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Dysphagia Symptoms & Treatment

Patient
 presents
 with
 SEVERITY
 
 TYPE
 dysphagia
 characterized
 by
 UNDERLYING
 CAUSE
 resulting
 in
 WHAT
 I
 SEE.
 

Swallow
 Initiation
 (watch
 for
 hyoid
 movement)
 should
 be
 triggered
 when
 bolus
 head
 is
 rolling
 off
 back
 of
 tongue
 (LIQUIDS)
 or
 at
 vallecula
 (SOLIDS)
 

ORAL
 STAGE
  Underlying
 cause
  What
 I
 see:
  Try
 to
 compensate
 during
 meals
 with…
 
Anterior
 loss
 of
 bolus
 
 
Weak/incomplete
 lips
 closure
 
Tongue
 thrust
  Bolus
 poorly
 chewed
 
 

Weak
 jaw
 movement
  Residue
 collection/oral
 stasis
 in
  Head
 tilt
 
 strong
 side
 
Decreased
 rotary
 movement
 (munching)
  lateral
 sulcus
 (pocketing)
  Lingual
 sweep
 (w/finger
 prn)
 
Decreased
 dentition,
 poor-­‐fitting
 dentures
  Place
 bolus
 on
 strong
 side
 
Neck
 extension
 
Buccinator
 weakness
  Place
 bolus
 on
 strong
 side
 
Modify
 bolus
 size
 
Tongue
 weakness/incoordination
  Posterior
 escape
 of
 the
 bolus
 
  Slurp
 and
 swallow
 
Decreased
 sensation
 
 

Tongue
 weakness/incoordination
  Residue
 collection
 on
 tongue
  Thermal
 stimulation
 

Tongue
 weakness/incoordination
  Difficulty
 a-­‐p
 transit
  Head
 tilt
 
 strong
 side
 
Chin
 tuck
 

 
 
  Multiple
 swallows
 
Valsalva
 maneuver
 (effortful
 swallow)
 
Neurosensory
 deficit
  Swallow
 delay
  Head
 turn
 
 weak
 side
 

Decreased
 sensation
 in
 the
 pharyngeal
 wall
 (neurosensory
 deficit)
  Unable
 to
 initiate
 swallow
  Chin
 tuck
 
Supraglottic
 swallow
 
Poor
 tongue
 base
 retraction
  Residue
 in
 the
 vallecula
  Super-­‐supraglottic
 swallow
 
Vocal
 quality
 check
 
PHARYNGEAL
 STAGE
  Incomplete
 epiglottal
 inversion
 
Head
 turn
 
 weak
 side
 
Decreased
 laryngeal
 elevation
  Residue
 in
 the
 pyriforms
  Super-­‐Supraglottic
 swallow
 
Valsalva
 maneuver
 (effortful
 swallow)
 
Decreased
 PES
 opening
 

Weak
 pharyngeal
 constrictiors
  Residue
 on
 postpharyngeal
 wall
 

Swallow
 delay/neurosensory
 deficits
  Penetration/aspiration
 B4
 swallow
 

Posterior
 escape
 of
 the
 bolus
 

Incomplete
 epiglottal
 inversion
  Penetration/aspiration
 during
 

Timing
 issue
 with
 airway
 closure
 (e.g.
 d/t
 VF
 paralysis,
 arytenoids
  swallow
 

coming
 forward
 towards
 pedial
 of
 epiglottis
 

Residue
 in
 the
 pyriforms
 or
 vallecula
  Penetration/aspiration
 during
 
Backflow/Reflux
  swallow
 

Reduced
 PES
 opening
 d/t
 reduced
 laryngeal
 elevation
  Residue
 at
 the
 PES
 

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Compensatory Strategies (use during meal)


