(1) Dysphagia Assessment.docx

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Dysphagia Assessment Normal Phases of Swallowing 1. Oral Preparatory Awareness (tiny aspect of cognition) Senses Stimulate Not a physical state of swallowing, but the perceptual or the cognitive side of it It is very important to look into the cognitive side of feeding because it will entail the success of the proceeding phases  Feeding/eating is one of our primitive skills  If patients with cognitive impairment react to food = food is a good material for cognitive therapy o You always need to try for feeding; do not be afraid  If patients with cognitive impairment do not react to food = there’s a risk of aspiration because they tend to keep the food in their mouth for too long 2. Oral Phase Jaw grading, biting, latching Bolus manipulation, mastication Bolus formation Bolus cohesion (when the food is being prepared for propulsion) Borderline: once food touches any of the trigger points for swallow ------------------------ initiation of swallow reflex ------------------------------3. Pharyngeal Phase Swallow reflex (1s – normal swallowing time) o Pharyngeal plexus work (work of both CN 9 and 10)  If there’s a problem at the pharyngeal level of swallowing, it a problem of both CN 9 and 10 o Swallow reflex is a dance (6) – in one second, there’s a lot happening from top to bottom and everything has to be coordinated.  Velopharyngeal port closure Possible implications: o nasal regurgitation o lack of intraoral pressure: a positive pressure at the upper area and a negative pressure at lower area of the body will help in pushing down the bolus; any issues with that mechanism will disrupt the swallowing process  Anterior-superior movement of hyoid Anterior movement: triggers the opening of the UES so that the food can be sucked in the esophagus; anterior digastric muscle is involved Superior movement: help the food push down Possible implications: o Vallecular residue: since the superior movement of the laryngeal inlet closes the epiglottis (*the epiglottis does not move by itself, it gets triggered) o Deflection o Penetration (food particles above glottis) or aspiration (food particles below glottis) o If there is only the superior movement: post-swallow the patient will cough due to the pyriform sinus pooling  Epiglottic deflection Epiglottis is very important for the protection of your laryngeal inlet; first gatekeeper  Adduction of the vocal folds Second gatekeeper

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 Pharyngeal constriction Circular and longitudinal muscles of the pharynx will contract to make sure there is no residue left in the region Possible implications: o Post-swallow coughing (even when the others are working functionally): because the residue can go down once the larynx goes back to its resting phase  Opening of upper esophageal sphincter Initiates the esophageal phase by means of peristalsis Esophageal Phase Once the esophageal phase is affected: refer to GI doctor Peristalsis: movement of the smooth muscles to push down the bolus o active in nature; purely involuntary o can only be facilitated when the body is moving appropriately (the lesser the physical activity, the lesser the function of peristalsis) Possible implications: o Bad breath (may smell sour or like vomit): acidic-like smell due to reflux o Constipated o Case sample: A patient with nasogastric tube consumes milk and shows signs of white residue at the tongue are will only mean that the milk goes up due to reflux. A smell of rotten milk will also be observed in this scenario. Advice: o Changing bed-position from time to time o Encourage physical activities *Talk to family/PT about these advices

Cranial Nerve Assessment Connected to the physical aspect: the movement of our OPM mechanism The ones for swallowing: o CN 5: trigeminal nerve (MIXED) **this is what triggers the anterior-posterior movement of hyoid Sensory Sensation of the face *focusing on the V3 (includes hard palate) issues: drooling, pocketing, feeling hot/cold, sensation of tongue (anterior 2/3), feeling hot or cold, oral residue, anterior spillage Motor Mastication (muscles: lateral pterygoid, masseter, temporalis) issues: jaw grading (e.g. if the patient is spastic/flaccid), poor bolus formation, oral residue, open-mouth posture, fatigue* Assessment different size of food cuts  for jaw grading and ability to chew it introduce the food at the molar side  for tongue movement (especially if the patient has a flaccid tongue)  if they can’t swallow for the second/third try = dukutin mo yung food o CN 7: facial nerve (MIXED) Sensory Taste (in the chorda tympani nerve) issues: decreased taste levels o increase taste input especially patients with dementia (aging affects taste) and/or patients with cognitive issues = to

