Disfagia

Chapter 10:
Dysphagia
Justice
Communication Sciences and Disorders: An
Introduction
Copyright 2006 by Pearson Education, Inc.

Upper Saddle River, New Jersey 07458
All rights reserved.
10.1
Focus Questions
What is dysphagia?
How is dysphagia classified?
What are the defining characteristics of
dysphagia?
How is dysphagia identified?
How is dysphagia treated?
Justice
Introduction

10.2
Introduction
Dysphagia: impairment in the ability to
swallow because of neurological or
structural problems that alter the normal
swallowing process
ASHA expanded the Scope of Practice for
speech-language pathologists to include
swallowing disorders in late 1980s
Dysphagia intervention now makes up
about 50% of a SLPs caseload in medical
settings (e.g., hospital, nursing homes)
Justice
Introduction

10.3
Case Study #1: Sylvia Anderson

78-year old with Alzheimers dementia
living in a nursing home needs minimal
to moderate assistance while eating
Lately, hasnt been finishing meals, has
gurgly voice quality during mealtime, and
has recently had severe coughing
episodes while eating
SLP suspects a pharyngeal stage
swallowing problem and wants a further
instrumental assessment at local hospital
Justice
Introduction

10.4
Case Study #1 Questions

Transporting Sylvia to the local hospital for
an instrumental examination is costly.
How can the costs be justified?
How might reliance on others for
assistance with feeding influence
nutritional status and hydration?
Justice
Introduction

10.5
Case Study #2: Lee Chin

43-year old bilingual man who has
persistent dysphagia following cancer of
the right buccal space
To treat the cancer, Lee had radiation
therapy and neck dissection
Currently exhibits pharyngeal dysphagia,
aspiration, hoarse vocal quality, and right
lower facial weakness
Currently receives nutrition through a gtube
Justice
Introduction

10.6

Is Lee a candidate for dysphagia therapy
at this time? Why or why not?
What education should be provided to Lee
regarding his situation?
Justice
Introduction

10.7
Case Study #3: Martin Coleman

45-year old man diagnosed with ALS 18 months
ago
Unable to work, on a puree diet with thin liquids,
has lost 15 pounds in past two months, just
recovered from severe aspiration pneumonia
MBS shows severe oral and pharyngeal dysphagia
with aspiration
Martin and his family now need to decide whether
or not to resort to feeding tube, and want to consult
their priest to make sure decision is in keeping with
their religious beliefs
Justice
Introduction

10.8

As the speech-language pathologist, what
are your responsibilities to this client and
his family in making their decision?
What support systems should be provided
to this family during their decision-making
process?
Justice
Introduction

10.9
I. What is Dysphagia?
Disorder of swallowing rendering person
unable to safely and/or efficiently eat or
drink
To understand disorder swallowing, must
first understand the normal swallowing
process
Justice
Introduction

10.10
The Normal Swallow

Innate ability which is present in the
developing fetus
Necessary to maintain nutrition and
hydration
Adults swallow approximately 580 times
daily unconsciously
Swallowing is a four-phase process:
Oral preparatory phase
Oral phase
Pharyngeal phase
Esophageal phase
Justice
Introduction

10.11
Oral Preparatory Phase

Begins as food or liquid enters the mouth
Containing, manipulating, and preparing
the food or liquid into a bolus
Chewing (mastication) occurs to grind solid
bolus into manageable texture
Requires coordination of lips, tongue, teeth,
mandible, and cheeks
Duration: variable depending on substance

Respiration: normal through the nose
(mouth closed)
Justice
Introduction

10.12
Oral Phase
Bolus is propelled to the back of the mouth
stripping action by the tongue
Tension in the cheeks (buccal muscles)
Duration: 1-1.5 seconds

Respiration: normal through the nose
Justice
Introduction

10.13
Pharyngeal Phase
Begins as the bolus reaches the tonsils (faucial

pillars)
Pharygeal swallow reflex is triggered:
Pharyngeal wall and back of tongue move together
and pharyngeal muscles squeeze to move bolus
down through the pharynx
Upper esophageal sphincter opens to allow

passage of bolus into esophagus
Time: 1 second
Respiration: briefly halted (apneic moment)
During bolus transit, risk of food or liquid
entering the airway
Justice
Introduction

