Dysphagia Swallowing Disorder

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DysphagiaSwallowing Disorder

• Presented by
• Angie Dubis Bohn
• Compiled by Nehal Kothari

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Anatomy of Normal Swallow

• Oral structures
• Lips Swallowing begins as soon as food is put in
  mouth. Help in stripping food off the spoon and
  retaining bolus in mouth.
  
• Teeth Process of mastication. Chewing and
  grinding the food.
  
• Cheeks Performs flattening action.
• Tongue Moves bolus from side to side.

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Oral structures
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Stages of Swallowing

• A. Oral Stage
• B. Pharyngeal Stage
• C. Esophageal Stage
• Oral Stage
• Oral Prep and Oral transit
• Oral Prep involves reduction of bolus via
  mastication. Salivary glands produce saliva which
  is mixed with bolus during reduction.
  
• Cheeks flatten and holds the bolus in contact
  with teeth.
  
• Tongue and jaw movements are coordinated to keep
  the food between the teeth.
  

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Oral Transit

• Bolus is medialized on the back of the tongue.
• Soft palate elevates.
• Lips and cheek muscles contract.
• The posterior tongue depresses.
• Remaining of the tongue presses against the hard
  palate.
  
• Bolus is propelled towards the throat (pharynx).

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Pharyngeal Stage

• Anatomical Structures
• Larynx
• Pharynx
• Two tubes in throat Trachea (wind pipe) and
  Esophagus (food pipe)
  
• Physiology
• Swallow reflex is triggered at the faucial
  arches.
  
• To prevent nasal regurgitation, velopharyngeal
  closure is achieved.
  
• Complete closure of true vocal folds.
• Retroversion of the epiglottis.
• Contraction of pharyngeal constrictors and
  laryngeal elevation takes place.
  
• Larynx protects the airway.

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• As bolus moves from pharynx, it divides with
  appx. ½ flowing down each side of pharynx
  (throat). These 2 portions join together at the
  opening of esophagus.

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Pharyngeal Stage
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Image of larynx and vocal folds
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Changes following stroke

• Oral structures
• Lip weakness
• Anterior loss of bolus. Loss of food.
  Difficulty in holding the bolus in mouth.
  
• Tongue weakness
• Difficulty with process of mastication and
  bolus transit. Residue may remain in oral cavity.
  Pre mature spill over may occur too.
  
• Cheeks weakness
• Difficulty with retaining food in the mouth.
  May result in pocketing of food on the weak
  side.
  
• Reduced Oral Sensitivity
• Food is not felt in the mouth and may be
  lost earlier in the oral cavity and aspirated
  before swallow.
  
• Jaw weakness
• May affect the adult rotary chewing
  pattern.
  

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Changes following stroke

• Weakness of throat
• Laryngeal muscles may not be strong enough
  to move up and down. Epiglottis does not
  completely fall down. Material enters the airway.
  May result in choking or coughing ? Aspiration.
• Disorders that may affect pharyngeal stage are
• Delayed or absent swallow reflex
• Inadequate velum closure resulting in nasal
  regurgitation
  
• One sided weakness of pharynx
• Reduced peristalsis
• Reduced laryngeal elevation and closure
• Cricopharyngeal dysfunction

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• Reduced Sensitivity Body fails to get the signal
  fast enough and food remains in airway, putting
  the person at risk for aspiration.
  
• 40 of the people present with silent aspiration
  following stroke. Owing to reduced sensitivity,
  no cough reflex is triggered. One figures out the
  underlying problem only once pneumonia develops.

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What changes occur following stroke
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Esophageal Stage

• Cricopharyngeus muscle relaxes. Allows food to
  pass into esophagus (food pipe). This food pipe
  connects to the stomach.
  
• In the esophagus, 3 peristaltic movements occur
  and aid in passage of food to the stomach.
  