  Strategy
  Use
 for
 (generally)
  Procedures
  Rationale
  Notes
 

General
  Any
 self-­‐feeding
 and
  Sit
 upright
 (90
 degrees),
  Provide
 best
 possible
 scenario
 for
 a
 safe,
  Do
 all
 this
 when
 possible
 –
 all
 

swallowing
  arms
 well
 supported
 and
  efficient
 swallow
 
  aspects
 may
 not
 be
 feasible
 

feet
 flat
 on
 floor,
 had
 

aligned
 w/trunk
 

Pelvis
 as
 far
 back
 in
 seat
 as
  Slouching
 in
 posterior
 pelvic
 tilt
 limits
 

possible
  hyoid
 elevation
 

Head
 tilt
 to
  Unilateral
 oral
 AND
  Tilt
 head
 after
 accepting
  Increased
 sensation/motor
 
 
strong
 side
  pharyngeal
 weakness
  bolus
 and
 during
 swallow
  strength/coordination
 on
 strong
 side
 may
 
facilitate
 improved
 oral
 control,
 and
 
Postural
 (take
 advantage
 of
 gravity)
  (face
 stays
 forward)
  bolus
 formation/propulsion
 

Head
 turn
 to
  Unilateral
 pharyngeal
  Rotate
 head
 90
 degree
  Helps
 prevent
 bolus
 from
 traveling
 to
  Pair
 w/chin
 tuck
 for
 potentially
 
weak
 side
  weakness;
 decreased
  after
 accepting
 bolus
 and
  weak
 side
 by
 reducing
 the
 size
 of
 this
  enhanced
 effects
 
PES
 opening
  during
 swallow
 (face
  side’s
 pharyngeal
 cavities;
 external
 pull
 
moves)
  may
 facilitate
 opening
 of
 PES
 

Chin
 tuck
  Swallow
 delay
  Tuck
 chin
 to
 chest
 before
  May
 widen
 vallecular
 space,
 preventing
  Greatest
 effects
 are
 in
 airway
 
w/pen-­‐asp;
  initiating
 swallow
  bolus
 from
 entering
 airway;
 narrow
  protection
 and
 tongue-­‐base
 
decreased
 tongue
  entrance
 to
 airway;
 pushes
 tongue
 base
  retraction;
 watch
 for
 bird-­‐necking
 
base
 retraction;
  backward
 toward
 pharyngeal
 wall;
 puts
  (CAN’T
 use
 w/poor
 lip
 closure
 or
 
vallecular
 pooling
  epiglottis
 in
 protective
 position
  oral
 control)
 

Side
 laying
  Diffuse
 pharyngeal
  Lay
 on
 side
 throughout
  Lateral
 head/trunk
 position
 reduces
  Pair
 w/multiple
 swallows
 for
 max
 
on
 strong
  residue
 d/t
 reduced
  meal
 on
 fully
 or
 semi-­‐ gravitational
 force
 on
 residue
 left
 after
  effect;
 adaptive
 equipment
 may
 
side
  pharyngeal
  reclined
 bed/chair
  swallow,
 allowing
 it
 to
 localize
 and
  help
 (swiveling
 spoon,
 straws)
 
contraction
  gather
 until
 swallow
 purposefully
 (rather
 
than
 aspirated)
 

Neck
  Diminished
 a-­‐p
  Take
 deep
 breath,
 hold
 it,
  Utilizing
 gravity
 to
 propel
 bolus
 into
  MUST
 have
 prompt,
 efficient
 
pharynx
  swallow
 response
 (or
 else
 bolus
 
extension
  transit
 d/t
 lingual
  then
 bring
 chin
 up/lean
  could
 roll
 directly
 into
 airway);
 

  can
 decrease
 PES
 ability
 to
 relax
 if
 
weak/incoordination’
  head
 back
  extended
 too
 far
 or
 for
 too
 long
 

Early
 ALS
 or
 altered
 
 

anatomy
 d/t
 cancer
 


 
 
 
 

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Compensatory Strategies (use during meal)


 
 
 
 
 
 

Lingual
  Decreased
 oral
  Use
 tongue
 to
 sweep
  Clears
 as
 much
 residue
 as
 possible
 to
  Use
 finger
 as
 needed
 (ex.
 lingual
 
prevent
 buildup;
 redirect
 residue
 to
  weakness)
 
sweep
 
  sensitivity;
 oral
  entire
 oral
 cavity
 to
 clear
  tongue
 blade
 for
 bolus
 development
 

 
weakness;
 oral
  oral
 residue
 following
  Liquid
 will
 help
 clear
 oral
 cavity
 residue
 
unable
 to
 be
 management
 by
 lingual
  Some
 pts
 may
 have
 hard
 time
 
residue;
 pocketing
  each
 swallow
  sweep
  initiating
 a
 dry
 swallow;
 try
 using
 
