Dysphagia: Chapters 4-6 (head And Neck – Flashcards
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Why is it important to understand the relationship between dysphagia and head and neck cancer?
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Dysphagia is one of the most common (>60% of HNC patients) sequelae of HNC and its treatments.
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What is cancer?
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The result of cell growth that is out of control. This proliferation of cell growth is called hyperplasia.
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What is metastasis?
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Traveling of cells. It can occur when cancer cells enter the bloodstream or the lymph system and move to different parts of the body.
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What are some general cancer warning signs?
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unexplained weight loss, fever, fatigue, pain, and skin changes
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What are some specific cancer warning signs?
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white patches/spots in the mouth/tongue indigestion or difficulty swallowing (SLP notices) nagging cough or hoarseness (SLP notices) changes in bowel/bladder function sores that don't heal unusual bleeding/discharge thickening/lump in any part of the body recent changes in a wart/mole or any new skin changes
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What are symptoms of oral cancer?
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lump/thickening of cheek, white/red patch on gums or tongue
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What are symptoms of nasal and pharyngeal cancer?
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NONE early
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What are symptoms of supraglottic cancer?
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Painful swallow and globus-neck mass also present, but rarely noted early
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What are symptoms of glottic cancer?
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hoarseness, stridor, or airway obstruction
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What are symptoms of subglottic cancer?
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hoarseness, airway obstruction
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What are some salient (noticeable, important) characteristics of cancer related fatigue?
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Tired/weary/exhausted after sleep Lack of energy/interest for daily activities Trouble concentrating/thinking clearly/remembering Negative feelings/irritability/impatience/lack of motivation Less attention to appearance Spending more time lying in bed or sleeping
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What are some general consequences of malnutrition?
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Increased susceptibility to infection, reduced immunity Respiratory failure Poor wound healing Skin breakdown Death
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How are cancers staged?
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The TNM system and staging classifications (0-IV). The staging classifications equate to 5-year survival predictions post-treatment.
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Describe the TNM system.
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T = primary Tumor size and extension N = regional lymph Node spread M = presence of distant Metastasis
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Describe the staging classifications 0-IV.
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Stage 0-II describe cancers that are relatively small with no metastasis. Stage III describes larger cancers or cancers with some lymph spread. Stage IV describes more serious, widespread cancers, with IVC describing cancers with distant metastasis.
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What must be considered before determining a cancer treatment?
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Location Stage Patient's age Patient's general health Medical team experience Patient's post-treatment functioning Patient's post-treatment quality of life Will the treatment be palliative (pain relief, etc.) or curative?
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What are the most common treatments for head and neck cancers?
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Surgery, radiation, and chemotherapy
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Why/when choose surgery to treat cancer?
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When the cancer is small. To (ideally) remove primary tumor and leave no trace of cancer cells in the margin tissues.
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What are some examples of surgery to treat head and neck cancer?
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primary tumor surgery, mandibulectomy (remove), mandibulotomy (split), maxillectomy, mohs surgery (taking little bits out, used to look for free margins), laser surgery, total/partial laryngectomy, laryngopharyngectomy, tracheostomy, gastrostomy, neck dissection, reconstructive surgery (flaps, etc)
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Describe the 50% rule.
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This "rule" suggests that removal of <50% of a structure will not result in a significant and permanent swallowing problem. This may be outdated. Patient characteristics before and after surgery must be taken into account. In general, the more tissue removed or relocated, the more likely dysphagia will present. Additionally, more treatments (chemo, rad, surgery combinations) relate to more problems with swallowing.
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What are some possible side effects for surgery for head and neck cancer?
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Swelling of the mouth/throat resulting in difficulty breathing (may be painful) Impaired speech or voice Difficulty chewing or swallowing Facial DISFIGUREMENT NUMBNESS in the face, neck, or throat Reduced MOBILITY in the neck and shoulder area (due to scarring) Decreased FUNCTION OF THE THYROID gland If cranial nerve(s) is/are damaged, motor or sensory deficits
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What are some contraindications of surgical removal of tumors?
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possibility of significant deficits to function (like speaking, chewing, swallowing) cosmetic defects
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What is radiation therapy?