boost the appetite for pleasure feeding (kahit bawal sakanila) Motor Controlling the face (lips, cheeks) issues: drooling (due to: decreased lip seal, decreased tone – cheeks), decreased intraoral pressure (due to orifice 1 and chamber 1), decreased bolus formation, decreased tone – cheeks: help contracts o CN 9: glossopharyngeal nerve (MIXED) @ nasopharynx to laryngopharynx Sensory Gag reflex: protective reflex and it is not primitive (it is with you for the rest of your life) Swallow reflex **If the gag reflex is a problem (due to hyposensitivity) but the swallow reflex is functional = NOT A PROBLEM **If the gag reflex is a problem and the swallow reflex is a problem = problem with CN 9 Taste of the posterior 1/3 of the tongue *sensation of the pharynx – when the food gets stuck: lump of food above the palate, soft palate, kanin sa PPW Motor *Things that we cannot see: -- you can only check this post-swallow by seeing: residue, coughing or aspiration --can only be assessed through instrumental means (e.g. FEES, MBS) Posterior pharyngeal wall movement  issues: post-swallow nasal regurgitation Pharyngeal constriction/elongation  issues: post-swallow coughing, pharyngeal residue, “di nag elevate si something” Velum elevation  issues: nasal regurgitation, food stuck at velum TRIGGER POINTS OF GAG REFLEX Base of tongue (@ sublingual parotid) Faucial pillars (1st or 2nd - actual point) Posterior pharyngeal wall **To open the mouth forcefully Using the cotton applicator… 1. Insert into the weak sides of the lips (side area joining the upper and lower lip) “Achilles’ heel of the lips” 2. Reach the molar = automatically opens mouth 3. Reach the faucial pillar – sweep and check bilaterally; keep it in the area for 5s (touching or tapping) 4. If the cotton applicator cannot go further, you are most likely at the PPW area o CN 10: vagus nerve (MIXED) Not so far away from 9 (different region lang) @ laryngeal mechanism/inlet Sensory Swallow reflex Cough reflex – sensory reflex General sensation of larynx **FEES: before starting the swallowing process, they tap each structure with the strobe (e.g. vocal folds, arytenoids) and see if they can trigger the cough reflex = to know if the larynx is functioning relatively okay. Motor Vocal fold adduction ~ reflection: decreased vocal quality (i.e. breathy)

Volitional cough – motor reflex **pre-swallow: vocal quality is breathy peri-swallow: coughs; di talaga nagsasara = paralyzed **pre-swallow: harsh post-swallow: gurgly without coughing = sensory issues – it is above the vocal folds what is your first gatekeeper?  epiglottis, so you have a problem with that if the bolus is stuck above the vocal folds; and vocal fold closure; and cough reflex o CN 11: accessory nerve (MOTOR) It controls all your neck muscles  Even though they are extrinsic, it helps the swallowing mechanism by providing stability Principle of recruitment: changing the posture can actually change the posture of the vocal being at the midline; gravity also pulls it down  Spasticity: that is why stretching is a good thing for these patients; also prior to feeding  Basic stretch: North South East West: maximum range of motion, add 10% pressure; have to make sure that the torso is stable  SW, NW, SE, NE (“ask the patient to turn to this side, then ask them to look up, and you stretch the shoulder part – have to elongate the muscle”)

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CN 12: hypoglossal nerve (MOTOR) All functions of your tongue (e.g. sweep, scrape, cupping, manipulation, propulsion) NOTES: Primary goal of swallowing/dysphagia assessment: nourishment/nutrition  achieved through volume o Regardless of what consistency, as long as the patient is well-nourished then you stick with that. o X: “ah kaya na niya mag tubig, ngayon mag mashed potato ka naman.” If you see your patient gets easily tired, then you do OPM before swallowing  can’t swallow anymore; so if the patient gets easily tired and your order is to do a swallowing assessment then you proceed with that (before OPM) with the cranial nerves in mind. In prioritizing, it doesn’t have to be in an ascending order (CN 5, 7, 9, 10, 11, 12), it still depends on the needs and background information of your patient TASTE: o Anterior 2/3: CN 5 o Posterior 1/3: CN 9 or 10 (?) Gag reflex: protective; swallow reflex: taking/nutritive In a formal report, separate CN testing for swallowing from the food trials -

CONSISTENCY Level 0

FOOD Thin water

AMOUNT **cc/mL/# of spoon

Level 2

Corn soup

Buccal pocketing

Level 4

Mashed potato with gravy

Coughed for 2 mins postswallow

*Manifestation: can be observed *Impression: cannot be observed; inference

PRESENTATION Cup/spoon/ straw

MANIFESTATION Anterior spillage

IMPRESSION Poor selfmonitoring Post-swallow residue (valleculae)