharynx. These include a spontaneous ,ss of the head back to use gravity to assist in clearing the )lus. Another is the use of a spontaneous dry swallow to ~sist in clearing any residual in the pharynx. Using liquid wash the food through the pharynx is also done, ternating between a liquid and solid / puree. Effortful swallow: This is a technique designed to improve ngue base movement posteriorly and thus improving earance of the bolus from the valleculae.
EHABILITATION AND THERAPEUTIC ECHNIQUES ead and neck patients are of particular importance !cause their limitations are caused by surgical removal or 38
change of the patient's anatomy necessary in the swallowing process. Radiation therapy has been shown to also affect the patient's ability to swallow after the surgical procedure has been completed. The hemilaryngecotomy is a procedure in which one of the true vocal folds is removed along with the vocal process of the corresponding arytenoid. In addition, the thyroid ala is removed. Physiologically, the major effect is the loss of or disruption of voice and difficulty swallowing. Remediation with these patients is usually a head turn to the affected side, thus closing off the affected side and directing all food/liquid into the nonaffected or stronger side. 12 Supraglottic laryngectomy requires removal of the hyoid bone, if it is involved, along with the entire ventricular folds, the epiglottis, and part of the thyroid cartilage. However, the vocal folds do remain intact, which is useful in the protection of the airway during swallowing. Problems are often seen within this population. In this case, the supersupraglottic swallow mentioned previously is proven to assist in the increased safety and effectiveness of the swallow. The supraglottic swallow is also beneficial; however, with the epiglottis being removed, the patient may need the extra pressure forces of the supersupraglottic swallow. Radical neck dissection refers to a surgical procedure in which the lymphatic system in the neck is removed to eliminate any cancer cells that may have metastasized. In addition to the removal of the lymph nodes, the sternocleidomastoid muscle is cut. This may interfere with neck rotation. Many times the tongue is involved with these patients, especially the base of tongue anterior to the hyoid. Parts of the tongue may need to be resected. A glossectomy refers to the surgical excision of some portion or all of the tongue. The severity of the swallowing disability is related to the extent of lingual resection, the mobility of the residual tongue, the type of reconstruction, involvement of other structures, the patient's motivation and ability to adapt, and the skill of the rehabilitation team. 13 Typically, postoperative swallowing assessment is done when the healing is complete. The initial assessment includes observation of how the patient handles his or her own secretions; examination of the anatomy, function, sensory response of the oral and pharyngeal structures; check for cough and swallow reflexes; observe for overt signs of aspiration; and test the ability to swallow very small amounts of water and puree consistency. The swallowing assessment should be done before the removal of the nasogastric feeding tube. Swallowing treatment is done in conjunction with speech treatment. They are typically seen daily while in the hospital as well as on an outpatient basis after discharge. The specific exercise and the nature of the compensatory movements to be taught mUst be determined individually and based on the type of difficulty the person is experiencing, the anatomic configuration and mobility of residual tongue, and the oral and pharyngeal sensory status. TM Range of motion exercises should attempt to increase vertical and anteroposterior lingual movement and lateral and horizontal movement of the mandible. Tongue strengthening exercises focus on lateralization and elevation. Both the tip and the dorsum of the tongue should receive attention. Resistance to movement in those directions can imposed with gradually progressive firmness using a tongue depressor as a means of increasing strength. Compensatory postures can be taught for a variety of DYSPHAGIA EVALUATIONAND TREATMENT
asons. When the patient has limited anteroposterior ,ngue movement, tilting the head backward will be ~lpful in moving the bolus to the back of the mouth. then the impairment is unilateral, tilt the head to the imaged side. When less than 50% of the tongue has been :cised, and when there is some mobility remaining in the sidual tongue, exercises should be devised to encourage ngue to palate contact. The patient should practice in anipulating objects in the mouth. An ice chip is usual in ds exercise because it also provides the sensory feedback the patient and the thermal stimulation. Moving the ice tip in a rotary motion and laterally is useful. The size of .e object initially is large and gradually reduced in size hen function returns or improves. The ability to control ~e bolus into a cohesive bolus is also practiced. Food quiring chewing is introduced in small amounts and :adually increased. When more than 50% of the tongue is been resected or mobility is minimal, tongue exercise ill be of little value. The patient should be fitted with an traoral prosthesis. 15Jaw and mouth opening exercises are meficial. Cancers of the palate are observed in the upper alveolar :lge, the hard palate, or the soft palate. Surgical excision is ;ually the primary treatment. The effects of a palatectomy l speech a n d / o r swallowing varies from minimal to vere, and is highly dependent on the location of the mor and the extent of the excision. Tumors of the veolar ridge or the hard palate may result in leakage of od or fluids and difficulty chewing. Tumors of the soft date will affect the ability to swallow without return of od or fluid through the nose. Patients with alveolar ridge hard palate defects are usually fitted for an intraoral •osthesis before surgery, and the prosthesis is inserted at e time of surgery. Continued therapy for this population useful in improving the patient's ability to manage food ith the prosthesis without difficulty.