Helps
 clear
 residue
 before
 consuming
  empty
 spoon
 and
 apply
 pressure
 
Cyclic
  Bolus
 manipulation
  Alternate
 solids
 and
  next
 bolus
 to
 prevent
 buildup
 of
 residue
  down
 on
 tongue
 
Often
 use
 spoonful
 of
 lemon
 ice
 
ingestions/
  deficits,
 residue
  liquids
 throughout
 meal
  Cold
 and
 sour
 material
 is
 most
 easily
  or
 citric
 acid
 cyclically
 
sensed
 and
 is
 most
 likely
 to
 trigger
 
Liquid
 wash
  swallow
 if
 normal
 bolus
 does
 not
 
 

Multiple
  Residue
 (anywhere
 in
  Swallow
 more
 than
 once
  Reduces
 need
 for
 tongue
 to
 transport
  Dementia
 population
 often
 has
 
bolus
 to
 molars
 and
 avoids
 weak
 side
  decreased
 sensitivity
 and
 requires
 
swallows
  digestive
 tract)
  following
 each
 bolus
 until
  larger,
 more
 textured
 bolus
 
Larger
 bolus
 is
 more
 easily
 sensed
 to
  May
 need
 external
 control
 (ex,
 
residue
 is
 cleared
 (#
 of
  trigger
 swallow;
 Smaller
 bolus
 may
 be
  hold
 arm
 back
 until
 completion
 of
 
easier
 to
 form
 and
 control
  each
 swallow,
 straw
 pinch,
 wrist
 
times
 indicated
 in
 MBS)
  Allows
 ample
 time
 to
 clear
 and
 swallow
 a
  weight,
 give
 ‘shot
 size’
 amounts
 
bolus
 before
 ingesting
 another;
  of
 liquids
 in
 cup)
 
Thermal
  Swallow
 delay
  Apply
 cold
 and
 sour
  acceptance
 of
 bolus
 too
 early
 can
  Good
 for
 pts
 w/partial
 
interfere
 with
 pressure
 buildup
 and/or
  glossectomy
 or
 if
 unable
 to
 
stimulation
  material
 to
 faucial
 arches
  laryngeal
 elevation,
 causing
 pen/asp
  manage
 own
 secretions;
 DO
 NOT
 
Leverages
 movement
 of
 intake
 air
 to
  use
 if
 poor
 airway
 protection
 or
 
Bolus
 Control
  or
 eat
 cold/sour
 bolus
  assist
 in
 bolus
 propulsion;
 uses
  pharyngeal
 stage
 deficits
 
aerodynamic
 pressure
 instead
 of
 lingual
 
 
after
 mastication
 of
  control
 

primary
 bolus
 
 
 

Bolus
  Pocketing,
 poor
  Accept
 bolus
 directly
 onto
 

placement
  lingual
 coordination;
  strong
 side
 of
 mouth
 by
 

on
 strong
  altered
 anatomy
  angling
 utensil
 toward
 

side
  unimpaired
 side
 

Modification
  Poor
 bolus
 control,
  Accept
 smaller/larger
 

of
 bolus
 size
  decreased
 sensation
  bolus
 
 

(swallow
 delay)
 
 

Modification
  Impulsive
 patients
  Increase
 time
 btwn
 

of
 intake
  accepting
 each
 bolus
 

rate
 

Slurp
 and
  Weak
 a-­‐p
 bolus
  Slurp
 or
 suck
 bolus
 
swallow
  movement
  towards
 pharynx
 


 
 
 
 

 

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Compensatory Strategies (use during meal)


 
 
 
 
 
 

Valsalva
  Decreased
 laryngeal
  Swallow
 hard
  Designed
 to
 increase
 function
 of
  Watch
 for
 bird-­‐necking;
 
suprahyoid/pharyngeal
 musculature,
  CAUTION
 w/cardiac
 pts
 (can
 
Maneuver
  elevation
 and/or
  resulting
 in
 increased
 tongue
 base
  increase
 vascular
 pressure)
 
retraction
 
 
pharyngeal
 
Requires
 a
 lot
 of
 coordination;
 DO
 
contraction
  NOT
 USE
 w/cardiac
 pts
 (can
 cause
 
arrhythmias)
 
