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Inefficient oral transit head back utilizes gravity to clear oral cavity [6]
(reduced lingual propulsion of bolus)
Delay in triggering the pharyngeal swallow chin down widens valleculae to prevent bolus entering
(bolus past ramus of mandible but airway;
pharyngeal swallow is not triggered) narrows airway entrance, reducing risk of
aspiration [11]
Reduced posterior motion of tongue base chin down pushes tongue base backward toward
(residue in valleculae) pharyngeal wall [11]
Unilateral vocal fold paralysis or surgical head rotated to places extrinsic pressure on thyroid cartilage,
removal damaged side improving vocal fold approximation, and
(aspiration during the swallow) directs bolus down stronger side [6, 16]
Reduced closure of laryngeal entrance and chin down puts epiglottis in more protective position;
vocal folds narrows laryngeal entrance [11]
(aspiration during the swallow) head rotated to improves vocal fold closure by applying
damaged side extrinsic pressure
Unilateral pharyngeal paresis head rotated to eliminates damaged side of pharynx from
(residue on one side of pharynx) damaged side bolus path [14, 16]
Reduced pharyngeal contraction lying down on eliminates gravitational effect on pharyngeal
(residue spread throughout pharynx) one side residue [6, 12, 15]
Unilateral oral and pharyngeal weakness on head tilt to directs bolus down stronger side by gravity
the same side stronger side [4, 6]
(residue in mouth and pharynx on same side)
Cricopharyngeal dysfunction head rotated pulls cricoid cartilage away from posterior
(residue in pyriform sinuses) pharyngeal wall, reducing resting pressure
in cricopharyngeal sphincter
Reduced range of tongue motion thick liquid initially, then, thick foods
thin liquid
Reduced tongue coordination liquid thick foods
Reduced tongue strength thin liquid thick, heavy foods
Delayed pharyngeal swallow thick liquids and thicker foods thin liquids
Reduced airway closure pudding and thick foods thin liquids
Reduced laryngeal movement/cricopharyngeal
dysfunction thin liquid thicker, higher viscosity foods
Reduced pharyngeal wall contraction thin liquid thick, higher viscosity foods
Reduced tongue base posterior movement thin liquid higher viscosity foods
geal delay time [1, 17]. These can be measured Food Consistency (Diet) Changes
from videofluoroscopy; the first two can also Generally, elimination of certain food con-
be measured with ultrasound. In some pa- sistencies from the diet should be the last
tients, pharyngeal delay time can be measured compensatory strategy examined [1]. Elimi-
from videoendoscopy. However, if a patient nating certain food consistencies, such as thin
exhibits premature spillage of a bolus because liquids, from the diet can be difficult for the
of oral abnormalities, videoendoscopy will patient. This should only be done if other
not be capable of distinguishing premature compensatory or therapy strategies are not
spillage from the onset of pharyngeal delay feasible, as in a patient with a movement dis-
time with the same accuracy as videofluoros- order whose posture changes continuously,
copy, since the oral stage of swallow cannot be who cannot follow directions and use swallow
visualized with videoendoscopy. maneuvers, and for whom oral sensory proce-
dures are inappropriate. Table 2 presents the
Modifications in Volume and Speed of easiest food consistencies and the food consis-
Food Presentation tencies to be avoided for each swallow disor-
For some patients, a particular volume of der.
food per swallow elicits the fastest pharyngeal
swallow [20, 28]. In patients with a delay in Intraoral Prosthetics
pharyngeal triggering or with weakened pha- Intraoral prosthetics can be an important
ryngeal swallows which require 2–3 swallows compensatory procedure to improve swallow-
per bolus, taking too much food too rapidly ing in oral cancer patients with significant loss
can result in a sizable collection of food in the of oral tongue tissue (25% or more) or tongue
pharynx and aspiration. Simply taking small- movement, in neurologic patients with bilat-
er boluses at a slower rate may eliminate any eral hypoglossal paralysis, in oral cancer pa-
risk of aspiration in these patients. tient groups with surgical ablation of part or
all of the soft palate, and in neurologic pa-
tients with palatal paralysis.
A palatal lift prosthesis lifts the soft palate of controlling food in the mouth for chewing
into an elevated (closed) position in patients or swallowing.
with velar paralysis. A palatal obturator can These intraoral prosthetics are usually con-
be used in oral cancer patients with significant structed by a maxillofacial prosthodontist in
resection of the soft palate. The palatal re- cooperation with the speech-language pathol-
shaping prosthesis recontours the hard palate ogist/swallowing therapist. Construction
to interact with the remaining tongue, filling should begin within the first 4–6 weeks post-
in the areas of the hard palate where the operatively to prevent the patient’s develop-
patient’s tongue cannot make contact and en- ment of poor habits for swallowing which will
abling the patient to control and propel the need to be dishabituated when they receive
bolus more efficiently (fig. 1). A palatal aug- the prosthesis. The speech-language patholo-
mentation or reshaping prosthesis can be ex- gist/swallowing therapist provides input re-
tremely effective in patients with significant garding the amount of palate lowering needed
tongue resections or bilateral tongue paralysis and the best contour of the palate.