In the oral phase of the swallow, Parkinson patients exhibit a typical repetitive anterior to posterior rolling pattern in the lingual propulsion of the bolus. The bolus is held in a normal position when the swallow is begun. Then the tongue rolls the bolus posteriorly. The tongue back does not always lower to allow the bolus to pass into the pharynx and the bolus rolls forward. Some Parkinson patients exhibit a delay in the triggering of the swallow reflex, although typically not severe. Pharyngeal strength is often reduced resulting in residual in the valleculae and pryiform sinus after the swallow. This residual typically increases with each bolus. Incomplete laryngeal closure results in increased risk of aspiration, especially with thin liquids. More frequently the aspiration is that of the residual and happens after the swallow is completed. Therapy for this population includes thermal stimulation to improve the patients sensory awareness of the bolus and compensatory strategies to improve airway protection. Experience has shown that the chin tuck head position is most useful in the protection of the airway. Thermal stimulation/sensitization of the pharyngeal swallow is based on two types of research which intensify areas of the mouth containing sensory receptions which play a role in triggering of the swallow. Cold stimulus has been shown to be most effective in eliciting a swallow. The purpose then of thermal stimulation is to increase sensory awareness in the oral cavity prior to the swallow and to decrease any delay between the oral and pharyngeal swallow. The clinician uses a size 00 laryngeal mirror, dipped in a cup of ice and water, to rub the faudal arches four or five times in a rapid fashion. The patient is then asked to swallow saliva or a small amount of thickened cold liquid. This is done several times. 1 The result will be an increase in the timing of the initiation of the swallow reflex. TABLE 2. Swallowing Disturbances Problem
EUROLOGICAL POPULATION: ISORDERS AND TREATMENT
roke (cortical and brainstem) typically results in a deyed or absent swallow reflex. This results in aspiration ;fore the swallow. 16 Disrupted lingual movement is obrved, which decreases oral transit time and reduces oral •essure. Reduced laryngeal elevation and tongue base traction are also observed. This results in both aspiration :fore, during, and after the swallow. Criocophayrngeal /sfunction is noted secondary to reduced pressure within e pharynx, thus not allowing opening for the food to ~ss. Difficulty is also noted with noncortical and brain~m strokes. A hemiparesis or paralysis will impair the ltient's generalized strength of the swallow. If a paralysis present, the patient will have difficulty with lingual ovement, resulting in reduced bolus preparation and •opulsion of the bolus during oral transit. Reduced laryngeal muscles will result in increased residual on the fected side. Laryngeal elevation may be reduced as well. ~erapy should be initiated immediately to improve range motion of the tongue, adduction of the vocal folds, and imulation of the swallowing reflex. The pattern of recovy of normal swallowing in patients after cerebrovascular :cident is not well documented. However, typically 75% gain ability to maintain one's nutritional and hydration ;eds by mouth within the first 3 months after the :cident. 17 Patients with Parkinson's disease may exhibit a number swallowing disorders in all three stages of deglutition. /IANDA C. HEMBREE
Oral stage Reduced lip closure Reduced tongue elevation
Reduced tongue lateralization Anterior/posterior movement Reduced jaw movement Reduced oral awareness Triggering of the swallow Delayed/absent reflex
Therapy Technique Lip exercises Tongue exercises Food positioning Prosthesis Postural techniques (head tilt to stronger side or head tilt back) Prosthesis Tongue exercises Position of food Postural changes Jaw exercises Oral stimulation Thermal stimulation postural changes Tongue propulsion technique
Pharyngealstage Reducedtongue base
Effortful swallow, supraglottic swallow Tongue retraction exercises Unilateral weakness Postural change (head turn to affected side) Reduced pharyngealpressure Alternate between liquids and solids, multiple swallows Effortful swallow Reduced laryngeal elevation Supraglottic swallow pitch elevation exercises Reduced laryngeal closure Supersupraglottic swallow postural changes (chin tuck, head rotation) Supraglottic swallow Adduction exercises Teflon injection Cricopharyngeal dysfunction Postural changes Mendelsohn maneuver Dilation Myotomy
189
S w a l l o w i n g disturbances related to physiological disorers are specific to each task the a n a t o m y is required to 3replete (Table 2). D y s p h a g i a rehabilitation is usually best accomplished rith a t e a m of professionals, including the radiologist, the afient's m a n a g i n g physician, s p e e c h - l a n g u a g e patholoi s t / s w a l l o w i n g specialist, a n d the dietitian. The swallow~g therapist is the k e y to the success of the team. This ~dividuaI participates in the diagnosis of the patient's wallowing disorder a n d plans the a p p r o p r i a t e t h e r a p y trategies, in consultation w i t h t h e p a t i e n t ' s physician. The peech-language pathologist w o r k s w i t h the patient on pecific exercise p r o g r a m s for degtufition. Positive prognosc o u t c o m e for patients w i t h s w a l l o w i n g p r o b l e m s is ased on a p p r o p r i a t e evaluation of the particular p r o b l e m s well as on the a p p r o p r i a t e therapeutic techniques used. )ften techniques are c o m b i n e d for the patients w i t h mltiplicity of disorders affecting swallowing. The length f t h e r a p y is varied for each population. Follow-up is ssential for all patients.
