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Assessment And Management of Oro-Pharyngeal Dysphagia

SamiaSamia BassiounyBassiouny, M.D., M.D.Professor of Professor of PhoniatricsPhoniatrics

E. N.T. DepartmentE. N.T. DepartmentppAinAin Shams University, Shams University,

Cairo, EgyptCairo, Egypt

Swallowing is the successful passage of food and drinks from the mouth to the stomach.

Phases of swallowingg

1- Oral phase:

a- oral preparatory phase.

b- oral voluntary phase.

2- Pharyngeal phase.

3- Esophageal phase.

Justice, L. M. (2006): Communication sciences and disorders: An introduction. New Jersey: Pearson Education.

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:Oral preparatory phaseconsists of manipulation of food and its mastication. It necessitates: - Good lip closure.- Optimal tone of buccal musculature to prevent

falling into sulci.- Rotatory action of the tongue and the mandible for

chewing.Palatolingual seal to prevent vallecular spill over- Palatolingual seal to prevent vallecular spill-over.

Oral voluntary phase:

It’s a mechanical stage; entails propulsion of the food backwards by the tongue until the head of the bolusbackwards by the tongue until the head of the bolus reaches the faucial pillars and the tongue base triggering the pharyngeal swallow (involuntary reflexive swallow).

O l i i 1Oral transit time <1sec.

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Pharyngeal phase (swallow reflex)=involuntary stage of swallow:

- V-p closure to prevent nasal reflux.- Laryngeal elevation and forward movement of the y g

hyoid bone (2cm). - Laryngeal closure to prevent the penetration of

food into the laryngeal inlet.- Pharyngeal peristalsis to propel the bolus clearing

any residue.- Cricopharyngeal opening (UES) allowing theCricopharyngeal opening (UES) allowing the

bolus to move into the esophagus.

Pharyngeal transit time: ½- 1 sec.

- Studies the anatomy and the physiology of oral and pharyngealphases of swallowing.

- Triggering of the swallowing reflex in relation to the position ofthe bolus

Videofluoroscopy (Modified Barium Swallow or Cookie swallow)

the bolus.- All motor aspects of swallow in both lateral and AP views:

movements of the larynx, hyoid bone, tongue base, pharyngealwalls and the cricopharyngeal region.

- Assesses the transit times, speed and efficiency of bolusmovements.

- Identification of residue (amount, place), penetration andaspiration.

- Assesses the symmetry of bolus movement (AP view).

Kuo, P., Holloway, R. H. and Nguyen, N. Q. (2012): Current and future techniques in the evaluation of dysphagia. J Gastroenterol Hepatol, 27(5):873-81.

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Modified Barium Swallow [Cookie swallow]

- Defines management strategies that will improve thedysphagic patient’s swallowing safety or efficiency

Logemann, J. (1993): A Manual for Videofluoroscopic Evaluation ofSwallowing, ed 2. Austin, Pro-Ed.

Equipment for VideofluoroscopyTable, Fluoroscopy tube, Monitor

&Control room.

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Food presentationThe patient is asked to swallow three swallows of

each of the following :

(a)3 ml, 5 and 10 ml thin liquid (20% barium sulfate[prontobario H.D.®] and 80% water);

(b) 3, 5, and 10 ml thick liquid (50% barium and50% water);

(c) 3, 5, 10 ml semisolid (pudding mixed withbarium powder) and

(d) ¼ of a cookie (coated with pudding + bariumpowder)

Abou-Elsaad, T. (2002) : Effect of diet variables on the biomechanical measures of swallowing in strokepatients. A paper presented at 17th world congress of the IFOS, 28th Sept.-3rd Oct ., Cairo , Egypt.

Normal lateral radiographic view of the oropharynx taken from a modified

barium swallow procedure.

Palate Epiglottis

Laryngeal inlet

Valleculla

Hyoid bone

Vocal Folds

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Dysphagia

• Breakdown in any of the phases of normal swallowing dysphagia.

• Breakdown in any of the sensory or motor events which comprise the oral preparatory,

l d h l f ll ioral and pharyngeal stages of swallowing.

Causes of Oro-pharyngeal dysphagia

(1) Neurologic, neuromuscular and muscular.

(2) Head and neck tumours and malignancies (primary, surgical resection (degree and extent)and reconstruction.

(3) Anatomic abnormalities (fibrosis (radiation) ,tracheostomy).

(4) Systemic

(5) Pharmacologic

(6) Psychogenic.

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Subtotal laryngectomy: reduced sensations at oro-pharyngeal isthmus.

Partial glossectomy: reduced deep sensations at tongue base, reduced propulsive power of the tongue. Delayed triggering of the swallowing reflex. residue aspiration before swallow.

* Glossectomy combined with mandible resection can impair laryngeal elevationand cricopharyngeal opening.

