DYSPHAGIA IN THE NEUROLOGIC AND HEAD AND NECK CANCER PATIENTKaren Ball MPA MS CCC-SLP BCS-S

Speech Language Pathologist

Queens College,

City University of New York (CUNY)

Karen.ball@qc.cuny.edu

BACK TO BASICS

Review normal swallow physiology (oral prep, oral stage, pharyngeal stage, esophageal stage)

What muscles are involved, neurological input (supra hyoid muscles, tongue, laryngeal, palatal, pharyngeal muscles)

Review cortical and peripheral input into the swallow (CNS/PNS, UMN/LMN)

Role of swelling (larynx post intubation, post anterior spine surgery, head/neck surgery)

BACK TO BASICS

Pressure generation and bolus transit during the pharyngeal stage of swallowing

Swallowing mechanism as a closed system

(McConnel)

PRESSURE GENERATION SYSTEM

Oropharyngeal pressure pump

Tongue (piston)

Pharyngeal wall (chamber)

(tongue base applies pressure to bolus tail, pharyngeal contraction also applies force to the bolus, increasing velocity and propulsion of the bolus through the pharynx)

PRESSURE GENERATION SYSTEM

PE segment pump

Larynx

Hypopharynx

Anterior movement of the larynx opens the PE segment

Esophageal pressure sub atmospheric, opening PE segment releases this, bolus is drawn into esophagus

NEURO DIAGNOSES

Acute

Chronic

Progressive

Combination (Patient with PD who is s/p CVA or TBI secondary to a fall)

Associated diagnoses:

Structural (osteophytes, diverticula, achalasia)

Diabetes

Physiological: (esophageal dysmotility, Gerd, LPR)

Psychological (anxiety, fear of choking)

NEURO DIAGNOSES

Contributing factors that could be present:

Metabolic encephalopathy

Confusion/Lethargy

AGE/Sarcopenia

NEURO INVOLVEMENT

Muscle tone: (spasticity, flaccidity)

Muscle weakness/paralysis

Bradykinesia

Major muscles(muscular structures) affected:

Tongue (oral tongue, tongue base)

Cheeks

Velo pharyngeal complex

Pharynx

UES

Vocal folds

Suprahyoid muscles

Intrinsic laryngeal muscles

H/N CANCER DIAGNOSES

Location

Staging (size)

Treatment (surgery, chemo/radiation, or combo) and response to treatment.

If surgery, how was the area of the resection reconstructed?

Presence of G-Tube and timing of placement.

H/N CA TREATMENT

Can change the mechanics of swallowing by altering the swallowing structures (surgery)

Can change the physiology of swallowing secondary to effects of Chemo/RT (fibrosis,)on the major muscles involved in swallowing.

Can change the desire to eat due to presence of sensory or taste changes or pain. Occasionally, fear can also contribute.

CLINICAL EXAMINATION

A thorough, well thought out clinical exam is essential.

Clinician style

Conservative? i.e.: “afraid” of aspiration (thickens everyone’s liquids, recommends NPO continually).

Realistic? (Common sense)

Thoughtful? i.e.: quality of life essential

Empathetic? Involve the patient in the decision making.

CLINICAL EXAMINATION

The COUGH

Indicative of airway protection

Is cough secondary to ingestion of food or liquid?

Nervous/anxiety provoked? (habit cough)

Secondary to globus?

Secondary to GERD/LPR?

We all cough!!!!

LANGMORE, ET AL “PREDICTORS OF ASPIRATION PNEUMONIA: HOW IMPORTANT IS DYSPHAGIA?”(DYSPHAGIA, 1998)

189 Elderly subjects recruited from outpatient clinics, acute care wards, and nursing home from the VA Medical Center, Ann Arbor, MI

Given an oral/pharyngeal/esophageal swallowing assessment, feeding assessment, functional status assessment, medical assessment, oral/dental assessment.