|EFERENCES t. Logemann J: Evaluation and Treatment of Swallowing Disorders. Austin, TX, Pro-ed, 1993 Z. Miller A: The search for the central swallowing pathway: The quest for clarity. Dysphagia 8:185-194, 1993 3. Linden P, Kuhlemeier K, Patterson C: The probability of correctly predicting subglottic penetration from clinical observations. Dysphagia 9:170-179, 1993
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4. Zenner P, Losinski D, Mills RH: Using cervical auscultation in the clinical dysphagia examination in long-term care. Dysphagia 10:2731, 1995 5: Sasaki CT, Susuki M, Horiuchi M, et ah The effect of tracheostomy on the Iaryngeal ctosure reflex. Laryngoscope 87:1428-1433, 1977 6. Martin B, Sesle B: The role of the cerebral cortex in swallowing. Dysphagia 8:195-20Z 1993 7. Logemann J: Manual for the Videofluoroscopic Study of Swallowing. Austin, TX, Pro-ed, 1993 8. Schmidt J, Halas M, Halvorson K, Reding M: Videofluoroscopic evidence of aspiration predicts pneumonia and death but not dehydration following stroke. Dysphagia 9:7-21, I994 9.. Martin B, LogemamnJ, Shaker R, Dodds W: Normal laryngeal valving patterns during three breath-hold maneuvers: A pilot investigation. Dysphagia 8:11-20, 1993 10. Rastey A, Logemann J, Kah_rilas P, et ah Prevention of barium aspiration during videoftuoroscopic swallowing studies: Value of change in posture~AJR Am J Roentgenot 160:1005-1009, 1992 11. Kahrilas PJ, Logemann JA, Gibbons P: Food intake by maneuver: An extreme compensation for impaired swallow. Dysphagia 7:155-159, 1992 12. Logemann J, Pauloski BR, et al: Impact of the diagnostic procedure on outcome measures of swallowing rehabilitation in head and neck cancer patients. Dysphagia 7:I79-186, 1992 13. Casper JK, Colton RH: Clinical Manual for Laryngectomy and Head and Neck Cancer Rehabilitation. San Diego, CA, Singular Publishing, 1993 14. Logemann JA: Aspiration in head and neck surgical patients. Ann Otol Rhinol Laryngo194~373-376,1985 15. Muz J, Hamlet SL, Davis LP, et al: Objective assessment of swallowing f~ncfion in head and neck cancer patients. Head Neck t3:33-39, 1991 16. Johnson E, McKenzie S, Sievers A: Aspiration pneumonia in stroke. Arch Phys Med Rehabi174:973-976, 1993 17. Veis S, Logemamn J: The nature of swallowing disorders in CVA patients. Arch Phys Meal Rehabi166:372-375, I985
DYSPHAGIA EVALUATION AND TREATMENT
Dysphagia, or swallowing disorders, has recently become one of the largest growing areas of evaluation and treatment by speech-language pathologists. Many studies have been completed to assist the professional in the diagnosis and treatment of dysphagia. In an acute care setting, the need to assess the patients ability to swallow is extremely important. Evaluation techniques include the bedside examination, the use of cervical auscultation, the blue dye test and the use of videofluroscopic evaluation. Evaluation of such a varied caseload takes extreme skill and knowledge of the anatomy and physiology of the swallow as well as understanding the changes that may occur with various insults to the brain or a change in the anatomy, secondary to head and neck surgeries. Treatment of the disorder is dependent on the disruption to the normal anatomy or physiology that has taken place. Rehabilitation techniques will be discussed with regard to the head and neck patient and the neurologically impaired.
Dysphagia, or swallowing disorders, involves many aspects of the anatomy and physiology of the head and neck. Normal oropharyngeal swallowing physiology is dependent on rapid neuromuscular coordination of structures in the oral cavity, pharynx, and larynx during a brief cessation of respiration. Normal swallowing functions can be separated into four phases: oral preparatory, oral stage, pharyngeal stage, and the esophageal stage. The anatomic areas involved in deglutition include the oral cavity, pharyngeal cavity, larynx, and esophagus. The structures within the oral cavity include the lips, teeth, hard palate, soft palate, uvula, mandible, floor of mouth, tongue, and faucial arches. The structures within the pharyngeal cavity include the tongue base, the epiglottis, the posterior pharyngeal wall, the thyroid, and cricoid cartilage. The opening into the larynx is known as the laryngeal vestibule, which ends at the superior surface of the false vocal folds. There are two distinct spaces formed by these structures within the pharynx which play an important role in swallowing. The space between the base of tongue and the anterior surface of the epiglottis is called the valleculae. The space between the posterior portion of the thyroid cartilage and the posterior pharyngeal wall is called the pyriform sinus. These end inferiorly at the circopharyhgeus muscle. This muscle serves as the valve at the top to the esophagus. The esophagus consists of a hollow muscular tube with a sphincter at each end. The physiology of the swallow takes place in four distinct phases1: The oral preparatory phase, the oral phase or voluntary phase of the swallow, the pharyngeal phase, and the esophageal phase. The frequency of deglutition varies with each activity. Swallowing frequency is the greatest during eating and the least during sleeping. Mean deglutition frequency is approximately 580 swallows per dayJ Swallowing and respiration are reciprocal functions, ie, respiration halts during deglutition. Swallowing has been described as an airway protective reflex because of the reciprocity. 2
From St. Lukes-Roosevelt Hospital, Speech and Hearing Department, New York, NY. Address reprint requests to Amanda C. Hembree, MA, CCC-SLP, St. Lukes-Roosevelt Hospital, 425 W 59th St, Ste 4E, New York, NY 10019. Copyright © 1997 by W.B. Saunders Company 1043-1810/97/0804-0009505.00/0