Mendelson
  Decreased
 PES
  Mid
 swallow
 hold:
 keep
  Increases
 duration
 of
 PES
 opening
  DO
 NOT
 USE
 w/cardiac
 pts
 
Maneuver
  opening
  hyoid
 suspended
 for
 2
 
secs
 
 
Maneuvers
  Supraglottic
  Silent
 aspiration;
 
Take
 deep
 breath
 and
 hold
  Provides
 volitional
 airway
 protection
 
swallow
  delayed
 airway
  firmly
 during
 swallow;
 
after
 swallow,
 cough
 
protection
  before
 inhalation;
 repeat
 

Super-­‐ Impaired
 airway
  Supraglottic
 swallow
 
 
Supraglottic
  protection;
 diffuse
  where
 swallow
 is
 ‘hard’
 
swallow
  pharyngeal
  (as
 if
 to
 swallow
 larger
 
weakness;
  pill)
 
Vocal
 quality
  pharyngeal
 
check
  carcinoma
  Speak
 after
 each
 swallow;
  Wet
 vocal
 quality
 may
 be
 a
 useful
 
if
 voice
 is
 ‘wet’,
  indicator
 of
 those
 who
 have
 laryngeal
 
Altered
 anatomy
  dys/aphonic,
 cough/clear
  dysfunction
 and
 are
 at
 risk
 of
 aspirating
 
throat
 and
 swallow
 again
 


 

Premature
 spillover/loss
 of
 bolus
 is
 not
 the
 same
 as
 swallow
 delay
 

Former
 is
 d/t
 oral
 motor/neuromuscular
 deficit
 (poor
 lingual
 strength/control),
 Latter
 is
 d/t
 neurosensory
 deficit
 (decreased
 sensation)
 

-­‐-­‐-­‐-­‐-­‐-­‐-­‐
 

Aspiration
 Pnemonia:
 Caused
 by
 material
 you
 have
 swallowed
 (secretions,
 food,
 liquid)
 that
 causes
 pnemonia
 

VS
 

Aspiration
 Pneumonitis:
 Caused
 by
 material
 originating
 from
 the
 stomach,
 i.e.
 material
 that
 has
 already
 been
 swallowed
 (gastric
 contents,
 reflux,
 
vomit)
 
 Leads
 to
 inflammation
 in
 the
 lungs
 d/t
 acid!
 

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Rehabilitation ExercisCeosm(upsenosuattsoidryeSotrfamteegaielssto(uismepdruorvinegpmerefoarlm) ance during meals)


  Impact
 on
 Swallowing
  Exercise
  Procedure
  Rationale/Notes
 

Cryotherapy
 
 (Hyper)
 
  Ice
 lips
 then
 passively
 stretch,
 follow
 with
 icing
  Temporarily
 reduces
 

Lips
  Difficulty
 removing
 bolus
 from
  Beckman
 Oral
  after
 exercise
 to
 maintain
 therapeutic
 effect
  spasticity/pain
 by
 reducing
 
spoon
  Stretching
 Protocols
  nerve
 conduction
 velocities
 
Provide
 firm
 directed
 pressure
 to
 stretch
 lips,
 
Acceptance
 of
 bolus
  moving
 them
 into
 lateral,
 superior,
 and
 inferior
  Slowly
 and
 progressively
 
relieves
 spasm
 

Anterior
 loss
 of
 bolus
  (Hyper)
  positions
 
Strengthen
 w/T.D.
  Hold
 tongue
 depressor
 btwn
 lips
 parallel
 to
 floor
 
 

Decreased
 pressure
 generation
  Life
 Savor
 resistance
  for
 60
 secs
 
for
 bolus
 propulsion
 
Tie
 Life
 Savor
 to
 a
 piece
 of
 floss,
 place
 behind
 pts’
 
 
lips
 (but
 in
 front
 of
 teeth),
 pull
 floss
 for
 resistance
 

Strengthen
 w/Widget*
  Close/open
 or
 hold
 closed
 using
 lips
 only
 
 


 
 
 
 
 

IOPI
 (Iowa
 Oral
  Pts
 holds
 bulb
 between
 tongue
 and
 palate
 to
  Typical
 adult
 can
 achieve
 max
 

