III. Abnormal Swallowing

1
III. Abnormal Swallowing
2
Signs and Symptoms

• Dysphagia refers to difficulty swallowing.
• Swallowing difficulty can occur from a number of
  causes, and is frequently associated with stroke,
  neurological disease, and head and neck cancer.
  
• In addition, swallowing problems sometimes occur
  with viral infections, bacterial and fungal
  infections of the upper airway, psychogenic
  causes, and surgeries or disease processes that
  do not directly involve the oral, pharyngeal, or
  laryngeal structures.

3
Adults

• A number of symptoms, whether in isolation or in
  combination, can be a sign of dysphagia in
  adults.
  
• Symptoms of dysphagia may be as follows
• Patient has difficult initiating a swallow
• Patient refuses food or avoids foods that require
  mastication
  
• Food spills from the patients mouth during
  mastication
  
• Food remains in buccal pockets
• Patient eats slowly (especially with solids)

4
Adults

• Patient complains that food wont go down or
  that food gets stuck
  
• Patient exhibits frequent throat clearing
• Patient coughs, gags, or chokes before, during,
  or after a swallow
  
• Patient regurgitates food after meals
• Patient has difficulty breathing during or
  immediately after meals
  
• Patient has a hoarse voice
• Patient experiences nasal or esophageal reflux

5
Adults

• Patient has a gurgly or wet voice quality
• Patient complains of heartburn
• Patient has excessive secretions
• Patient drools
• Patient experiences excessive weight loss
• Patients appetite is decreased
• X-ray reveals chronic lung changes
• Patient has frequent or recurrent pneumonia
• Patient has recurrent URIs

6
Adults

• Infiltrates are noted on chest x-ray, indicating
  some fluid density has built up in the lungs
  (usually of the right middle or lower lung
  lobe)
• Patient has frequent or recurring low-grade
  fevers
  
• Patient has foul mouth odor
• Patient has an oro- or naso-gastric tube and
• Leakage of food or saliva from the tracheostomy
  site.
  

7
Adults

• Although these behaviors can be symptoms of
  dysphagia, they do not necessarily indicate a
  swallowing disturbance.
  
• Certain disease processes and neurological
  injuries can predispose an individual to
  swallowing disturbances.
  
• Individuals who exhibit confused mental state,
  may have difficulty with the degree of vigilance,
  planning, judgment, and perceptual skills
  required for safe eating.

8
Adults

• Individuals who exhibit characteristics of
  dysarthric speech production may have inherent
  weakness and decreased range of motion for
  muscles utilized in the phases of swallow.
• Individuals with either right- or left-hemisphere
  damage may experience problems with the ability
  to cooperate with swallowing techniques and
  strategies.

9
Adults

• Individuals with right hemiplegia and aphasia may
  become overwhelmed or confused when eating around
  others engaged in conversation.
  
• Individuals with right-hemisphere brain damage
  may have problems with the praxis of eating, and
  may have difficulty organizing the motor sequence
  to move food from plate to mouth, and with
  judging how much food to take in one bite and how
  much to chew.

10
Infants/Children

• Childrens food preferences and eating habits are
  highly variable over short periods of time,
  particularly among toddlers and pre-schoolers.
  
• Consideration must be given to whether a childs
  growth and eating patterns fit within normal
  variation or suggest problematic patterns.
  
• A related consideration is recognizing feeding
  problems in children with chronic illnesses or
  developmental disabilities.
  

11
Infants/Children

• Symptoms of potential feeding problems may be
  indicated by differences in nutritional and
  growth indices, developmental indices, and
  behavioral indices.
• Nutritional and growth indices that are
  potentially indicative of feeding disorders
  include
  
• Child is notably below or above normal levels on
  standard growth charts (i.e., weight or
  length/stature is below the 5th percentile,
  weight is above 95th percentile)

12
Infants/Children

• Childs rate of growth has increased or decreased
  dramatically without sufficient medical
  explanation.
  
• Child has a restricted dietary range, rejects
  textures, or has insufficient or excessive total
  food intake
  
• Health professional has recommended that the
  child take high-calorie supplements (e.g.,
  Polycose, nutritional milkshakes) for catch-up
  growth and
• Nutritional deficiency is suggested by physical
  signs (e.g., anemia, unusual body order).
  