The oral preparatory phase has various movement patterns which are dependent on the type of bolus consistency that is being swallowed. The oral preparatory phase begins as soon as the bolus enters the mouth and the labial seal is maintained. The labial seal is important, because it prevents food or liquid from falling from the mouth. A liquid bolus has a certain amount of cohesiveness that is maintained during the phase. The bolus is held between the tongue and the anterior hard palate in preparation for the swallow. The tongue may cup around the liquid bolus and seal against the hard palate. The tongue back raises to meet the hard palate, thus providing a seal against leakage into the pharynx. The soft or solid bolus requires mastication and manipulation of the substance to form a cohesive bolus before the initiation of the oral phase. The mandible and tongue are observed to move in a rotary lateral movement. The upper and lower teeth are thus responsible for crushing the material in the oral preparatory phase. This cycle is repeated until a bolus is formed. During the oral preparatory phase, the velum is normally pulled actively anteriorly and rests against the back of the tongue. The larynx and pharynx are at rest during the preparatory phase. The airway is open and nasal breathing may continue until the voluntary swallow is initiated. The oral stage of the swallow is initiated when the tongue begins posterior movement of the bolus by squeezing the bolus posteriorly against the hard palate. The tongue is noted to produce an anterior-posterior movement, rolling the bolus from the anterior portion of the oral cavity to the posterior. At the point when the bolus passes the anterior faucial arches, the oral stage has been completed. The oral stage typically takes less than i second to complete. The pharyngeal stage of the swallow begins with the triggering of the swallow reflex. One is unable to swallow unless there is something in the mouth to swallow, either food, liquid, or saliva. The triggering of the swallow is caused by a sensory input to the brain when food passes the anterior faucial arches. Several events then take place simultaneously. These include (1) the elevation and retraction of the velum and complete closure of the velopharyngeal port to prevent material from entering the nasal cavity; (2) the elevation of the larynx, (3) the retraction of the tongue base, (4) the contraction of the muscles of the posterior pharyngeal wall, and (5) anterior-inferior move-
OPERATIVE TECHNIQUES IN OTOLARYNGOLOGY--HEAD AND NECK SURGERY, VOL 8, NO 4 (DEC), 1997: PP 185-190
1 85
ment of the epiglottis. The pressure force of the bolus is responsible for the initiation of this action. Also, by this force, the cricoesophogeal sphincter opens and allows the bolus to pass into the esophagus. The pressure is originally generated during the oral stage of the swallow when the tongue movement pushes the bolus pastthe faucial arches. If one or more of these functions is weak or absent, the swallow mechanism will not function properly. Normally, during this transit through the pharynx, the bolus does not hesitate and a smooth movement is observed. Very little food is left in the pharynx. The esophageal phase begins when the food enters the esophagus at the cricopharyngeal juncture until it passes into the stomach at the gastroesophageal juncture. The esophageal phase of the swallow is not amenable to any kind of therapeutic exercise program; the videofluoroscopic study of the swallow does not tend to involve the examination of the esophagus. A standard barium swallow or upper gastrointestinal series would be more appropriate. The evaluation procedure is varied. Head and neck surgical patients, patients with cerebrovascular accidents, and tracheostomized patients will be discussed in this article. The following assessment measures will be discussed: a bedside examination, cervical auscultation, "blue dye" test, and the modified barium swallow study.
THE
BEDSIDE
EXAMINATION
A careful and complete case history is necessar~ noting the patient's primary diagnosis, neurological status, laryngeal function, respiratory status, nutritional status, and history of any dysphagic symptoms. On initial examination of the patient, structures necessary for a safe and productive swallow are examined. An evaluation of the patient's memory/cognitive status is completed. A screening of the patient's language skills is also completed. Lingual and labial strength and range of motion are assessed. Diadochokinetic speech tasks / pu / / tu / / ku / are useful in assessing the tongue strength and mobility. The / p u / sound indicates the ability to successfully maintain labial closure with adequate breath support to produce a plosive consonant. The / t u / s o u n d allows assessment of the tongue tip movement, and the / k u / sound is an indication of the ability to elevate the back of the tongue. The patient is asked to produce a volitional swallow. Light touch on the thyroid cartilage provides an approximation of laryngeal elevation during the swallow. Abnormal signs such as drooling or coughing on their own secretions are noted. The patient is then given a small bolus to swallow. At an acute care institution, typically water (thin liquid) is at the bedside. Assessment is made of both the oral and pharyngeal stage of the swallow. Oral transit time is noted as well if a delay in the initial of the swallow is present. Overt signs of aspiration are noted at this time, ie, a cou~h reflex, or nasal or oral regurgitation. After the patient has completed the swallow, the patient is asked to phonate a simple / a h / t o assess grossly for laryngeal penetration or possible aspiration. A "wet" vocal quality is indicative of penetration or aspiration. The patient is then given a puree consistency to assess lingual movement necessary for the preparation and propulsion of the bolus into the pharyngeal cavity. Rotary movement of the jaw is observed and digital pressure under the chin assists in assessing tongue movement. Excessive tongue pumping should be noted. The pharyngeal swallow is observed and the examination is complete. It is important to remember that a patient can 186
silently aspirate, and a bedside examination may be normal; however, the patient continues to present with recurrent aspiration pneumonia. This may be indicative of silent aspiration. Recommendations are made on the clinical judgment of the clinician. A diet is recommended and conference with the physician is made. It is at this time that further clinical assessment is decided upon. If the results of the bedside examination are at all indicative of dysphagia, a modified barium swallow (MBS) study is ordered. Signs observed during bedside examination and what they indicate are summarized in Table 1. CERVICAL
AUSCULTATION