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Use of high-energy x-rays to kill cancer cells, leading to shrinkage of the tumor.
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Why/when choose radiation to treat cancer?
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As a primary treatment for small tumors, after surgery to destroy residual small pockets of cancer cells, or before surgery to shrink tumors (ideally results in more successful surgical removal and fewer residual deficits.
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What are some examples of radiation to treat head and neck cancer?
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External beam radiation: involves aiming a high-energy radiation beam at the tumor an surrounding tissues. Applied on a conventional, once-daily schedule (ex- Intensity Modulated RT) or an altered fractionation schedule (this one may increase acute toxicity). Uses >50 Gy Internal radiation: aka brachytherapy, implants of small pellets or rods containing radioactive material into or lean the cancer site. Uses up to 40 Gy
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What are some possible side effects for radiation for head and neck cancer?
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Redness an skin irritation in treated area Permanent change to salivary glands (xerostomia, thickened saliva) Bone pain Nausea, vomiting Fatigue Mouth sores and sore throat Dental problems Painful swallowing Loss of appetite Reduced or altered sense of taste (sometimes smell) Earaches from hardening of earwax Hypothyroidism Fibrosis leading to reduced movement Peripheral neuropathy Bone, cartilage, soft tissue necrosis
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What are some contraindications of radiation?
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Poor dental health Fatigue may be worsened by damage to the thyroid gland in certain treatments
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Discuss side effects of acute toxicity from radiation.
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They don't start immediately, most start 2-3 weeks into treatment. Typical radiation symptoms, included in acute toxicity, but weight loss of >10% is worrisome.
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Discuss later-occurring side effects of radiation.
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Mucosal fibrosis and atrophy Xerostomia Dental caries (cavities) Infections Loss of weight and appetite Depression/anxiety
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Discuss the most late-occurring side effects of radiation.
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Tissue necrosis (soft tissue and osteonecrosis) is at a greater lifetime risk Taste dysfunction (dysgeusia, ageusia) Dysphagia
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What is chemotherapy?
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The use of powerful drugs to kill cancer cells. May be administered by mouth, intravenously, injection into muscle, under the skin, or directly into the tumor.
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What is meant by "adjuvant" and "neoadjuvant"?
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Adjuvant refers to treatment that is given in addition to the primary treatment. Neoadjuvant refers to treatment given as a first step to shrink a tumor before the primary treatment.
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What are some possible side effects of chemotherapy?
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Fatigue Nausea, vomiting Hair loss Xerostomia Loss of appetite Reduced sense of taste Weakened immune system Diarrhea or constipation Open sores in the mouth potentially leading to infection
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What are the physiologic effects and swallowing problems that result from a partial glossectomy?
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PE: removes <50% of the tongue, anterior tissue removal difficulties S: patient has trouble holding and preparing the bolus
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What are the physiologic effects and swallowing problems that result from a total glossectomy?
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PE: removes >50% of the tongue, flap technique influences result S: patient has trouble moving materials from the oral cavity, they have reduced tongue driving force, and they may show reduced pharyngeal clearance
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What are the physiologic effects and swallowing problems that result from a tonsil/base of tongue (BOT) resection?
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PE: reduced anterior tongue range S: reduced tongue driving force, difficulty moving materials through the oropharynx, premature movement of liquids and delayed movement of solids, nasal regurgitation, reduced pharyngeal swallow and constriction
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What are the physiologic effects and swallowing problems that result from a palatal resection?
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PE: removes >50% of soft palate, incomplete velar seal S: Velar leak results in retrograde (directed/moving backward) movement of materials into the nasopharynx
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What are the physiologic effects and swallowing problems that result from an anterior floor of mouth (FOM) resection?
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PE: reduced anterior tongue range, unable to lateralize tongue, reduced ability to elevate hyoid or larynx, reduced opening of upper esophageal sphincter S: (if tongue is mobile, few problems with anterior floor of mouth resection) Reduced control of bolus, reduced tongue driving force, difficulty moving material through oropharynx, delayed triggering of pharyngeal swallow, reduced clearance of bolus from pharynx
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What are the physiologic effects and swallowing problems that result from a partial pharyngeal resection?