13
Infants/Children

• Developmental indices that are potentially
  indicative of feeding disorders include
  
• Existence of oral-motor problems in sucking,
  swallowing, or chewing
  
• Childs feeding skills are below the level
  anticipated by developmental age (e.g., resists
  self-feeding or utensil use despite having
  sufficient motor coordination.
• Behavioral indices that are potentially
  indicative of feeding disorders include
  

14
Infants/Children

• Child has bizarre food habits (e.g., pica, steals
  food) or maladaptive mealtime habits (e.g., eats
  only in front of television)
  
• Mealtimes routinely last less than 10 minutes or
  more than 30 minutes
  
• Child (excluding infant) eats more than three
  meals and three snacks per day, or child of any
  age east less than three times per day
  
• Child is disruptive or has tantrums at
  mealtimes
  
• Child gags, vomits, or ruminates on food during
  or after meals and
  

15
Infants/Children

• Inappropriate affect is indicated around feeding
  (e.g., persistent lack of interest in feeding,
  strong fears related to food).
  
• Although these behaviors can be symptoms of
  feeding disturbance, they do not necessarily
  indicate a swallowing disturbance.
  
• Medical abnormalities affecting neuromuscular
  functioning may interfere with eating responses.
  
  
• Congenital anomalies, inherited conditions,
  chronic illnesses, constitutional factors, and
  medications can also affect feeding.
  

16
Infants/Children

• Previous illnesses, hospitalizations, and
  accidents (e.g., choking, swallowing poisonous
  substances) may affect feeding by providing an
  aversive conditioning history.
• Moreover, these experiences may have prevented
  the child from progressing through the normal
  feeding stages because development of proper
  eating was considered less important in light of
  the medical condition.
• Mealtime problems have been estimated to occur in
  roughly 1/3 of children with developmental
  disabilities.
  

17
Infants/Children

• A childs feeding-related behaviors may be
  reflective of overall developmental delays or the
  problems may be specific to feeding.
  
• SLPs who treat children with feeding disorders
  work primarily with children who have
  
• difficulty consuming enough nutrition to gain
  weight and grow
  
• difficulty with oral motor skill acquisition
  and
  
• aspiration risk and/or disorders of oropharyngeal
  swallowing.
  

18
Infants/Children

• However, based on the diverse nature of feeding
  problems, referrals to SLPs also may be prompted
  by concerns related to
  
• Oral defensiveness
• Gagging/vomiting with meals
• Difficult mealtime behavior
• Failure to thrive or under nutrition/inadequate
  intake
  
• Food refusal
• Picky eating
• Dependence on alternative means of nutrition
  and
  
• Food stuffing or pocketing in the oral cavity.

19
Infants/Children

• It is important that the SLP consider swallowing
  physiology when determining the reason for the
  feeding disorder.
  
• A child who refuses to eat enough to gain weight
  adequately may be experiencing slow gastric
  motility or constipation.
  
• A child who refuses to transition to textures may
  be experiencing gastroesophageal reflux (GER) or
  other gastrointestinal impairments.
  
• Severe GER can cause eating to be painful.

20
Infants/Children

• Early experiences with pain during oral intake
  can cause the child to stop eating and develop
  behavior problems (e.g., batting the spoon) that
  make it difficult, if not impossible for the
  parent to feed the child.
• Limited experiences with oral intake often result
  in failure of the childs oral sensorimotor
  response to develop normally.
  
• These children often do not demonstrate hunger
  and often struggle with parents for control
  during feeding in an attempt to demonstrate their
  aversion to or avoidance of sensory stimulation.
  

21
Infants/Children

• It is important to remember that often the
  presenting signs, e.g., weak suck, gagging, oral
  defensiveness, are related to underlying medical,
  motor/sensory, and behavioral issues, but these
  signs are not the cause of the problem.

22
Aspiration

• Aspiration refers to nasal, oral, pharyngeal,
  laryngeal, or gastric contents (secretions, food,
  liquid) that are drawn into the trachea by
  inspiration.
• Glottal aspiration occurs when any of these
  contents fall below the level of the true vocal
  folds.
  
• Pulmonary aspiration occurs when any of these
  contents fall into the pulmonary bronchi.
  

23
Aspiration

• Penetration is defined as the entry of material
  into the pharynx and/or the vestibule of the
  larynx in the absence of the swallow.
  
• Penetration leading to aspiration may occur
  before the swallow response, when the airway is
  still open.
  
• Penetration leading to aspiration may occur
  during the swallow response if the laryngeal
  valves are not functioning properly.
  

24
Aspiration

• Penetration leading to aspiration may occur after
  the swallow response when the larynx lowers and
  opens for inhalation.
  
• Aspiration may be prevented if the material is
  expectorated from the larynx/trachea back into
  the pharynx and swallowed.
  
• Aspiration is usually thought to be silent if
  the individual does not immediately cough or
  throat clear in response to the aspirant.
  

25
Aspiration

• Because of aging or various diseases of the CNS,
  a cough often does not appear when material
  reaches the area of the vocal cords it occurs
  later.
• Often times there is a delay of several minutes
  for the aspirate to make its way into trachea or
  bronchi.
  