Clinical examination alone is unreliable in the detection of aspiration, planning a diet, or managing dysphagia. A bedside examination may not show overt signs of difficulty; however, the patient continues to present with aspiration pneumonia. 3 In this case, the patient may be silently aspirating. Cervical auscultation is a method used to assess the pharyngeal phase of the swallow. Cervical auscultation is a general term that describes several techniques. Auscultation with a laryngeal microphone provides a broader spectrum sound of muscle and fluid movement and breath exchanges, whereas a stethoscope narrows the spectral range of sound for enhanced detection of low frequency breath sounds. The use of the stethoscope provides adequate transmission of sound frequencies up to 1,000 Hz. Studies have shown that with the normal adult, respiratory apnea occurs during pharyngeal swallows, usually during the expiatory phase of breathing. Expiration usually follows the swallow apnea, and the length of expiration after the swallow varies. 4 It has been found that respiratory patterning is more variable, swallow apnea is less consistent, and inspiration occurs more frequently after the swallow with dysphagic adults. The breath sounds in dysphagic patients are different, often characterized by respiratory bubbling, throat clearing, and vocal stridor. The use of cervical auscultation is used to further assess the patient's pharyngeal stage of swallowing and to assist in distinguishing those who aspirate. Cervical auscultation has a variety of limitations. Currentl~ there is a lack of agreement on nomenclature, and no data exist to support the correlation of acoustic sounds with specific swallowing events. However, cervical auscultation is believed to be helpful in the further assessment of patients at the bedside examination. THE
'BLUE
DYE' TEST
This evaluation measure is done with those patients who have undergone a tracheotomy. The most common indication for a tracheotomy is airway obstruction, which can be either chronic or acute. Acute airway obstruction may be TABLE 1. Signs Observed During Bedside Examination and What They Indicate Bedside signs of dysphagia Coughing, choking during or after swallow with thin liquid "Gurgley" vocal quality Sticking in the back of the throat Regurgitation Long time to initiate swallow Food accumulates in mouth
Indication Upper airway penetration/aspiration Material on the vocal folds Residual in the valleculae/pyriform sinus Reduced velopharyngeal competency Decreased sensation in pharynx Poor lingual movement
DYSPHAGIA EVALUATIONAND TREATMENT
due to an infectious process, such as obstructive adenotonsillitis, acute epiglottisis, or any deep neck space infection that could cause airway compromise by swelling of or extension to surrounding tissues. Chronic airway obstruction is usually due to the presence of a mass, sometimes benign but most often malignant, and may occur at any level from the oropharynx to the larynx, including the subglottic area. Chronic or acute airway obstruction may also result from vocal cord paralysis, particularly bilateral adductor paralysis. A tracheotomy may also be performed in patients who require prolonged ventilator support. It also facilitates pulmonary toilet in patients who cannot clear their own secretions adequately. The major swallowing disorder associated with tracheotomy is aspiration. A tracheotomy may cause desensitization of the larynx so that the patient may be unaware of aspiration, and the protective cough mechanism that would ordinarily clear the airway may be blunted. The tracheotomy also reduced laryngeal elevation. Also observed is the uncoordinated laryngeal closure due to chronic upper airway bypass. The blue dye test is used with those patients who present with a tracheotomy. The patient participates in all the aspects of the bedside examination, and cervical auscultation is used. However, when the presentation of food is done, the food is saturated with blue food coloring. The reason for the color blue is so that it can be detected if suctioned from the trachea. Because the tracheotomy creates decreased intrapharyngeal air pressure, the tracheostomy tube is covered during the swallow in an attempt to increase pressure within the pharynx during the swallow. Also, this may increase subglottic sensory receptors before the swallow and may improve the vocal fold closure, s Most swallows occur during the exhalatory phase of the respiratory cycle, with exhalation temporarily stopped by the swallow. 6 Exhalation usually resumes after the swallow. Thus, if the patient's tracheostomy is occluded during and immediately after the swallow, the exhalatory airflow after the swallow potentially contributes to clearance of residual food away from the top of the airway, lessening the risk of aspiration after the swallow. It is also best that the cuff is deflated before attempting any swallows. An inflated cuff may irritate the trachea as the larynx elevates during the swallow. Or, the inflated cuff may restrict laryngeal elevation. The patient is then observed for 8 hours after feeds. If the presence of blue is noted when suctioning the patient or on the outside of the tracheotomy tube, it is suggestive of aspiration. However, this does not completely answer our question. It is not sufficient to note that the patient is in fact aspirating, but as a clinician, one must find out why.
THE MODIFIED BARIUM SWALLOW STUDY (ass) The modified barium swallow study is designed to study the anatomy and physiology of the oral preparatory, oral, pharyngeal and cervical esophageal stages of deglutition, 7 and to define management and treatment strategies that will improve the oropharyngeal dysphagic patient's swallowing safety or efficiency. The MBS study uses fluoroscopy, which is a radiographic technique permitting observation of movement. The use of videofluoroscopy allows for permanent recording of the study. The patient is brought into the fluoroscopy suite and positioned in their usual feeding position. This is AMANDA C. HEMBREE