Pressure
 Instrument)
  achieve
 target
 isometric
 pressure
 reading
 (reps
 or
  pressure
 of
 60
 kiloPa;
 shown
 

bulb
  maintained
 hold
 for
 target
 #
 of
 secs)
  to
 improve
 lingual
 tone
 

Difficulty
 forming
 bolus
  Strengthen
 w/Widget
 *
  Reps,
 holding;
 Hold
 up
 bottom
 to
 top
 w/tongue
 
 

Tongue
  Difficulty
 transporting
 bolus
  only,
 keeping
 jaw
 steady
 (and
 vice
 versa);
 
Lateralizationpush
 one
 side
 to
 the
 other,
 keep
 

Premature
 spillover/posterior
  Increase
 ROM
 w/T.D.
  neck
 stationary
 
 
escape
 
Extend
 tongue
 to/through
 all
 planes,
 with
 tongue
 
depressor
 resistance
 against
 tongue
 blade
 

Decreased
 ability
 for
 lingual
  Dexterity
 w/Life
 Savor
  Tie
 Life
 Savor
 to
 piece
 of
 floss,
 have
 pt
 move
 LR
 
 
sweep
 

Beckman
 Oral
 
 
 

Stretching
 Protocols
 

(Hyper)
 


 
 
 
 
 

Buccinators
  Decreased
 pressure
 generation
  NMES/E-­‐Stim
  Apply
 stimulation
 pads
 to
 main
 branch
 of
 facial
  DO
 NOT
 place
 over
 infected/
 
for
 bolus
 propulsion
 
  nerve;
 must
 using
 during
 functional
 swallowing
  cancerous
 area;
 beware
 
(~6
 tx
 of
 1
 hr
 each)
  exercises
 (ex,
 mastication)
 to
 effectively
 target
  cardiac/laryngospasm
 pts;
 

Decreased
 ability
 to
 clear
 stasis
  muscles
  Doesn’t
 work
 on
 skin
 flaps
 
taken
 from
 other
 part
 of
 body
 

Decreased
 sucking
 ability
  Strengthen
 w/Widget*
  Reps,
 holding
 btwn
 teeth
 and
 check
 
 

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Rehabilitation ExercisCeosm(upsenosuattsoidryeSotrfamteegaielssto(uismepdruorvinegpmerefoarlm) ance during meals)

Pharyngeal
 
  VP
 Close
 
  Masticators
 
  Gum
 to
 promote
 rotary
  Pt
 chews
 gum
 on
 a
 piece
 of
 floss,
 maintaining
 its
  Munching
 mastication
 will
 
motion
  shape
 in
 “ball”
 form
  result
 in
 elongated
 piece
 
Decreased
 mastication
  Strengthen
 w/Widget*
  Bite
 widget
 in
 reps
 or
 hold
 
 
Decreased
 jaw
 opening
  DynaSplint
 
  Progressively
 stretches
 jaw
 
(trismus)
  Worn
 by
 pts
 for
 increasing
 amounts
 of
 time
 every
 
Thera-­‐bite
  day,
 multiple
 times
 a
 day;
 has
 custom
 mouth
 
 

  piece
 

  Same
 as
 DynaSplint
 but
 not
 custom-­‐made
 for
 
 
each
 pt
 

 

Nasal
 regurgitation
  Strengthen
 w/CPAP
  Wear
 while
 producing
 various
 phonemes
  Positive
 airway
 pressure
 
machine
  provides
 resistance
 
Decreased
 intraoral
 pressure
 for
  VCT
 (Velopharyngeal
  Pt
 inhales
 deeply
 then
 exhale
 thru
 straw
 at
  Straw
 at
 least
 1
 cm
 diameter;
 
sucking
 and
 bolus
 propulsion
  Closure
 Test)
  constant
 pace
 for
 as
 long
 as
 possible
 against
  normal
 low
 limit
 is
 against
 5
 
resistance
 of
 12
 cm
 water
 pressure
  cm
 of
 water
 for
 5
 secs
 

  EMST
  (see
 below)
  Enhances
 levator
 veli
 palatini
 
 

 
 

 