• The "delayed cough" often reported, occurs when
  aspirate passes through the glottis, often with
  no cough, and trickles down until it reaches the
  receptors in the lower trachea or bronchi that
  trigger a cough.

26
Aspiration

• While observing a meal or during a bedside
  examination, one has to wait, for up to a couple
  of minutes after the patient has finished
  swallowing, for a possible cough.
• If the cough occurs, it varies from very slight
  (usually in the elderly) or loud and hacking,
  indicating the aspirate has reached either the
  lower trachea or the bronchi.
• If you hear a cough at bedside after the patient
  has swallowed, and you have had to wait, it is
  almost certainly aspiration.
  

27
Aspiration

• During the 4-5 minutes it takes to complete a
  videofluoroscopic examination, aspiration, in the
  form of the delayed cough" is frequently
  missed.
• Delayed cough may not occur on every swallow, and
  may therefore be intermittent so it is important
  to look for other signs of aspiration besides
  sound, e.g., cough or throat clearing.
• Indeed, cough is not the only, nor actually the
  most reliable sign of aspiration.
  

28
Aspiration

• Other signs of aspiration include gurgly/wet
  voice quality, and respiratory changes, including
  rapid respiratory rate and wheezing.
  
• Silent aspiration of saliva occurs commonly in
  normal adults during sleep or unconsciousness
  without any obvious health effects if their
  immune systems are operating satisfactorily
  (Huxley, 1976).
• However, constant, chronic silent aspiration of
  bacteria-laden saliva in dehydrated patients, in
  those with periodontal disease, and in those NPO
  patients receiving tube-feeding has the potential
  to result in pulmonary problems.

29
Aspiration

• Too much emphasis has been placed on the fact of
  aspiration and too little on its nature and
  content.
  
• Respiratory physiology of the normal lung, as
  well as evidence from near-drowning victims,
  makes it clear that the lungs have a remarkable
  ability to withstand several types of insult and
  to clear itself of invaders.
• When the host is malnourished, in extremely ill
  health, or otherwise immuno-compromised, the risk
  of aspiration becomes an issue.
  

30
Aspiration

• The fundamental issue with aspiration and whether
  it is potentially problematic is the nature and
  volume of the aspirate and the patients defense
  system.
• The majority of large volume and particulate
  aspirations are comprised of vegetable matter and
  can result in the inert-nontoxic syndrome.
  
• The clinical response to this form of aspiration
  ranges from chronic respiratory complaints, such
  as cough and wheezing, to atelectasis (stagnation
  of secretions), or if the aspiration is massive,
  sudden death.

31
Aspiration

• Acidic aspirates, such as gastric contents and
  foods with low pH, such as lemon and other fruit
  juices, can potentially injure delicate lung
  tissue, rendering the mucosal barrier of the
  lower respiratory tract incompetent.
• The resulting irritant-toxic syndrome may result
  in acute pneumonitis or acute respiratory
  distress syndrome (ARDS).
  
• In addition, particulate-matter aspiration can be
  contaminated by anaerobic flora of the
  oropharyngeal cavity.
  

32
Aspiration

• Anaerobes predominate in the oral flora of
  patients with periodontal disease and xerostomia.
  
  
• Oropharyngeal flora can achieve extremely high
  concentrations, especially in the presence of
  periodontal disease.
  
• While normal saliva has 108 organisms/mL, saliva
  from a patient with gingivitis may contain 1011
  organisms/mL.
  

33
Aspiration
Aspiration of pathogens from a previously
colonized oropharynx is the primary route by
which organisms gain entrance to the lungs and
produce infectious aspiration syndromes.
While pneumonia is part of the infectious
aspiration syndrome, other infectious syndromes
can result, including lung abscess.
The microbiology of aspiration pneumonia is
intimately tied to the flora of the oropharyngeal
cavity.
34
Aspiration
Like other respiratory tract infections,
aspiration pneumonia most commonly manifests in
patients with underlying disease that predisposes
to host defense impairment. Conditions which com
promise host immunity to aspirates include
diabetes mellitus, congestive heart failure,
COPD, malnutrition, renal failure, and
malignancy. However, only 25 to 50 of all aspi
rations progress to pneumonia.
35
Aspiration Summary

• The clinical response to aspirated material is
  dependent on the interplay between the
  characteristics of the aspirate and those of the
  host.
• If the aspirate is small in volume, but highly
  contaminated with bacteria, then even relatively
  strong host defenses may be overwhelmed and
  pneumonia can result.
• If the aspirate is large in volume, but small in
  contagion, then pneumonia will result only if the
  aspirated organisms are highly virulent or the
  host defenses severely compromised.