important because it allows the clinician to mimic the atmosphere with which the patient is currently having problems. A lateral view is initially obtained. The patient is given four bolus consistencies: thin and thick liquid, puree and solid, all saturated with barium. Initially, a small amount of each consistency is used to fully assess the anatomy and physiology of the oral cavity and pharynx. The patient is given larger amounts as the study continues to tax the anatomy, thus revealing any difficulty with the swallow. The view is obtained before during and after the swallow. It is important to note any residual that may be present after the initial swallow has been triggered. The patient may not aspirate before or during the swallowing. It has been noted that the patient may aspirate after the swallow on residual material s After the lateral view is obtained, the patient is turned so that a posterior-anterior view can be obtained. It is in this view that the symmetry of the swallow can be assessed. During this time, vocal fold function can be observed. A major purpose of the MBS is to identify treatment strategies that will improve the safety or efficiency of the patient's swallow. Treatment strategies should be introduced when a significant swallowing disorder is observed, that is, one that causes aspiration or a highly inefficient swallow with a great deal of oral or pharyngeal residual. The radiographic study should not always be terminated when a patient aspirates. Instead, a treatment strategy should be introduced that is selected based on the nature of the patient's disorder. In general, treatment strategies are introduced in the radiographic study in the following order: (1) postural technique, (2) increased sensory input, (3) treatment strategies, (4) volume changes, and (5) changes in diet or food consistency.7 The goal of the radiographic study is to maintain oral intake of foods that are safe and can be swallowed efficiently, even if it is under limited circumstances such as while using a particular postural technique or a particular swallowing maneuver. It is very helpful to be able to assess the effectiveness of therapy procedures radiographically. In the standard protocol, liquid volume is increased as long as no aspiration occurs. If aspiration occurs, the study should not be stopped. Instead, the clinician should examine the patient's swallowing physiology to determine the reason for the aspiration. The clinician should then introduce a change in the patient's posture. If the particular posture is not effective, a swallowing maneuver may be introduced alone or in combination with a postural change. Postural variation may change pharyngeal dimensions or the gravitational flow of food through the oral cavity and pharynx that may, therefore, reduce the patient's aspiration and increase the amount of material entering the esophagus. These compensatory techniques are used as temporary measure to improve food intake while the patient recovers or undergoes swallowing therapy. Not every postural change will assist in the decrease or elimination of aspiration. It is important to understand the physiological changes that each particular postural change produces. Head tilting forward/chin tuck: This pushes the anterior wall of the pharynx posteriorly significantly narrowing the airway entrance and pushing the tongue base and the epiglottis significantly farther backward toward the posterior pharyngeal wall. In some patients, the chin tuck posture results in a widened vallecular space as the tongue falls forward and the epiglottis falls somewhat backward. The chin tuck posture is often helpful for the patient with a 187
elayed swallow, reduced laryngeal closure, and reduced rogue base retraction. 9 Tilting head backward: This facilitates gravitational drain~e of food out of the oral cavity and thus improves the ~eed of the oral transit time used with those patients with oor tongue control or with part of the tongue surgically ~moved. Rotating the head to the damaged side: This closes the yriform sinus on that side. Thus, patients with unilateral haryngeal weakness or paralysis can benefit from directLg the food down the opposite or stronger side. In all lses, the patient's head should be turned toward the amaged side. The external pressure on the damaged vocal ~rd moves the cord to midline, thus improving airway osure. All of these postures can be used in combination with ae another. These postures are used as a compensatory rategy and do not change the patient's physiological lpability or neuromuscular control. 1° Various swallowing maneuvers can be introduced durtg the radiographic study. These maneuvers are used in :tempt to assist the patient in improving swallow safely if Lepostural changes are not helpful. Supraglottic swallow: This is used to close the vocal folds ffore and during the swallow, thus protecting the trachea om aspiration. The patient must be alert, relatively ;laxed, and able to follow simple directions without _~comingupset or confused. 9 Extended supraglottic swallow: This is used with those ~tients who have severe reductions in the tongue mobility r severely reduced tongue bulk because of surgical proceures or oral cancer with little or no oral transit. Supersupraglottic swallow: This is designed to close the ltrance to the airway voluntarily by tilting the arytenoid ~rtilage anteriorly to the base of the epiglottis before and aring the swallow. Laryngeal elevation brings the aryte~id cartilage closer to the posterior surface of the epiglot3, so that the arytenoid does not have to move as far ~teriorly. The extra effort involved in the supersupraglot: swallow increases the anterior tilt of the arytenoid to ose the entrance of the airway early, both before and aring the swallow. This maneuver is partially helpful in rose patients with a supraglottic laryngectomy, thus aproving the tongue base reaction as well as the anterior It of the arytenoid. Mendelsohn maneuver: This uses information on the omechanics of cricopharyngeal opening to improve laryn.~al elevation and cricopharyngeal opening during the vallow, n The Mendelsohn maneuver is designed to imrove laryngeal elevation and the duration and width of icopharyngeal opening during the swallow. Voluntary maneuvers: These are used to clear any residual )lus within the pharynx. These include a spontaneous ,ss of the head back to use gravity to assist in clearing the )lus. Another is the use of a spontaneous dry swallow to ~sist in clearing any residual in the pharynx. Using liquid wash the food through the pharynx is also done, ternating between a liquid and solid / puree. Effortful swallow: This is a technique designed to improve ngue base movement posteriorly and thus improving earance of the bolus from the valleculae.