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PE: reduced pharyngeal wall constriction, reduced elevation of hyoid and larynx S: Difficulty clearning materials from the pharynx, delay triggering swallow
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What are the physiologic effects and swallowing problems that result from a hemilaryngectomy?
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PE: Unilateral resection, partial airway closure S: Unilateral pharyngeal weakness, reduced airway protection
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What are the physiologic effects and swallowing problems that result from a supraglottic laryngectomy?
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PE: Incomplete posterior tongue movement, restricted arytenoids motion, partial airway closure S: Delay in bolus propulsion, difficulty with elevation of structures for swallow, reduced airway protection
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What are the physiologic effects and swallowing problems that result from a total laryngectomy?
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PE: Removal of vibratory source, alternative source surgically developed S: Issues with reduced negative pressure, bolus transit, Anatomic/physiologic stenosis of PES possible
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What are some of the main issues resulting from a total laryngectomy?
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Scarring - pseudoepiglottis at BOT (pull apart pouch) Anatomic stenosis - strictures, webs, fistulas in PES area Reduced propulsion force PES dysfunction Often poor esophageal motility (may be related to lifestyle issues)
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What is motility?
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Motility describes the contraction of the muscles that mix and propel contents in the gastrointestinal (GI) tract.
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What are examples of and what is done to treat anatomic stenosis?
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Ex: strictures, webs, and fistulas Tx: Dilation
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What is done to treat physiologic stenosis?
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Botox may be one treatment. Dilation will NOT help.
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What are dysphagia-contributing potential complications and side effects of radiation therapy?
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Mucositis Xerostomia Sensory changes (taste, smell) Fibrosis (including trismus) Neuropathy Changed anatomy (e.g. stricture) Odynophagia (painful swallow) Loss of appetite Edema Infection (fungal, bacterial) Dental changes
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What are some characteristics of dysphagia associated with radiation therapy? (KNOW THIS)
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Dry mouth Bolus control deficits Altered taste Pain Smaller bolus, multiple swallow attempts Less frequent swallowing Longer meal times
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Discuss the effect of radiation therapy on teeth.
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Poor dental health prior to radiation can cause serious infections resulting in death if the teeth are not removed prior to radiation. Oral health suffers during and after radiation, so dental health must be monitored due to a dry, acidic oral cavity, etc.
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What is mucositis?
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Painful inflammation and ulceration of the mucous membranes lining the digestive tract.
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What does an SLP do as a member of the Tumor Board?
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Ax speech/language/swallowing Management of speech/language/swallowing pre-during-post Provide patient ed and counseling Follow-up
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When should the SLP begin assessment?
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At the time of Dx!
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What are some later dysphagia-related problems after radiation therapy?
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Mechanical obstruction Secretion management Xerostomia Stricture Trismus Fibrosis Malnutrition Osteodionecrosis Soft tissue necrosis Dental caries/cavities
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What is a stricture?
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It is a narrowing or tightening of a structure
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What is trismus?
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Reduced ability to open the mouth secondary to tonic contraction of the muscles
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What is fibrosis?
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An abnormal replacement of fibrotic tissue (as in scarring) often resulting in a change of function of that tissue
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In general, what can a clinician expect from a patient after radiation?
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Reduced swallowing efficiency Less movement of structures Prolonged transit times Reduced CP opening Incomplete clearance Nutritional decline
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What should be considered during a dysphagia Ax?
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clinical and instrumental assessment Assess impact factors (pain, dryness, taste/smell, nutrition, psychological issues, complaints) Gather clinical Hx Mouth and dentition Oral motor (tongue, jaw, opening, velum, lip, intelligibility, cough, management of secretions) Condition of neck musculature Voice Swallowing QOL
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How can we measure nutritional health?
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BMI, MNA (mini nutritional assessment), 3-day diet record
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What is cervical auscultation?
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The use of a stethoscope to assess swallow sounds and airway sounds. Judgments are then made on the normality or degree of impairment of the sounds.
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Name some scales than can be used to assess swallowing and related difficulties.