36
Aspiration Summary

• Even patients who aspirate noninfectious material
  may progress to pneumonia as a result of lung
  injury caused by noxious aspirate material, a
  condition known as aspiration pneumonitis.
• Aspiration pneumonia, like other respiratory
  tract infections, usually occurs in patients with
  underlying disease.
  
• It most commonly occurs in post-stroke or
  post-gastrectomy patients, and in those with
  dysphagia, GER, xerostomia, periodontal disease,
  dementia, or underlying serious illness.

37
Aspiration Summary

• Aspiration pneumonitis in someone with
  oropharyngeal dysphagia is caused byreflux,
  regurgitation, and/or vomition.
  
• It goes like this
• Patient has diabetes, Parkinsons disease, COPD,
  or other disease involving GER or is nauseated
  for other reasons.
  
• The patient may also be someone with an
  oropharyngeal swallowing impairment causing delay
  in swallow, spillage over tongue, discoordination
  or a combination of these andother problems.

38
Aspiration Summary

• The patient may be asleep, sedated, obtunded,
  comatose and lying supine and otherwise unable to
  sit up quickly and produce an appropriate, fast
  swallow.
• The patient refluxes/regurgitates/vomits.
• Emesis or vomition occurs when gastric and often
  small intestinal contents are propelled up to
  andout of the mouth.
  
• It results from a highly coordinated series
  ofevents as the follows

39
Aspiration Summary

• A deep breath is taken, then the glottis closes
  and the hyoid moves anteriorly to open the upper
  esophageal sphincter.
  
• Also, the soft palate elevates to close off the
  posterior nares.
  
• The diaphragm contracts sharply downward to
  create negative pressure in the thorax, which
  facilitates opening of the esophagus and distal
  esophageal sphincter.
• Simultaneously with downward movement of the
  diaphragm, the muscles of the abdominal walls are
  vigorously contracted, squeezing the stomach and
  thus elevating intragastric pressure.

40
Aspiration Summary

• With the pylorus closed and the esophagus
  relatively open, vomiting/reflux/regurgitation
  occur.
  
• In a patient who is not alert or able to become
  alert quickly and, at the same time coordinate a
  pharyngeal swallow quickly, aspiration is almost
  inevitable.
• Returning yet again to the four essential
  factors
  
• How much is aspirated?
• What is aspirated?
• Over how long a period? and
• How adequate is the patient's defense system?

41
Aspiration Summary

• A large amount of aspirate of stomachcontents is
  usually lethal, while chronic, smaller amounts
  are missed until a bacterial infection occurs
  several days later or chronic bronchiolitis
  develops.
• This is the reason that (bacterial) aspiration
  pneumonia is over-identified in children and
  adults alike and pneumonitis missed.

42
Aspiration Summary

• Specific issues to consider when evaluating ICU
  patients for aspiration risk, include patient
  position, site of enteral feeding, volume of
  gastric contents (higher volume has greater
  risk), and size of any feeding tube.
• Studies have suggested a reduced risk of
  aspirating gastric contents in semi-erect
  patients, in those whose feeding tubes are in the
  small bowel, and in those with small-bore feeding
  tubes.

43
Aspiration Summary

• Patients with prolonged hospitalization and
  underlying illness may become colonized by
  enteric gram-negative bacilli.
  
• The gram-negative pneumonias of the elderly, both
  in nursing homes and at home, have been well
  researched and identified as being related to the
  aspiration of saliva.
• The elderly in nursing home are at greater risk
  from aspiration of reflux and oral bacteria than
  from aspiration of foodstuffs.
  

44
Aspiration Summary

• Oral hygiene and the aspiration of
  bacteria-filled saliva, which cannot be
  prevented, are the most important first level
  risk factors to be considered.
• In addition to oral hygiene, the patient's immune
  response determines the risk of developing
  pneumonia.
  
• Therefore, oral care becomes much more important
  in the aspirating patient than small amounts of
  water to drink.
  

45
Aspiration Summary

• Because the elderly do not complain of the usual
  symptoms of pneumonia, high fever, disturbing
  cough, and chest pain, it is often difficult to
  diagnose.
• Pneumonia is the fifth leading cause of death in
  the elderly (over 65) in the U.S.
  
• It is probably the most common primary cause of
  death in all progressive diseases.
  
• Aspiration of certain foods present more danger
  than others.
  

46
Aspiration Summary

• One of the reasons that ice cream is favored in
  LTC by older residents its because it is sweet
  and sweet is the one taste sensation that remains
  at a normal threshold in the aged.
• The problem with ice cream, is the high fat
  content of the cream and aspiration of fat or
  oils in the lungs is very hazardous.
  