EHABILITATION AND THERAPEUTIC ECHNIQUES ead and neck patients are of particular importance !cause their limitations are caused by surgical removal or 38
change of the patient's anatomy necessary in the swallowing process. Radiation therapy has been shown to also affect the patient's ability to swallow after the surgical procedure has been completed. The hemilaryngecotomy is a procedure in which one of the true vocal folds is removed along with the vocal process of the corresponding arytenoid. In addition, the thyroid ala is removed. Physiologically, the major effect is the loss of or disruption of voice and difficulty swallowing. Remediation with these patients is usually a head turn to the affected side, thus closing off the affected side and directing all food/liquid into the nonaffected or stronger side. 12 Supraglottic laryngectomy requires removal of the hyoid bone, if it is involved, along with the entire ventricular folds, the epiglottis, and part of the thyroid cartilage. However, the vocal folds do remain intact, which is useful in the protection of the airway during swallowing. Problems are often seen within this population. In this case, the supersupraglottic swallow mentioned previously is proven to assist in the increased safety and effectiveness of the swallow. The supraglottic swallow is also beneficial; however, with the epiglottis being removed, the patient may need the extra pressure forces of the supersupraglottic swallow. Radical neck dissection refers to a surgical procedure in which the lymphatic system in the neck is removed to eliminate any cancer cells that may have metastasized. In addition to the removal of the lymph nodes, the sternocleidomastoid muscle is cut. This may interfere with neck rotation. Many times the tongue is involved with these patients, especially the base of tongue anterior to the hyoid. Parts of the tongue may need to be resected. A glossectomy refers to the surgical excision of some portion or all of the tongue. The severity of the swallowing disability is related to the extent of lingual resection, the mobility of the residual tongue, the type of reconstruction, involvement of other structures, the patient's motivation and ability to adapt, and the skill of the rehabilitation team. 13 Typically, postoperative swallowing assessment is done when the healing is complete. The initial assessment includes observation of how the patient handles his or her own secretions; examination of the anatomy, function, sensory response of the oral and pharyngeal structures; check for cough and swallow reflexes; observe for overt signs of aspiration; and test the ability to swallow very small amounts of water and puree consistency. The swallowing assessment should be done before the removal of the nasogastric feeding tube. Swallowing treatment is done in conjunction with speech treatment. They are typically seen daily while in the hospital as well as on an outpatient basis after discharge. The specific exercise and the nature of the compensatory movements to be taught mUst be determined individually and based on the type of difficulty the person is experiencing, the anatomic configuration and mobility of residual tongue, and the oral and pharyngeal sensory status. TM Range of motion exercises should attempt to increase vertical and anteroposterior lingual movement and lateral and horizontal movement of the mandible. Tongue strengthening exercises focus on lateralization and elevation. Both the tip and the dorsum of the tongue should receive attention. Resistance to movement in those directions can imposed with gradually progressive firmness using a tongue depressor as a means of increasing strength. Compensatory postures can be taught for a variety of DYSPHAGIA EVALUATIONAND TREATMENT
asons. When the patient has limited anteroposterior ,ngue movement, tilting the head backward will be ~lpful in moving the bolus to the back of the mouth. then the impairment is unilateral, tilt the head to the imaged side. When less than 50% of the tongue has been :cised, and when there is some mobility remaining in the sidual tongue, exercises should be devised to encourage ngue to palate contact. The patient should practice in anipulating objects in the mouth. An ice chip is usual in ds exercise because it also provides the sensory feedback the patient and the thermal stimulation. Moving the ice tip in a rotary motion and laterally is useful. The size of .e object initially is large and gradually reduced in size hen function returns or improves. The ability to control ~e bolus into a cohesive bolus is also practiced. Food quiring chewing is introduced in small amounts and :adually increased. When more than 50% of the tongue is been resected or mobility is minimal, tongue exercise ill be of little value. The patient should be fitted with an traoral prosthesis. 15Jaw and mouth opening exercises are meficial. Cancers of the palate are observed in the upper alveolar :lge, the hard palate, or the soft palate. Surgical excision is ;ually the primary treatment. The effects of a palatectomy l speech a n d / o r swallowing varies from minimal to vere, and is highly dependent on the location of the mor and the extent of the excision. Tumors of the veolar ridge or the hard palate may result in leakage of od or fluids and difficulty chewing. Tumors of the soft date will affect the ability to swallow without return of od or fluid through the nose. Patients with alveolar ridge hard palate defects are usually fitted for an intraoral •osthesis before surgery, and the prosthesis is inserted at e time of surgery. Continued therapy for this population useful in improving the patient's ability to manage food ith the prosthesis without difficulty.
In the oral phase of the swallow, Parkinson patients exhibit a typical repetitive anterior to posterior rolling pattern in the lingual propulsion of the bolus. The bolus is held in a normal position when the swallow is begun. Then the tongue rolls the bolus posteriorly. The tongue back does not always lower to allow the bolus to pass into the pharynx and the bolus rolls forward. Some Parkinson patients exhibit a delay in the triggering of the swallow reflex, although typically not severe. Pharyngeal strength is often reduced resulting in residual in the valleculae and pryiform sinus after the swallow. This residual typically increases with each bolus. Incomplete laryngeal closure results in increased risk of aspiration, especially with thin liquids. More frequently the aspiration is that of the residual and happens after the swallow is completed. Therapy for this population includes thermal stimulation to improve the patients sensory awareness of the bolus and compensatory strategies to improve airway protection. Experience has shown that the chin tuck head position is most useful in the protection of the airway. Thermal stimulation/sensitization of the pharyngeal swallow is based on two types of research which intensify areas of the mouth containing sensory receptions which play a role in triggering of the swallow. Cold stimulus has been shown to be most effective in eliciting a swallow. The purpose then of thermal stimulation is to increase sensory awareness in the oral cavity prior to the swallow and to decrease any delay between the oral and pharyngeal swallow. The clinician uses a size 00 laryngeal mirror, dipped in a cup of ice and water, to rub the faudal arches four or five times in a rapid fashion. The patient is then asked to swallow saliva or a small amount of thickened cold liquid. This is done several times. 1 The result will be an increase in the timing of the initiation of the swallow reflex. TABLE 2. Swallowing Disturbances Problem