* Simental and Carrau (2004): Irradiated patients have reduced oral and pharyngeal functions including longer oral transit times, increased pharyngeal residue, and reduced cricopharyngeal opening timesreduced cricopharyngeal opening times.

* Logemann et al.(2003): Chemotherapy for head and neck cancer can cause mucositis (40%), pain, oral bleeding and ulcers.

Assessment

• (1) define the nature of the anatomic or physiologic dysfunction(s) in the oral cavity or

Aim of the assessment:

physiologic dysfunction(s) in the oral cavity or pharynx which is (are) causing the patient’s swallowing difficulty;

• (2) examine the effectiveness of selected treatment strategies, and

• (3) enable development of a treatment plan In• (3) enable development of a treatment plan. In order to prevent aspiration and pneumonia/ malnutrition and dehydration.

Palmer, J.; DuChane, A. and Donner, M. (1991): The role of radiology in the rehabilitation of swallowing. In B. Jones and M. W. Donner (Eds.), Normal and abnormal swallowing: Imaging in diagnosis and therapy (pp. 214-225). New York: Springer.

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Protocol of assessment

I- Elementary diagnostic procedures.

II- Clinical diagnostic aids.

III- Additional instrumental measures.

Protocol of assessment (Cont.)

I- Elementary diagnostic procedures:-Bed side clinical assessment:

1- Patient’s interview: complaint analysis, history of thepresent illness.

2- Auditory Perceptual Assessment (APA) of languageand speech.

3- Clinical examination: general examination, vocal tractexamination, neck examination, neurological examinationand observation during trial feeding.

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• Value : good indicator of oral, pharyngeal and laryngeal anatomy sensory or motor functionslaryngeal anatomy, sensory or motor functions.

• Behavioral, language and cognitive functions.

• Trial feeding if deemed safe for the patient.

• Disadvantage: inability to visualize the larynx and pharynx.

Protocol of assessment (Cont.)

II Cli i l di ti idII- Clinical diagnostic aids:-

1- Videofluoroscopy (Modified Barium Swallow).

2-Videoendoscopy (Fiberoptic endoscopic

evaluation of swallowing (FEES).

3- Formal testing of speech, language, and cognitive

abilities.

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• A fiberoptic endoscopic evaluation of swallowingA fiberoptic endoscopic evaluation of swallowing(FEES) : to assess the pattern of disordered swallowing indysphagia. It involves passing a nasendoscope into theoropharynx where anatomical structures can be directlyvisualised. The swallowing mechanism can be studiedwhen the patient ingests a small volume of a coloured meal(Singh and Hamdy, 2006).( g y )

Clinical findings revealed endoscopicallyg p y

Airway closure achieved by true vocal folds (TVFs) adduction, false vocal folds adduction, arytenoids medial and anterior movement.

Mobility of arytenoids.

Amount and location of secretions.

Frequency of spontaneous swallowing.

Aspiration before and after the swallow.

Coordination of bolus flow and airway protection.

Coordination of breathing and swallowing.

Ability to sustain adduction of TVFs for several seconds.

Effectiveness of postural change to alter anatomy and path of bolus flow.

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•View with fibreoptic endoscopic evaluation of swallowing. (1) Route to oesophagus; (2) trachea; (3) vocal folds; (4) aryepiglottic folds; (5) epiglottis; (6) fluid with green dye.

Singh, S. and Hamdy, S.(2006): Dysphagia in stroke patients. Postgrad Med, 82(968): 383–391.

38 years old female patient, CPA glioma

Delayed triggering of the pharyngeal response

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16 years old female patient, post CVA

Premature spillage, delayed triggering of the reflex, residue in valleculae and pyriform sinus.

58 years old male patient (bulbar dysarthria) , residue in valleculae remaining after semisolid swallow. Cookie swallow with premature spillage, delayed triggering of the reflex, with peace-meal deglutition and multiple dry swallows.

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52 years old female patient, CVA . Residue in pyriform fossae with absent swallow reflex

54 years old male patient, post-supracricoid laryngectomy Aspiration during swallowing

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eg. 1. Massive aspiration after VPL + intact cough reflex

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62 years old male patient, total laryngectomy, tracheostomy, misplaced speech valve

52 years old male patient, base of the tongue squamous cell carcinoma, partial laryngectomy, aspiration for thin and thick liquids.

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57 years old male patient, post brain stem infarctionOral and pharyngeal phases disorders

9 years old male child, post-removal of brain astrocytoma Absent pharyngeal reflex, and cricopharyngeal dysfunction with aspiration post-swallow

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43 years old male patient, post CVA, bulbar dysarthria

Aspiration during cup drinking (thin)

28 years old male patient, bulbar dysarthria

Severe residue in valleculae and pyriform sinus with cricopharyngeal dysfunction

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A-P view.

56 years old male patient, Stroke. Unilateral pharyngeal weakness. Residue in valleculae and pyriform sinuses.