10.14
Pharyngeal Phase Protective

Mechanisms
Soft palate elevates to stop bolus from

flowing upward into nasal area
Larynx moves forward and higher in the neck
to reduce risk of entrance into airway
Epiglottis forms a cover over the larynx
Vocal folds come together to close the
entrance into the larynx
If material does enter the larynx, reflexive
cough to expel it will occur
Justice
Introduction

10.15
Esophageal Phase
Bolus is propelled through the esophagus
by an involuntary wave or contraction
Moves from the upper esophageal
sphincter through the lower esophageal
sphincter and into the stomach
Time: 8-20 seconds, can be influenced by
age (often increase in duration in elderly
population)
Respiration: normal through nose and
mouth
Justice
Introduction

10.16
Disordered Swallow: Dysphagia

Impairment can occur in one, some, or all of the
four phases of swallowing
Some persons have impairments that result in
aspiration (food or liquid moves below the level
of vocal folds into the airway)
Some persons have to alter their diet to control
the consistencies, but this can cause difficulty
maintaining hydration and nutrition
Some persons require an enteral feeding tube
for nutritional maintenance
Justice
Introduction

10.17
Additional Considerations
Dysphagia should not be confused with a
disruption in feeding, but it is one
subgroup of feeding disorders
Dysphagia is not a disease but a symptom
of several etiologies (e.g., neurological
injuries, progressive brain diseases)
Social and psychological impacts of
dysphagia: changes in eating routines and
food choices, decreased personal
independence, and challenge to
participating in community activities
Justice
Introduction

10.18
Prevalence and Incidence

Statistics on who experiences dysphagia:
14% of acutely hospitalized patients
30-35% of patients in rehabilitation facilities
50% of residents in nursing home
environments
Justice
Introduction

10.19
II. How is Dysphagia Classified?

No universally accepted system, but usually
based on etiology, manifestation, and
severity
Some available instruments:
Penetration-Aspiration Scale: 8-point scale to
describe degree of airway protection during the
swallow (1 = no material enters airway,
8 = aspiration)
New Zealand Index for Multidisciplinary
Evaluation of Swallowing: rates swallowing
performance on a scale from 0 to 4 (0 = no
significant impairment, 4 = profound impairment)
Justice
Introduction

10.20
III. Defining Characteristics of

Dysphagia
Structural abnormalities or physiological
deficits for each of the phases of swallowing:
Oral preparatory
Oral
Pharyngeal
Esophageal
SLP manages oral preparatory, oral, and

pharyngeal dysphagias (i.e., oropharyngeal
dysphagia); gastroenterologist manages
esophageal dysphagia
Justice
Introduction

10.21
Oral Preparatory Phase

Dysphagia
Likely causes: head and neck cancers,

stroke, Parkinsons disease
Characteristics:
Decreased lip closure
Problems controlling ingested materials
Problems biting or chewing
Inefficient oral preparation (long duration)
Justice
Introduction

10.22
Oral Phase Dysphagia

Likely causes: stroke, progressive
neurological diseases
Characteristics:
Difficulty moving bolus to the back of mouth
Inability to control bolus flow
Delayed initiation of bolus movement
Justice
Introduction

10.23
Pharyngeal Phase Dysphagia

Likely causes: head and neck cancers,
neurological disorders
Characteristics:
Incomplete palatal elevation (nasal reflux)
Delayed initiation of pharyngeal swallow reflex
Weak tongue and pharyngeal muscle forces
Reduced laryngeal elevation (more prone to
aspiration)
Inadequate opening of the upper esophageal
sphincter (bolus cannot move into the
esophagus)
Justice
Introduction

10.24
Esophageal Phase Dysphagia

Likely causes: reflux, certain cancers
Characteristics:
Structural abnormalities in esophagus
Decreased esophageal motility or contraction
Inadequate opening of lower esophageal
sphincter (bolus cannot move into stomach)
Excessive opening of the lower esophageal
sphincter, allowing backward flow of contents
from stomach to esophagus (reflux)
Justice
Introduction

10.25
Stroke
Dysphagia Causes:
Neurological Disease
Interruption in blood supply to brain, resulting in

brain damage
Frequency of dysphagia is about 50%
Increases risk for malnutrition, aspiration, and
pneumonia
Traumatic brain injury

Dysphagia is common complication of
neurological damage (from 26 71%)
Delay in pharyngeal swallow reflex, decreased
pharyngeal constriction, and oral motor problems
Justice
Introduction