EUROLOGICAL POPULATION: ISORDERS AND TREATMENT
roke (cortical and brainstem) typically results in a deyed or absent swallow reflex. This results in aspiration ;fore the swallow. 16 Disrupted lingual movement is obrved, which decreases oral transit time and reduces oral •essure. Reduced laryngeal elevation and tongue base traction are also observed. This results in both aspiration :fore, during, and after the swallow. Criocophayrngeal /sfunction is noted secondary to reduced pressure within e pharynx, thus not allowing opening for the food to ~ss. Difficulty is also noted with noncortical and brain~m strokes. A hemiparesis or paralysis will impair the ltient's generalized strength of the swallow. If a paralysis present, the patient will have difficulty with lingual ovement, resulting in reduced bolus preparation and •opulsion of the bolus during oral transit. Reduced laryngeal muscles will result in increased residual on the fected side. Laryngeal elevation may be reduced as well. ~erapy should be initiated immediately to improve range motion of the tongue, adduction of the vocal folds, and imulation of the swallowing reflex. The pattern of recovy of normal swallowing in patients after cerebrovascular :cident is not well documented. However, typically 75% gain ability to maintain one's nutritional and hydration ;eds by mouth within the first 3 months after the :cident. 17 Patients with Parkinson's disease may exhibit a number swallowing disorders in all three stages of deglutition. /IANDA C. HEMBREE
Oral stage Reduced lip closure Reduced tongue elevation
Reduced tongue lateralization Anterior/posterior movement Reduced jaw movement Reduced oral awareness Triggering of the swallow Delayed/absent reflex
Therapy Technique Lip exercises Tongue exercises Food positioning Prosthesis Postural techniques (head tilt to stronger side or head tilt back) Prosthesis Tongue exercises Position of food Postural changes Jaw exercises Oral stimulation Thermal stimulation postural changes Tongue propulsion technique
Pharyngealstage Reducedtongue base
Effortful swallow, supraglottic swallow Tongue retraction exercises Unilateral weakness Postural change (head turn to affected side) Reduced pharyngealpressure Alternate between liquids and solids, multiple swallows Effortful swallow Reduced laryngeal elevation Supraglottic swallow pitch elevation exercises Reduced laryngeal closure Supersupraglottic swallow postural changes (chin tuck, head rotation) Supraglottic swallow Adduction exercises Teflon injection Cricopharyngeal dysfunction Postural changes Mendelsohn maneuver Dilation Myotomy
189
S w a l l o w i n g disturbances related to physiological disorers are specific to each task the a n a t o m y is required to 3replete (Table 2). D y s p h a g i a rehabilitation is usually best accomplished rith a t e a m of professionals, including the radiologist, the afient's m a n a g i n g physician, s p e e c h - l a n g u a g e patholoi s t / s w a l l o w i n g specialist, a n d the dietitian. The swallow~g therapist is the k e y to the success of the team. This ~dividuaI participates in the diagnosis of the patient's wallowing disorder a n d plans the a p p r o p r i a t e t h e r a p y trategies, in consultation w i t h t h e p a t i e n t ' s physician. The peech-language pathologist w o r k s w i t h the patient on pecific exercise p r o g r a m s for degtufition. Positive prognosc o u t c o m e for patients w i t h s w a l l o w i n g p r o b l e m s is ased on a p p r o p r i a t e evaluation of the particular p r o b l e m s well as on the a p p r o p r i a t e therapeutic techniques used. )ften techniques are c o m b i n e d for the patients w i t h mltiplicity of disorders affecting swallowing. The length f t h e r a p y is varied for each population. Follow-up is ssential for all patients.
|EFERENCES t. Logemann J: Evaluation and Treatment of Swallowing Disorders. Austin, TX, Pro-ed, 1993 Z. Miller A: The search for the central swallowing pathway: The quest for clarity. Dysphagia 8:185-194, 1993 3. Linden P, Kuhlemeier K, Patterson C: The probability of correctly predicting subglottic penetration from clinical observations. Dysphagia 9:170-179, 1993
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4. Zenner P, Losinski D, Mills RH: Using cervical auscultation in the clinical dysphagia examination in long-term care. Dysphagia 10:2731, 1995 5: Sasaki CT, Susuki M, Horiuchi M, et ah The effect of tracheostomy on the Iaryngeal ctosure reflex. Laryngoscope 87:1428-1433, 1977 6. Martin B, Sesle B: The role of the cerebral cortex in swallowing. Dysphagia 8:195-20Z 1993 7. Logemann J: Manual for the Videofluoroscopic Study of Swallowing. Austin, TX, Pro-ed, 1993 8. Schmidt J, Halas M, Halvorson K, Reding M: Videofluoroscopic evidence of aspiration predicts pneumonia and death but not dehydration following stroke. Dysphagia 9:7-21, I994 9.. Martin B, LogemamnJ, Shaker R, Dodds W: Normal laryngeal valving patterns during three breath-hold maneuvers: A pilot investigation. Dysphagia 8:11-20, 1993 10. Rastey A, Logemann J, Kah_rilas P, et ah Prevention of barium aspiration during videoftuoroscopic swallowing studies: Value of change in posture~AJR Am J Roentgenot 160:1005-1009, 1992 11. Kahrilas PJ, Logemann JA, Gibbons P: Food intake by maneuver: An extreme compensation for impaired swallow. Dysphagia 7:155-159, 1992 12. Logemann J, Pauloski BR, et al: Impact of the diagnostic procedure on outcome measures of swallowing rehabilitation in head and neck cancer patients. Dysphagia 7:I79-186, 1992 13. Casper JK, Colton RH: Clinical Manual for Laryngectomy and Head and Neck Cancer Rehabilitation. San Diego, CA, Singular Publishing, 1993 14. Logemann JA: Aspiration in head and neck surgical patients. Ann Otol Rhinol Laryngo194~373-376,1985 15. Muz J, Hamlet SL, Davis LP, et al: Objective assessment of swallowing f~ncfion in head and neck cancer patients. Head Neck t3:33-39, 1991 16. Johnson E, McKenzie S, Sievers A: Aspiration pneumonia in stroke. Arch Phys Med Rehabi174:973-976, 1993 17. Veis S, Logemamn J: The nature of swallowing disorders in CVA patients. Arch Phys Meal Rehabi166:372-375, I985
DYSPHAGIA EVALUATION AND TREATMENT