47
Aspiration

• In vulnerable infants and children, recurrent
  aspiration of even small volumes has been found
  to be a significant cause of morbidity, with
  complications including pneumonia, respiratory
  disease, and growth compromise or failure to
  thrive (Mercado-Deane et al., 2001 Newman et
  al., 2001Radford, Stillwell, Blue,
  Hertel,1995).
• Development of interstitial lung disease and
  fibrosis has been linked with chronic aspiration
  in children(Ahrens, Weimer, Hofmann,1999).
  

48
Aspiration

• Children and adolescents with histories of
  prematurity, low birth weights, and chronic lung
  disease (CLD) frequently exhibit recurrent
  respiratory problems and lung function
  abnormalities (Greenough, 2000).
• Repeated aspiration can worsen underlying lung
  injury, particularly in children with underlying
  CLD or neurogenic dysphagia (e.g., cerebral
  palsy).

49
Aspiration

• In older children and adults with neurogenic
  dysphagia, respiratory distress and hypoxemia
  during mealtimes have been associated with
  aspiration events (Rogers, Arvedson, Buck, Smart,
  Msall, 1994 St Cyr, Ferrara, Thompson,
  Johnson, Foker, 1989).
• Unfortunately, there is no tool or procedure for
  predicting how well an individual is able to
  tolerate aspiration.
  
• We have no answer to the question, "How much
  aspiration is too much?" before a child develops
  respiratory consequences.
  

50
Aspiration

• Many factors can shift an individual's threshold
  of aspiration tolerance.
  
• Influences include, but are not limited to
• the underlying diagnosis and prognosis
• overall medical, health, and nutritional status
  and
  
• the extent of the dysphagia.
• Ultimately, the impact of the dysfunction is
  determined by the balance between severity of the
  swallowing impairment and the child's
  compensatory mechanisms (Loughlin Lefton-Greif,
  1994).

51
Aspiration

• The variability in clinical presentations
  associated with swallowing dysfunction and
  recurrent aspiration complicate evaluation and
  management efforts.
• Some children may present with chronic symptoms,
  such as pneumonia or persistent coughing.
  
• Others demonstrate episodic difficulties, such as
  coughing or increased congestion while feeding.
  
• Responses to aspiration may differ according to
  age or the degree of maturity.
  

52
Aspiration

• Whereas younger infants may present with apnea or
  bradycardia, older children may cough or choke
  (Heuschkel et al., 2003 Thach, 2001).
  
• Another factor complicating the clinical
  identification of aspiration is that children may
  demonstrate similar respiratory presentations
  (e.g., wheezing or apnea), regardless of whether
  the response is triggered reflexively by vagally
  mediated receptors in the nasopharynx or larynx,
  or by direct aspiration.

53
Aspiration

• It is well known that children with histories of
  younger gestational ages and low birth weights,
  neurogenic conditions, and congenital
  malformations of the upper aerodigestive tract
  are at increased risk for dysphagia.
• In fact, approximately 50 of children under one
  year of age who are diagnosed with swallowing
  dysfunction carry diagnoses of neurologic
  impairment or congenital syndromes (Newman et
  al., 2001).

54
Aspiration

• However, clinicians need to be aware that other
  groups of children may also be at risk for
  chronic or transient dysphagia with concomitant
  aspiration.
• Recent studies have identified children with
  isolated neonatal dysphagia (Heuschkel et al.,
  2003 Sheikh et al., 2001).
  

55
Aspiration

• It has also been shown that previously
  asymptomatic infants may develop symptomatic
  swallowing dysfunction and aspiration following a
  viral infection (e.g., respiratory synctial virus
  RSV Hernandez, Khoshoo,Thoppil, Edell, Ross,
  2002 Khoshoo, Ross, Kelly, Edell, Brown, 2001
  Khoshoo Edell,1999).
• Children with CLD, particularly those requiring
  supplemental oxygen therapy, are at greatest risk
  for severe responses to RSV.
  
• Therefore, it is reasonable to suspect that this
  group of children is at substantial risk for
  swallowing related difficulties following
  infection.

56
Cough and Airway Clearance

• The cough is the primary lower airway protective
  response after aspiration.
  
• It is triggered by irritation of the trigeminal
  nerve endings of the upper respiratory passages,
  including the lower trachea and bronchi.
  
• Cough can also be triggered by pressure on the
  trachea or on the laryngeal nerves, irritation of
  the external auditory canal, tracheal
  obstruction, irritation of the gastric mucous
  membrane, and diseased or malformed teeth.