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A represents food bolus and B indicates marked
presence of upper air in the esophagus inferior
to food bolus.
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Conditions that can affect esophageal transit

• Lax Cricopharyngeus muscle
• Reduced esophageal peristalsis
• Partial or total esophageal tumors
• Barrets esophagus
• Normal tissue covering is replaced due to
  prolonged reflux and severe damage to the
  covering or tissue of esophagus.
  
• Esophageal web
• Achalasia Failure to relax

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Barrets Esophagus
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Recap of Stages of Swallowing
Initial stages of eating and swallowing under
voluntary control. This means that it is governed
by the brain.
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Oral Stage
Once food enters the mouth the teeth break it
down into smaller and smaller pieces. This has
the dual function of making the food easier to
swallow and increasing the surface area of food
on which the saliva can act. The tongue, lips an
d cheeks assist the teeth in the process by
allowing the food to be "rolled" around the oral
cavity. The mechanical action described above pr
oduces a softened bolus of food which is now
ready to be swallowed. The correct biological
term for swallowing is deglutition.
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Pharyngeal Stage
The picture shows the voluntary stage of
deglutition. Here the bolus is pushed into the
upper part of the pharynx (known as the
oropharynx) by the action of the tongue. 
The pharyngeal stage of deglutiton is stimulated
when the bolus enters the oropharynx. This stage
of swallowing is mainly due to a reflex response.

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Recap pf Pharyngeal Stage

• This sets off muscular contractions in the
  pharynx. The soft palate closes off the
  nasopharynx. The vocal cords in the larynx are
  moved up and towards the front of the throat thus
  closing it off to the passage of food. This is
  extremely important in preventing food from
  entering the airway.I am sure we have all
  experienced the unpleasant feeling of food or
  drink going the "wrong way"!!
• Another effect of the process is to widen the
  opening of the oesophagus thus making the passage
  of the bolus along the alimentary canal easier.

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Recap

• As the bolus pushes it's way into the oesophagus
  it automatically pushes the epiglottis downwards
  further closing off the airway.

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Recap of Esophageal Stage
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Animation of the whole process

• http//greenfield.fortunecity.com/rattler/46/image
  s/swallow.gif
  

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Understanding the process through MBS images

• Summary

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Recap of Pharyngeal Stage
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What can we do?

• Diet Modifications
• To maintain nutrition and ensure safety during
  swallowing.
  
• Remember ! different facilities may use
  different names for these diet levels.
  
• Level I Puree
• Level II Mechanical Soft
• Level III Advanced
• Regular diet

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Level I

• Puree Diet
• Homogenous, very cohesive, pudding-like,
  requiring very little chewing ability.
  
• Examples Apple Sauce, Pudding, Smooth mashed
  potato, Pureed scrambled eggs and cheese.
  

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Level II

• Cohesive, moist, semi-solid.
• Requires some chewing ability.
• Ground or minced meats with fork-mashable fruits
  vegetables.
  
• Excludes most bread products, crackers, and other
  dry foods.
  

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Level III

• Soft solid.
• Requires more chewing ability.
• Easy-to-cut meats, fruits, vegetables.
• Excludes hard, crunchy fruits vegetables,
  sticky foods, very dry foods.
  

Soft bread
Cake
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Regular Diet

• Any solid textures

Carrot
Corn
Bagel
Chips
Nuts
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Liquids

• Thin water, coffee, tea, soda, ices or anything
  that will liquefy in the mouth within a few
  seconds.
  
• Nectar-Like thickened to nectar consistency
  such as apricot or peach nectar
  
• Honey-Like thickened to honey consistency
• Spoon Thick thickened to a pudding consistency

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Thickeners
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Thickening Liquids

• Thickening liquids can be achieved using modified
  food starch thickeners (a powder that is added to
  the liquid). The problem with this method of
  thickening is that the final product is not
  always the consistency prescribed.
• There is much room for staff error using powdered
  thickeners, but if staffing is not an issue, it
  is a less expensive method. There are now many
  thickening packets available too. The advantage
  of using that they do not alter the consistecy of
  the liquid after a while.

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Compensatory Strategies
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• Questions??

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• Thank You