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University of Washington HRQOL, WHO Mucositis Scale, University of Michigan Xerostomia Scale, Therabite range of motion scale. PRO (patient reported outcome), VAS (visual analog scale), MDADI, MDASI, SSQ
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Describe the University of Washington's HRQOL scale related to swallowing.
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Higher numbers indicate greater problems. The HRQOL measures general pain, mouth pain, throat pain, disfigurement, activity level, limits to recreation, chewing, swallowing, amount of saliva, consistency of saliva, taste, speech changes, amount and consistency of mucus/phlegm
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Describe WHO Mucositis Scale.
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1-4 scale of severity
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Describe University of Michigan Xerostomia Scale.
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8 question questionnaire from 1-10
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Describe Therabite range of motion scale.
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how far can jaw open vertically? trismus?
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Describe PRO (patient reported outcome).
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Any report of the status of a patient's health condition that comes directly from the patient
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Describe VAS (visual analog scale).
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like the Wong 10-point scale
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Describe MDADI.
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Describes cancer symptoms related to dysphagia
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Describe MDASI.
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Describes cancer symptoms
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Describe SSQ.
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17 question questionnaire, mark on a line.
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What are some common interventions for mucosal changes resulting from RT?
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Salivary supplements Water Analgesics Ice chips Mouthwash Gels Prescription medications Mechanical cleansing
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What are some common interventions for muscle changes resulting from RT?
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Cold (including ice chips) Stretching activities Various exercises
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What are some common interventions for mucositis?
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Bland rinses Mucosal coating agents Lubricating agents Topical anesthetics Cellulose film-forming agents to cover localized ulcerative lesions Low Level Laser to improve salivary flow Honey
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What is the SLP's role in Tx of swallowing?
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Counseling for potential deficits and side effects, demonstration and training of assistive devices, provide follow-up mechanisms
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What are the primary remediation issues of patients with HNC?
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Dysphonia, dysarthria, dysphagia, dysgusia/dysosmia, nutrition impairment, psychological
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What are treatment strategies in the acute stages?
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address side effects, keep eating as long as possible, exercise, temporary alternative source (doctor ultimately decides), active therapy (pharyngocise)
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What are treatment strategies after Tx?
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reinitiate and expand oral feeding
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What are treatment strategies in later stages?
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Figure out what's left and what's (not) moving FUNCTION of structures is key, what are they doing? No magic treatment, just hard work Know when to quit Are the problems new? Have previous problems increased? Treat the underlying problem and the symptom as well MULTIDISCIPLINARY APPROACH
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Know how CN 10 related to latent effects of treatment.
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Vagus nerve lesions produce palatal and pharyngeal paralysis; laryngeal paralysis; and abnormalities of esophageal motility, gastric acid secretion, gallbladder emptying, and heart rate; and other autonomic dysfunction.
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Know how CN 12 relates to latent effects of treatment.
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Formation of a bolus, oral stages of swallowing.
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What can cause or contribute to esophagitis? (differential Dx)
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Gastroesophageal reflux Infections (candida, viral) Trauma (prolonged nasogastric intubation) Acute chemical ingestion (lye, industrial acids) Drug induced esophagitis Radiation Skin conditions Others (like Crohn's disease, Behcet's syndrome)
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Describe the esophagus.
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A distensible (stretchable) 21-27cm tube. It extends from the pharynx to the stomach and is collapsed at rest. Proximal=striated (voluntary), distal=smooth (involuntary). Middle 3rd=mixed muscles (transition zone). There are 2 muscular levels, inner=circular, outer=longitudinal.
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How is the proximal esophagus innervated?
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RLN & sympathetic plexus
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How is the distal esophagus innervated?
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autonomic input
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Describe the esophageal stage of swallowing.
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Relies on peristalsis of sequentially timed medullary discharges that move the bolus through the esophagus.
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What is peristalsis?
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Orderly ring-like contractions that push material through the esophagus.
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Describe the differences between primary and secondary peristalsis and tertiary contractions.
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Primary peristalsis is initiated when the bolus enters the esophagus. Secondary peristalsis is initiated by bolus distention of esophagus at a specific location. Tertiary contractions are NOT ORDERLY and may disrupt bolus transit.