57
Cough and Airway Clearance

• Because of ageing or various diseases of the CNS,
  a cough often does not appear when material
  reaches the area of the vocal cords, it occurs
  later.
• The so-called "delayed cough" occurs when
  aspirate passes through the glottis and trickles
  down until it reaches the receptors in the lower
  trachea or bronchi.
• Silent aspiration is generally defined as the
  absence of a cough response following an
  aspiration event.
  

58
Cough and Airway Clearance

• In infants and children, silent aspiration may
  predispose infants and children to lung injury.
  
• Silent aspiration is common in children with
  dysphagia with estimates ranging from 70-97
  depending upon age and the underlying etiology of
  the dysphagia (Arvedson, Rogers, Buck, Smart,
  Marshall, 1994 Lefton-Greif et al., 2000 Newman
  et al., 2001 Sheikh et al.,2001).

59
Cough and Airway Clearance

• Although the reasons for the high incidence of
  silent aspiration in young children are unknown,
  one hypothesis is that silent aspiration may
  result from a blunting of airway defense
  mechanisms (e.g., cough Loughlin
  Lefton-Greif,1994).
• A possible explanation for this blunting may be
  related to the maturation and transformation of
  laryngeal chemoreflex responses (LCRs).
  

60
Cough and Airway Clearance

• Laryngeal chemoreflex responses (LCRs) are
  comprised of several airway protective reflexes.
  
• Some LCRs (e.g., rapid swallowing, laryngeal
  constriction, and apnea) are though to emerge
  during fetal development as a protective
  mechanism against potential aspiration of
  amniotic fluid (Thach, 2001).
• Others, such as coughing, may become more
  important during post natal life.
  

61
Cough and Airway Clearance

• The hypothesis of LCR maturation may be
  consistent with observations of prolonged apnea,
  bradycardia, and rapid swallowing in preterm
  infants who have trouble coordinating breathing
  and swallowing.
• Their responses differ from normal adults who
  cough after aspirating.
  
• Silent aspiration is particularly problematic in
  children under 2 years of age because the
  protective cough mechanism is absent during the
  period of greatest lung growth (Thurlbeck, 1982).
  

62
Cough and Airway Clearance

• Furthermore, caregivers and clinicians may
  underestimate the presence of swallowing
  dysfunction in this population because silent
  aspiration, by definition, does not provide overt
  evidence of airway contamination.

63
GER and LPR

• Many adults and children with swallowing
  disorders will also have other upper airway
  disorders that are often exacerbated or caused by
  gastroesophageal reflux (GER) into the upper
  airway.
• Extraesophagel reflux (EER) or laryngopharyngeal
  reflux (LPR) has been implicated in such
  disorders as asthma, chronic cough, and
  hoarseness in adults.
• Along with "asthma," another red flag for GER is
  chronic sinusitis in children and adults.

64
GER and LPR

• In children, it has been additionally implicated
  in apnea, recurrent croup, subglottic stenosis
  and chronic upper airway infections.
  
• However, unlike GER, the symptoms of LPR are
  often silent or non-episodic, as in the case of
  hoarseness in adults and chronic upper airway
  infections in children, causing it to be
  underdiagnosed.
• Individuals with GER are frequently prescribed
  proton pump inhibitors (PPIs) such as Prilosec,
  Prevacid, Aciphex, and Protonix.

65
GER and LPR

• PPIs don't stop reflux, they just stop the
  production of gastric acid although about 30 of
  people get breakthrough acid during sleep,
  thevery worst time.
• Indeed, McGlashan, Johnstone, Sykes, Strugala,
  and Dettmar (2009) investigated whether any
  improvement in LPR-related symptoms, using the
  Reflux Symptom Index (RSI), and clinical
  findings, using the Reflux Finding Score (RFS),
  could be achieved with treatment with a liquid
  alginatesuspension (Gaviscon) compared to
  control (no treatment).

66
GER and LPR

• 24 patients were randomized to receive 10
  mlliquid alginate suspension (Gaviscon(R)
  Advance) four times daily after meals and at
  bedtime, and another 25 patients were randomized
  into thecontrol group (no treatment).
• Patients were assessed pretreatment and at 2, 4
  and 6 months post treatment.
  
• Significant differences between treatment and
  control were observed for RSI at the 2-month and
  6-month assessments and for RFS at the 6-month
  assessment.

67
GER and LPR

• The researchers concluded that significant
  improvement in symptom scores and clinical
  findings were achieved with liquidalginate
  suspension (Gaviscon(R) Advance) compared to
  control and further evaluation for the management
  of patients presenting with LPR is warranted.
• Another case of the problems with PPIs and
  pneumonitis was personally reported on the
  dysphagia listserv by Suzanne Morris (2/21/09).
  