[29, 30]. Postoperative patients often indicate Compensatory procedures are usually used
that it feels as if their tongue ‘fits their mouth temporarily until the patient’s swallow recov-
again’ with the prosthesis in place. Without ers or direct therapy procedures to improve
the prosthesis the patient has a large oral cavi- oropharyngeal motor function take effect. Oc-
ty and a very small tongue which is incapable casionally, patients with severe neurologic or
Supraglottic swallow Reduced or late vocal fold closure voluntary breath hold usually closes vocal
folds before and during swallow [38]
delayed pharyngeal swallow closes vocal folds before and during delay
Super-supraglottic swallow reduced closure of airway entrance effortful breath hold tilts arytenoid forward
closing airway entrance before and during
swallow [38, 39]
slow laryngeal elevation speeds laryngeal elevation [39, 56]
Effortful swallow reduced posterior movement of the effort increases posterior tongue base
tongue base, reduced oropharyngeal movement [42]
pressure
Mendelsohn maneuver reduced range of laryngeal movement laryngeal movement opens the UES;
prolonging laryngeal elevation prolongs
UES opening [32, 35, 36]
discoordinated swallow normalizes timing of pharyngeal swallow
events [31]
prove bolus clearance from the valleculae [1, low, don’t let your Adam’s apple drop. Hold it up with
40–42]. The instructions for the effortful your muscles for several seconds.
Alternate instructions: Swallow your saliva several
swallow are:
times and pay attention to the feeling in your throat as
you swallow. Can you feel that in the middle of the
As you swallow, squeeze hard with all of your mus- swallow everything squeezes together at the top of your
cles. throat? Next time when you swallow, hold the squeeze
for several seconds and don’t let go.
The Mendelsohn maneuver is designed to
increase the extent and duration of laryngeal All of these maneuvers can be practiced
elevation and thereby increase the duration with the patient, using no food. The patient
and width of cricopharyngeal opening [31, 32, can be given slow, step-by-step instructions
43–47]. This latter maneuver can also im- for practice, asking them to swallow their
prove the overall coordination of the swallow saliva.
[31]. Instructions for the Mendelsohn ma- During the diagnostic videofluorographic
neuver are: study, if postural techniques and oral sensory
facilitation techniques do not improve swal-
Swallow your saliva several times and pay atten-
low physiology sufficiently to allow the pa-
tion to your neck as you swallow. Tell me if you can
feel that something (your Adam’s apple or voice box) tient to begin some oral intake, voluntary
lifts and lowers as you swallow. Now, this time, when swallow maneuvers may be appropriate.
you swallow and you feel something lift as you swal- However, these maneuvers require the ability
to follow directions carefully and are not fea- these maneuvers during the swallow, a signif-
sible in patients who have cognitive or signifi- icant limitation.
cant language impairment. These maneuvers Recently, a new exercise, a head-raising
also require increased muscular effort and are exercise [49], has been described to strengthen
not appropriate in patients who fatigue easily. laryngeal motion during swallowing and
Usually, voluntary maneuvers are utilized thereby affect opening of the upper esophage-
temporarily as the patient’s swallow recovers, al sphincter. The exercise effect has been ex-
and are then discarded as the patient’s swal- amined in older normal individuals where
low physiology returns to normal. However, hyoid and laryngeal motion tends to dimin-
there are patients who can only swallow safely ish. Hyoid motion is responsible in large mea-
and efficiently using a voluntary maneuver sure for upward forward laryngeal motion
permanently [31, 32, 48]. For some patients, during swallow which, in turn, is largely re-
best swallow is achieved by a combination of sponsible for opening the upper esophageal
postural changes and swallow maneuvers. Op- sphincter [36, 43]. The exercise consists of 3
timal contributions of postures and maneu- repetitions of the individual lying on their
vers are presented in table 4. back and lifting their head up so they can see
Each swallow maneuver has a specific their toes without raising their shoulders and
goal to change a selected aspect of pharyngeal holding it for 1 min and then relaxing for
swallow physiology [1]. Changes in these tar- 1 min. Then 30 repetitive short head raisings
get components of the oropharyngeal swal- are done and the exercise done 3 times a day.
low can be observed or measured, e.g., dura- Results of application of the exercise to nor-
tion and onset of closure of the airway en- mal older subjects revealed improved anterior
trance (super-supraglottic swallow), extent laryngeal movement, extent of upper esopha-
and duration of laryngeal elevation (Mendel- geal sphincter anterioposterior opening and
sohn maneuver) [31, 32, 35–38, 40, 41, 44– reduced hypopharyngeal intrabolus pressure.
46]. In general, the effects of swallow ma- Indirect therapy involves exercise pro-
neuvers are best observed and measured us- grams or swallows of saliva but no food or liq-
ing videofluoroscopy. The effects of these uid is given. Any of the therapy procedures
maneuvers on swallow safety (aspiration) described above can be done indirectly or
and efficiency (residue) may be observed at directly. Even swallow maneuvers can be
times using videoendoscopy. However, vid- practiced with saliva only. Indirect therapy is
eoendoscopy does not allow visualization of used in patients who aspirate on all food vis-
References
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