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What is a CP bar (cricopharyngeal bar)?
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A cricopharyngeal bar is a radiologic descriptor of a posterior impression at the pharyngoesophageal segment. The cricopharyngeal bar is a frequent incidental radiologic finding, which in many cases does not cause symptoms.
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What is a diffuse esophageal spasm?
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a condition characterized by uncoordinated contractions of the esophagus. (peristalsis disorder)
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What are some esophageal dysphagia disorder classifications?
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Structural, motility, LES abnormalities, PES disorders
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Describe anatomic stenosis and causes, assessment, and treatment.
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Difficulty with solid foods (esp. tough and fibrous). Liquid issues come from impaction of solid bolus. INACCURATELY LOCALIZED TO THE NECK. Some stenosis is never problematic (18mm) but 12mm or less always symptomatic. Caused by mucosal rings, benign strictures, and malignant tumors. Ax: radiopaque pill swallow (marshmallow) Tx: Dilation (ex balloon dilation)
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Describe stenosis rings and webs' causes, assessment, and treatment.
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Rings and webs are bands of mucosal and submucosal tissue. Rings are at the GE junction (ex. Schatzki ring most common) and webs are everywhere else. Webs near/in PES are usually asymptomatic. Assessment - imaging. Treatment: may be dilation for Schatzki.
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Describe Schatzki's rings
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Most common rings. Band-like constrictions ALWAYS assoc with hiatal hernia (but hiatal hernias are not always associated with Schatzki's rings) with unknown cause, typically happening at midlife. Intermittent solid food dysphagia. Tx - dilation
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What is a hiatal hernia?
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A hernia of the stomach past the diaphragm.
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Describe stenosis benign strictures and causes, assessment, and treatment.
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May be secondary to esophagitis like GERD but the patient may not hve GERD symptoms. Infections, drugs (that dissolve in the esophagus), trauma PROGRESSIVE solid food complaints. Tx - target both esophagitis and dilation/redilation
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How does a stricture affect esophageal swallowing?
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It can stop food from reaching the stomach. It can cause choking.
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Describe stenosis malignant strictures and causes, assessment, and treatment.
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Difficulty with solid foods and liquids, liquid problems NOT progressive. Tx - esophagectomy with potential for oropharyngeal dysphagia. 5 year survival 5%. Palliative stenting may be offered especially in tracheoesophageal fistulas (TEF).
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How are esophageal cancers managed surgically?
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Esophagectomy and gastric pullup, PEG insertion.
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Describe lumen.
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the inside space of a tubular structure.
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Describe luminal deformity due to extrinsic compression and causes, assessment, and treatment.
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Aortic aneurysm, cardiomegaly, lung cancer This is rarely symptomatic due to the elasticity of the contralateral esophageal wall, but when it is, Tx targets removal of or reduction of the external mass (limited options). Reduces bolus flow.
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What is dysphagia lusoria?
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abnormal condition characterized by difficulty in swallowing caused by aberrant right subclavian artery
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What is a diverticulum?
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It is an outpouching of a tubular organ. Small, usually asymptomatic. A consequence of an obstruction distal (below) the region of the bolus Symptoms include: liquids and solids problems, regurgitation of swallowed food into the mouth. Only treat them (myotomy or dilation) when symptomatic.
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How are pulsion diverticula and Zenker's diverticula different?
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Pulsion diverticula are caused by problems in the driving force of bolus movement (high intraluminal pressures) causing a hernia in weak areas of mucosal tissue.
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Describe disorders of peristalsis and causes, assessment, and treatment.
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Too much or too little contraction amplitude, prolonged contrations, and/or uncoordinated contraction patterns. Can be diffuse esophageal spams (high pressure, incomplete relaxation) and nutcracker esophagus (high manometry amplitudes, chest pain, normal esophagram). Tx - limited benefit, medications, food mod, can treat GERD or structural obstruction.
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Describe achalasia and causes, assessment, and treatment.
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Achalasia is a LES abnormality, failure to relax. Regurgitation hours after eating, aperistalsis comes secondarily. Tx usually successful, calcium channel blockers to relax smooth muscle, dilation, surgery, botox.