Followed for up to 4 years for an outcome of verified “aspiration pneumonia”

LANGMORE, ET AL “PREDICTORS OF ASPIRATION PNEUMONIA: HOW IMPORTANT IS DYSPHAGIA?”(DYSPHAGIA, 1998)

ResultsBest predictors: Dependent for feeding Dependent for oral care Number of decayed teeth Tube feeding >1 medical diagnosis Number of Medications Smoking

LANGMORE, ET AL “PREDICTORS OF ASPIRATION PNEUMONIA: HOW IMPORTANT IS DYSPHAGIA?”(DYSPHAGIA, 1998)

“Dysphagia was concluded to be an important risk for aspiration pneumonia, but generally not sufficient to cause pneumonia unless other risk factors were present as well”

CLINICAL EXAMINATION:LET’S THINK ABOUT:

ACTIVITY LEVEL AND ATTITUDE

Ambulation Status

Activity Level/Spunk

Nutritional Status

Independence with ADL’s i.e.: feeding

CLINICAL EXAMINATION: SOCIAL/CAREGIVER / LIVING SITUATION

Support System

Permanent Residence

ASPIRATION

Does aspiration of food lead to aspiration pneumonia???

J. Robbins has found that aspiration of thickened fluids is much more difficult to clear from the lungs than aspiration of thin liquids.

MD thoughts essential at this juncture. How tolerant are they of aspiration. How much is too much?

PS: we all aspirate/penetrate occasionally..does this mean we need to place ourselves NPO???

THICK LIQUIDS

Nectar thick

Honey thick

Thickeners available: natural foods (i.e.: applesauce)

Corn starch type: Thick it

Xanthan gum type (gel)(simply thick)

THICK LIQUIDS

You like?

Hydration needs generally considered 64 oz.. fluid per day

Do most of us attain this???

Probably not with normal liquids

Can we assume that patients will consume 64 oz. of thick liquids? (rarely)

PUREED FOOD

You like?

Hard sell to those who are cognitively intact….

We need to strive to maximize a patient’s desire when we recommend a diet level.

Consider taste, texture, caloric content.

How thick is it?

This can be a challenge if the patient is in the hospital or nursing facility. OR if the patient is not a cook!

THE INSTRUMENTAL EXAM

MBS: Gold standard, able to evaluate all stages of swallow

FEES: View before and after the swallow. Views structures best, can assess secretion management

THE INSTRUMENTAL EXAM

Logemann:

Instrumental Exam indicated when pharyngeal stage dysphagia is suspected

What happens when access to Instrumental examinations is limited?

THE INSTRUMENTAL EXAM

Careful, thoughtful clinical examinations can work!

Need to acknowledge some issues will not be able to be identified: (i.e.: Zenkers, osteophytes, esophageal motility, UES function)

You proceed as best you can with your excellent clinical judgement!

TREATMENT/TECHNIQUES

Mendlesohn Maneuver

Shaker Exercises

Masako Maneuver

Supraglottic Swallow

Effortful Swallow

Huck and Spit

TREATMENT/POSITIONS

Head turn to weak side

Chin tuck (cut out cup, straw)

Lean to strong side

TREATMENT/MISC.

Alternate liquids/solids (liquid flush)

Double swallow (dry swallow)

Add texture

Extra sauces and gravies (moisteners)

Caloric enhancement

TRENDS ON THE HORIZON

Exercise Physiology

EMST (Expiratory Muscle Strength Training)

Sapienza (Aspire Products LLC) emst150.com

IPRO (Isometric Progressive Resistance Oropharyngeal Therapy) Robbins

(Swallowsolutions.com) (lots of info on website)

(relation of IOPI, MOST) Targets effects of Sarcopenia. Importance of understanding resistance training in the context of functional reserve

AND REMEMBER!

The best exercise for swallowing is SWALLOWING!

AND

SWALLOWING SOMETHING!

QUALITY OF LIFE AS WELL AS PATIENT SAFETY ARE KEY

AND REMEMBER!

PATIENT’S RIGHTS

RIGHT TO SAY NO

CLOSE COOPERATION WITH MEDICAL TEAM

PATIENT ADVOCACY