68
GER and LPR

• She states that like many people she started on
  Prevacid for reflux that had been escalating with
  non-PPI drugs for years.
  
• At first, she thought the most wonderful
  medication in the world because for thefirst
  time things didn't hurt and she could sleep well
  at night.
• However over a 2.5 year period, both the
  frequency and the amount of the medication were
  gradually increased.

69
GER and LPR

• In spite of the changes, she ended up with
  several bouts of pneumonitis and finally a
  wholeseries of what she thought was the "stomach
  flu".
• The flu symptoms, which were intense and usually
  lasted for several days, were puzzling because
  she had never had any tendency toward this type
  ofinfluenza and was experiencing it at least
  once a month.
• Although totally familiar with all of the
  literature on GERD because of her work with kids
  with feeding and GI issues, she didnt relate
  much of it to her personal situation.

70
GER and LPR

• One day she started questioning whether the
  flu/gastritis and the pneumonitis could actually
  bedirectly related to the high levels of PPIs
  and low levels of stomach acid.
• She hypothesized that the lack of gastric acid
  over nearly 3 years had strongly interfered with
  her body's first line of defense for food-borne
  bacteria since there was little or no acid in the
  stomachto kill these bugs.

71
GER and LPR

• Additionally, the lack of acid reduces the body's
  ability to absorb Vitamin B-12, zinc,
  calcium,etc., which could result in at least
  subclinical malnutrition and reduce the power of
  her immune system.
• In consultation with Irene Campbell-Taylor, she
  began to wean herself from the Prevacid (PPI) and
  take Gaviscon after each meal andbefore bed.
  
• She has been off of all pharmaceutical reflux
  medications for more than 5 years.

72
GER and LPR

• She takes Gaviscon after meals (as needed).
• The episodes of painful heartburn are almost
  nonexistent and the flu-like episodes have
  stopped.
  
• When she intermittently experiences reflux that
  is identified by an accumulation of mucous and
  throat clearing and emerging esophagitis, she
  takes a 2-week course of Prilosec (PPI) to
  temporarily reduce the amount ofacid in order to
  enable the tissues to heal more rapidly.

73
GER and LPR

• This short term course doesn't bother her in
  other ways and that is actually how the PPIs
  weredesigned to be used (short term rather than
  long-term acid suppression).

74

• Pathophysiology of Swallowing Impairments

75
Disordered Behaviors The Oral Preparatory Phase

• In general, when the oral preparatory phase of
  swallow is disturbed, drooling and leakage of
  liquids are observed, as well as pocketing of
  more solid foods on the weaker side.
• These behaviors reflect deficits in facial and
  tongue musculature.
  
• Some specific disorders include
• Reduced labial closurefood falls from the mouth
  anteriorly
  

76
Disordered Behaviors The Oral Preparatory Phase

• Reduced mandibular range of motiondifficulty
  putting mandible into proper occlusion for
  chewing, especially in patients who have had
  lower jaw surgery and
• Reduced buccal tensionfood falls into the
  anterior or lateral sulcus as the patient is
  chewing.

77
Disordered Behaviors The Oral Preparatory Phase

• When there is reduced range and/or coordination
  of tongue movement, difficulty may be exhibited
  in pulling food back together into a cohesive
  bolus.
• Swallow may be initiated with food spread
  throughout the oral cavity.
  
• Some specific problems may include
• Reduced tongue movement laterally
• Reduced tongue elevation.

78
Disordered Behaviors The Oral Phase

• Problems with the oral phase affect lingual
  propulsion of the bolus through the oral cavity.
  
• Some specific disorders include
• Reduced tongue range/coordinationfood is not
  maintained cohesively for anterior to posterior
  lingual transport. May include the following
  behaviors
• Disturbed lingual peristalsissomewhat random,
  non-productive, disorganized motion.
  

79
Disordered Behaviors The Oral Phase

• Repetitive lingual rollingrepetitive upward and
  backward movement of the anterior tongue and
  failure of the posterior tongue to lower bolus
  can only move to midpalate before it rolls
  forward again.
• Reduced anterior to posterior tongue movementthe
  tongue moves minimally in posterior direction so
  food just sits on the tongue.

80
Disordered Behaviors The Oral Phase

• Reduced ability to shape the tongueliquid or
  paste cannot be held in a cohesive bolus so
  material spreads throughout the oral cavity and
  may fall into the anterior lateral floor of the
  mouth during attempts at oral transit.
• Tongue thrustfood is pushed up against the
  anterior teeth by forward protrusion of the
  tongue when the swallow is initiated.
  