Once the nature of the anatomical/physiological breakdown has beenidentified the clinician shouldintroduce treatment strategies duringthe radiographic study in order toobtain a direct evidence of the efficacyof these interventions.

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I- Compensatory strategies:

• Postural techniques:• Postural techniques:Introduced first; quick and have a significant impact on the safety and efficiency of the swallow.Systematically change the dimensions of the

h di ti f f d fl ith tpharynx, direction of food flow without increasing patient’s effort during the swallow.

Rationale for posture effectiveness

Posture applied if aspiration occurs

Disorder observed in fluoroscopy

Utilizes gravity to clear oral cavity

Head backInefficient oral transit (reduced posterior propulsion of bolus by tongue)tongue)

Narrows airway entrance, reducing risk of aspiration; widens valleculae to prevent bolus entering airway

Chin downDelay in triggering the pharyngeal swallow

Pushes tongue base Chin downReduced posterior motion gbackward toward pharyngeal wall

pof tongue base (residue in valleculae)

Places extrinsic pressure on thyroid cartilage, increasing adduction

Head rotated to damaged side

Unilateral laryngeal dysfunction (aspiration during the swallow)

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Rationale for posture effectiveness

Posture applied if aspiration occurs

Disorder observed in fluoroscopy

Puts epiglottis in more protective position; narrows laryngeal entrance;

Increases vocal fold closure by applying extrinsic pressure

Chin down

Head rotated to damaged side

Reduced laryngeal closure (aspiration during swallow)

Eliminates damaged side of pharynx from bolus path

Head rotated to damaged side

Unilateral pharyngeal paresis (residue on one side of pharynx)

Directs bolus down stronger side by gravity

Head tilt to stronger side

Unilateral oral and pharyngeal weakness on the same side (residue in mouth and pharynx on same side)

Eliminates gravitational effect onLying down on oneReduced bilateral pharyngeal Eliminates gravitational effect on pharyngeal residue

Lying down on one side

Reduced bilateral pharyngeal contraction (residue spread throughout pharynx)

Pulls cricoid cartilage away from posterior ph. Wall, reducing resting pressure in cricopharyngeal sphincter

Head rotationCricopharyngeal dysfunction

Logemann, J (1995): Dysphagia: Evaluation and Treatment. Folia Phoniatr Logop;47:140-164

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Aspiration decreased with head rotation to operated side + chin lowering down position + effortful swallowing

Video_1350281064.wmvVideo_1350281064.wmv

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Head forward position

• Sensory enhancement techniques ( to increase sensory input):Indications: Delayed triggering of the pharyngeal swallowIndications: Delayed triggering of the pharyngeal swallow. Due to impaired propulsive power of the tongue, reduced superficial sensations at oro-pharyngeal isthmus (partial laryngectomy), and reduced deep sensations at tongue base (resection).- Sour bolus- Cold bolus- Increase pressure of the spoon- Increase pressure of the spoon- Allowing self feeding- Exaggerated suck-swallow (poor saliva control as oral cavity tumours)- Thermo tactile stimulation

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Thermal stimulation

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• Modifications in the manner of feeding :

Indicated in delay triggering and weak pharyngealIndicated in delay triggering, and weak pharyngeal

swallow that require 2-3 dry swallows.

The amount of food

The time between swallows

Reduction of visual and auditory distractionsReduction of visual and auditory distractions.

• Diet Modification (consistency/viscosity)• Diet Modification (consistency/viscosity)

• Maxillo - facial prosthetic intervention :

- Palatal lift prosthesis

P l t l bt t- Palatal obturators

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II- Swallowing therapy procedures:

• Indirect swallowing therapy (no food)• Indirect swallowing therapy (no food)

• Direct swallowing therapy (with food)

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Swallowing maneuvers:

- Supraglottic: Deep breath, hold your breath, swallow, h ll d i d t l l f ld b f dcough, swallow. designed to close vocal folds before and

during swallowing.Zuydam et al.(2000) found that chin down and supraglottic swallow were effective in 50% of the patients who aspirated after resection of the oropharynx including the base of the tongue.

- Supersupraglottic: Effortful breath holding, tilts arytenoids forward closing airway before and during swallowingforward closing airway before and during swallowing, elevates the larynx. Used in decreased closure of the airway.

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- Effortful swallow: Swallow hard. Increases posterior motion of tongue base so improves residue clearance from th ll l U d i d d t i t fthe valleculae. Used in reduced posterior movement of tongue base.

- Mandelsohn maneuver: It increases the extent and duration of laryngeal elevation increase the duration of crico- pharyngeal opening.

III- Surgical management:

• Laryngeal suspensionLaryngeal suspension

• Crico- pharyngeal myotomy or dilatation

• Dilatation of the pharynx

• Vocal fold augmentation or medialization

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IV- Alternative routes of elimination:

NG tube- NG tube- Gastrostomy- I.V line

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