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Describe motor weakness and causes, assessment, and treatment.
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Scleroderma=loss of contraction, low LES pressure, severe GER, poor clearance, inflammation, strictures. Effect of diabetes, alcohol abuse, medication (delays gastric emptying) Tx - adjust meds Slowed transit, GER, poor clearance, etc.
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Is reflux always bad?
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No, happens normally and is immediately cleared.
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Describe GERD and it's relationship to esophageal dysphagia, causes, assessment, and treatment.
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Frequent LES relaxations and refluxate stays. heartburn. Negative QOL. Related to lots of other conditions. May cause: dysmotility, esophagitis, globus sensation. Ax - 24 pH probe, about 4.0 is normal. EGD (esophagogastroduodenoscopy) under sedation to see consequences of chronic GERD, transnasal esophagoscopy doesn't need sedation, manometry causes structural disorders, reduces bolus flow Tx - Enhance anti-reflux barrier, improve clearance and emptying, use lifestyle changes, medicatoin, and surgery.
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Describe laryngopharyngeal reflux and causes, assessment, and treatment.
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Reflux reaches laryngeal level. globus, voice complaints, chronic cough, soreness, halitosis, taste disorders. Ax nasopharyngeal probe, RSI, RFS.
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How are GERD and LPR different?
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GERD - nighttime most problems, low dose meds, stomach LPR - daytime most problems, higher dose meds, laryngeal level
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Describe and differentiate clinical tools for assessment of reflux, including the reflux symptom index (RSI) and the reflux finding score (RFS).
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Both are used as clinical tools for laryngophryngeal reflux. The RSI can be completed by the individual. It uses a Likert scale to measure problems with voice, throat clearing, coughing, sensations, and more. If the composite score is greater than 10, an evaluation should be used to test for Silent Gastroesophageal Reflux Disease or GERD. The RFS is an 8-item clinical severity scale based on findings during fiberoptic laryngoscopy. The scale ranges from 0 (no abnormal findings) to a maximum of 26 (worst score possible). The 8 items include subglottic edema, ventricular obliteration, erythema/hyperemia, vocal fold edema, diffuse laryngeal edema, posterior commissure hypertrophy, granuloma/granulation tissue, and excessive endolaryngeal mucus.
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Describe PES abnormalities and causes, assessment, and treatment.
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Caused by webs, CP bars, diverticula, and weakness.
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What is a Zenker's diverticulum?
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Zenker's diverticula are an abnormal pouch in the upper part of the esophagus in which food may become trapped causing bad breath, irritation, difficulty in swallowing, and regurgitation
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How do the pharynx and esophagus interact during a swallow?
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Secondary swallow attempts can interrupt primary peristaltic wave, residue on the esophagus is often reported by patients as being located in the pharynx
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Why might someone complain about food sticking in their throat if they actually have an esophageal swallowing dysfunction?
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Sensory output of the vagus nerve.
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Name some imaging (may not be imaging but visual representations of muscular contractions).
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Manometric Tracing or Primary Esophageal Peristalsis, High Resolution Manometry.
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We suspect esophageal dysphagia, and the patient presents with intermittent difficulties with solid foods only. What is a likely problem?
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Rings or webs
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We suspect esophageal dysphagia, and the patient presents with progressive difficulties with solid foods only. What is a likely problem?
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If they also have heartburn, it may be a peptic stricture. If they don't have heartburn, it may be carcinoma.
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We suspect esophageal dysphagia, and the patient presents with intermittent difficulties with solid foods and liquids. What is a likely problem?
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If they also have chest pain, they may be experiencing a diffuse spasm (peristalsis disorder).
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We suspect esophageal dysphagia, and the patient presents with progressive difficulties with solid foods and liquids. What is a likely problem?
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If they also have heartburn, it may be a progressive systemic sclerosis. If they don't have heartburn, but do have nocturnal SX, it may be achalasia.
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How are breathing and swallowing related?
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medulla oblongata controls, swallow coordination and airway protection. deficits affect the other
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How do airway treatments cause dysphagia?
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Intubation, respiratory support, tracheostomy, xerostomia related to oxygen support.