• Other oral phase problems include

81
Disordered Behaviors of the Oral Phase

• Piecemeal deglutition--bolus is not swallowed in
  single, cohesive mass only a portion or piece of
  the bolus is swallowed at a time. Repeated
  swallows are necessary to clear the oral cavity
  
• Aspiration before the swallowwhen unswallowed
  bolus or portion thereof falls into the open
  airway and makes its way into the pulmonary
  bronchi.

82
Disordered Behaviors The Pharyngeal Phase

• Disorders of the pharyngeal phase include
  dysfunctions of the swallow programming mechanism
  in the brainstem to organize and initiate the
  swallow response, or dysfunctions of any of the
  neuromuscular components that actualize the
  response behaviors.
• Problems may be seen at the level of the velum,
  the pharynx, the larynx, and/or the PE segment.

83
Disordered Behaviors The Pharyngeal Phase

• At the level of the velum, observed problems may
  include
  
• Reduced or inadequate velar elevation
• Material being refluxed through the nose.
• Since velopharyngeal (VP) closure during swallow
  lasts only a second or less, as the bolus passes
  the VP port, nasal reflux occurring later in the
  swallow is a result of dysfunction farther down
  the pharynx.
• If the bolus cannot pass through the pharynx into
  the esophagus, it may be refluxed upward into the
  nasopharynx when the VP port is normally open.
  

84
Disordered Behaviors The Pharyngeal Phase

• Reduced pharyngeal peristalsis results in a
  significant amount of food residue coating the
  pharyngeal walls after the swallow response has
  been triggered.
• Common sites of pharyngeal residue include
• Bilateral or unilateral vallecular stasis
• Bilateral or unilateral pyriform sinus stasis
• When residue is found in both the pyriform
  sinuses, the dysfunction is usually at the
  cricopharyngeus.

85
Disordered Behaviors The Pharyngeal Phase

• If residue in the pyriforms is combined with
  residue in other parts of the pharynx, it is a
  symptom of generalized pharyngeal dysfunction,
  and not an isolated cricopharyngeal problem.
• With any location of pharyngeal stasis, the
  patient is at risk for aspiration of the material
  after swallow, when the airway is again open for
  breathing.

86
Disordered Behaviors The Pharyngeal Phase

• At the level of the larynx, reduced anterior
  movement and/or closure of the larynx can result
  in penetration.
  
• When anterior movement is reduced, residual
  material may remain on top of the larynx after
  swallow.
  
• Lack of anterior movement of the larynx may also
  prevent the cricopharyngeus from relaxing tonic
  contraction to permit passage of the bolus.
  

87
Disordered Behaviors The Pharyngeal Phase

• Lack of adequate laryngeal closure may permit
  material to fall to the level of the vocal
  folds.
  
• If sensation is decreased, material may not be
  expectorated until farther down in the trachea.
  
• Material may continue to trickle in to the
  bronchi and pulled into the lungs.
  

88
Disordered Behaviors The Pharyngeal Phase

• Dysfunctions of the swallow programming mechanism
  in the brainstem to organize and initiate the
  swallow response may result in a delayed or
  absent swallow response.
• If the pharyngeal stage is not triggered by the
  time the bolus head reaches the point where the
  mandible crosses the tongue base, the pharyngeal
  swallow is said to be delayed.

89
Disordered Behaviors The Pharyngeal Phase

• However, in the elderly person, the swallow is
  often not initiated until the bolus reaches the
  valleculae or even the pyriform sinuses.
  
• Abnormal pharyngeal swallow delay is often
  accompanied by struggle behavior to stimulate the
  swallow.
  
• They may move the tongue base forward and
  backward and left the larynx up and down.

90
Disordered Behaviors The Pharyngeal Phase

• In infants, pharyngeal triggering and delay time
  is quite different from that of adults.
  
• The bolus may be collected in the valleculae
  before the pharyngeal swallow is triggered.
  
• In an infant, an abnormal delay is defined as
  more than 1 second between the last tongue pump
  and the onset of the swallow, or aspiration
  occurring during bolus collection.

91
Disordered Behaviors The Pharyngeal Phase

• If the central pattern generator in the brainstem
  does not program the entire pharyngeal swallow to
  trigger, the bolus may fall to the pyriform
  sinuses, or into the unprotected open airway.
• This is sometimes referred to as an absent
  swallow response.

92
Disordered Behaviors The Esophageal Phase

• The esophageal phase of swallowing may be
  affected by structural and/or motility changes in
  the esophagus.
  
• Common structural disorders consist of stenosis,
  or narrowing of the esophageal lumen, luminal
  deformity, and diverticula.
  
• Motility disorders affect the contraction
  amplitude, duration, and wave progression of
  esophageal peristalsis.