Decreased
 tongue
 base
  Masako
 Maneuver
  Place
 tongue
 btwn
 teeth
 or
 on
 alveolar
 ridge
 and
  Anteriorly
 stabilizing
 tongues
 
retraction
  swallow
 (NOT
 with
 bolus);
 may
 need
 to
 pair
 with
  allows
 for
 greater
 

Weak
 pharyngeal
 constrictors
  Valsalva
 for
 maximum
 benefit
  recruitment
 on
 pharyngeal
 

constrictors,
 bringing
 them
 

anteriorly
 to
 meet
 weakened
 

tongue
 base
 


 

*Widget:
 Not
 a
 technical
 term
 
 Tape
 2
 tongue
 depressors
 together
 (use
 medical/surgical
 tape,
 which
 is
 easily
 accessible)
 and
 
insert
 desired
 number
 of
 other
 depressors
 to
 create
 resistance
 for
 when
 pt
 tries
 to
 close
 the
 ends
 


  Example
 (using
 rubber
 bands,
 but
 tape
 work
 just
 as
 well):
 
 


 

 

 

 

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Rehabilitation ExercisCeosm(upseenosuattsoidryeSotrfamteegaielssto(uismepdruorvinegpmerefoarlm) ance during meals)


 
 
 
 
 
Laryngeal
 
 
Decreased
 laryngeal
 elevation
  Shaker
 (head-­‐lifting)
  Lay
 in
 supine
 position
 and
 lift
 head
 to
 look
 at
 toes;
  Simple
 isometric
 exercise
 

Pharyngeal
 residue
  Exercises
  sustain
 for
 1
 minute,
 rest
 1
 minute,
 repeat
 (3
  facilitates
 PES
 opening
 by
 

cycles
 total);
 also
 30
 reps
 of
 brief
 head-­‐lifts
 (like
 a
  increasing
 anterior/superior
 

Decreased
 epiglottic
  mini
 head
 sit-­‐up)
  excursion
 of
 larynx
 (and
 
retroversion
  possible
 decreased
 resistance
 
of
 cricopharyngeus)
 

Decreased
 approximation
 of
  Valsalva
 Maneuver
  Effortful
 (hard)
 swallow
  These
 compensatory
 
arytenoids
 to
 epiglottis
  Mendelson
 Maneuver
  Palpate
 hyoid/thyroid
 notch
 and
 hold
 larynx
  strategies
 can
 be
 performed
 
suspended
 for
 2
 secs
 (as
 if
 holding
 breath)
  w/o
 bolus
 for
 long-­‐term
 
Decreased
 PES
 opening
  EMST
 (Expiratory
  strengthening
 effects
 
Pt
 has
 1)
 nose
 clip
 to
 eliminate
 nasal
 airflow;
 2)
 
Increasing
 expiratory
 lung
 

Penetration/aspiration
  Muscle
 Strength
  mouthpiece
 with
 tight
 labial
 seal;
 3)
 hand
  volume/force
 1)
 increases
 
Training)
  pressure
 on
 cheeks
 to
 eliminate
 pocketing
 air
  hyolaryngeal
 displacement;
 2)
 


  improves
 glottic
 closure;
 3)
 

Maximum
 exhale
 into
 mouthpiece
 until
 air
 rush
 is
  creates
 higher
 airflow,
 which
 

heard,
 rest
 30-­‐60
 secs
 btwn
 trials
 and
 2
 min
 btwn
  increases
 sensation
 of
 

sets;
 5
 sets
 of
 5
 breaths,
 5
 days/wk
  tongue/oropharynx;
 4)
 


  increase
 afferent
 input
 to
 

If
 no
 fancy
 
 mouthpiece/device,
 use
 a
 balloon!
  cough
 centers/adductors
 

Vocal
 adduction
  Link
 fingers
 at
 chest
 level
 and
 push
 hands
  Increase
 movement
 of
 

exercises
  together
 or
 pull
 upward
 on
 seat
  weakened
 VF
 or
 facilitate
 

adduction
 of
 functioning
 VF;
 

Beware
 w/cardiac
 pts
 (may
 

increase
 vascular
 pressure)
 

Vocal
 Function
  Perform
 glides
 and
 sustained
 pitches
 as
 softly
 as
 
 

Exercises
  possible
 w/slightly
 nasalized
 tone;
 push
 palms
 

together
 to
 increase
 effortful
 closure
 


 

 

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