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List examples of artificial airways.
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endotracheal tubes, tracheostomy tubes, facial masks (CPAP, BPAP), nasal cannulas, mechanical ventilation
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Describe endotracheal tubes and problems that are associated with them.
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temporary, reduced laryngeal sensation, prolonged=complications like VF problems and pneumonia, multiple? do tracheostomy
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Describe tracheostomy tubes and problems that are associated with them.
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temp or perm, can permit speech, usually supports swallowing, larger=more problematic
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Why use a cuff?
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For adequate ventilation, NOT prandial aspiration protection.
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What is the best tracheostomy tube for speech?
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small, NON-CUFFED, fenestrated tube
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Describe complications of a tracheostomy.
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reduced smelling ability, infections, more secretions, rare fistulas, more aspiration (loss of sublottic pressure, poor laryngeal elevation, less sensitive airway, etc may cause this)
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Describe the relationship and confounding factors related to trachs and aspiration.
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loss of sublottic pressure, poor laryngeal elevation, less sensitive airway, etc, sicker patients, known respiratory disorders. trach may not be the CAUSE of aspiration.
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Describe trachs and laryngeal elevation.
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could be restricted
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Why should you work toward decannulation (removal) of a trach?
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It may help improve the swallow function. Smaller trachs may have better speech outcomes and give more sensation back.
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Describe trach occlusion.
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Maintains normal pressure. DEFLATE THE CUFF. Using a valve improves speech, reduces secretions, restores smell, improves coughing ability.
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What must be considered during an airway evaluation?
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cuff status, voicing, trach size and type, ability to cough, ventilator, # and time with intubations, PO2 saturation, swallows impact on respiration. Instruments: blue dye testing, endoscopy, SPO2, heart/breathing rates.
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How do you manage/treat a patient with a trach?
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No definitive swallow guidelines, know their med, neuro, and surgical history, Assess for outcome, occlude and check, compensate and check. Have they been medically compromised (long stay, chronic conditions, stability, strength, nutrition), patient issues.
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Describe the tracheostomy weaning protocol.
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No signif. aspiration risk, minimum 1 hour speaking valve, then increase
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What is iatrogenic dysphagia?
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secondary to med or surgical intervention. lots of head/neck surgeries could have edema and cranial nerve 9, 10, and 12 involvement.
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Describe anterior cervical fusion.
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stabilizes cervical spine. denervation from irritation to the pharyngeal plexus. irritation of RLN, loss of strength. most recover! Edema? delay?
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Describe osteophytes.
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Mechanical obstruction of the swallow. common when older, usually asymptomatic, >10mm aspiration, @ C3 and C6 most commonly symptomatic.
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Describe esophagectomy.
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from cancer. anastomotic fistula, potential for vocal fold immpbility. smaller meals, some anorexia.
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Describe skull-base surgeries.
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from cancer, mostly. acoustic neuroma, pituitary tumors. affects swallowing and speech and respiration.
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Describe head and neck trauma.
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injuries to the face, mouth, and throat. common dental issues, thermal burn injury (direct or inhalation) affects breathing and musocal tissue. sedated? alert? brain injury? medication use?
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Describe the effects of medications that affect cognition and motor function.
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Antipsychotics: motor, arousal. long term use - dyskinesias, oral prep/initiation probs CNS depressants: less striated muscle activity Antispasmodics: relaxes but weakens spastic muscles
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Describe the effects of medications that affect the GI system.
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Might inhibit smooth muscle activity (alcohol, antidepressants), poor gastric emptying Might lower LES pressures (respiratory disease drugs, some foods)
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What are problems that can be expected from medication use?
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Some can stick in esophagus and dissolve to cause erosion. Some cause problems. look for possible Rx to contribute.
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Describe COPD and the effects on swallowing.
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Chronic lung diseases that can limit airflow. Emphysema, chronic bronchitis, asthma, systic fibrosis. Airflow limitations, hyperinflation, failure to exhale CO2. Clinically complex for dysphagia. Ineffective/absent cough. Endurance issues, slow eating, frequent breaks. GERD may contribute and be related (COPD drugs affect LES)