10.26
Dysphagia Causes:
Progressive Neurological Disease
Parkinsons disease:
Incidence of dysphagia from 50% to 92%
Drooling, problems in bolus preparation and
transport, delayed swallowing reflex, aspiration,
residual materials in pharynx
Amyotrophic lateral sclerosis:

Also known as Lou Gehrigs disease, patients will
experience oropharyngeal dysphagia at some
point in their disease process
Dementia:
Dysphagia is common feature in moderate and
severe impairment levels
Justice
Introduction

10.27
Dysphagia Causes:
Head and Neck Cancers
Many patients with cancers of the mouth,

pharynx, and larynx experience dysphagia
prior to medical management of the
cancer, but treatments can cause
dysphagia or make the already existing
case more severe
The extent of the medical intervention to
combat the cancer influences the
swallowing profile
Justice
Introduction

10.28
Dysphagia Causes:
Medical Interventions
Surgical management: full or partial

removal of components of swallowing
Radiation therapy: reduced saliva
production, edema, tooth decay, and pain
Chemotherapy treatment: nausea,
vomiting, and fatigue
Tracheotomy: tube alters normal air
exchange, interfering with swallowing
performance
Justice
Introduction

10.29
IV. How is Dysphagia Identified?

SLP is responsible for these tasks:
Determine presence or absence of dysphagia
Determine underlying causes
Assess severity
Make recommendations
Design and implement rehabilitation plan
Share information with other professionals
Need to achieve a balance between

concern for safety issues and quality of life
Justice
Introduction

10.30
Consultation with the SLP

Referral from physician or nurse who
suspects swallowing impairment
Interdisciplinary approach to screening at
hospitals, rehabilitation centers, and
clinics:
Health care staff members should be trained
to recognize possible signs of dysphagia, and
then make referral to SLP for further
evaluation
Justice
Introduction

10.31
Clinical Swallowing Examination

Also called Bedside Swallow Examination:
Review of medical records
Comprehensive interview with client
Oral mechanism examination
Trial feedings observation
Feeding recommendations
Referrals for either:
Further instrumental assessment (need physicians
prescription to be covered by insurance)
Specialized testing by other professionals
Justice
Introduction

10.32
Instrumental Dysphagia Exam

More objective, quantifiable measure of
swallowing function
Commonly used approaches:
Fiberoptic Endoscopic Examination of
Swallowing: visualization of swallowing
through flexible tube with recordable camera
Ultrasonography: uses sound waves to
recreate a picture of structures (most
beneficial in oral phase evaluation
Videofluorscopy: same as a modified barium
swallow (most commonly used; gold
standard)
Justice
Introduction

10.33
V. How is Dysphagia Treated?
SLP works to remediate oropharyngeal

dysphagia
Compensatory approaches
Restorative approaches
To maintain nutrition, dietary modifications

and/or alternative nutrition via a feeding tube
Nasogastric, gastrostomy, jejunostomy
Include ongoing assessment of clients

response to intervention, and adjust goals
and approaches to fit evolving needs
Justice
Introduction


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Chapter 10:

Copyright 2006 by Pearson Education, Inc.

Copyright 2006 by Pearson Education, Inc.

Copyright 2006 by Pearson Education, Inc.

Case Study #1: Sylvia Anderson

Copyright 2006 by Pearson Education, Inc.

Case Study #1 Questions

Copyright 2006 by Pearson Education, Inc.

Case Study #2: Lee Chin

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Case Study #2 Questions

Copyright 2006 by Pearson Education, Inc.

Case Study #3: Martin Coleman

Copyright 2006 by Pearson Education, Inc.

Case Study #3 Questions

Copyright 2006 by Pearson Education, Inc.

Copyright 2006 by Pearson Education, Inc.

The Normal Swallow

Copyright 2006 by Pearson Education, Inc.

Oral Preparatory Phase

Duration: variable depending on substance

Copyright 2006 by Pearson Education, Inc.

Duration: 1-1.5 seconds

Copyright 2006 by Pearson Education, Inc.

Begins as the bolus reaches the tonsils (faucial

Upper esophageal sphincter opens to allow

Copyright 2006 by Pearson Education, Inc.

Pharyngeal Phase Protective

Soft palate elevates to stop bolus from

Copyright 2006 by Pearson Education, Inc.

Copyright 2006 by Pearson Education, Inc.

Disordered Swallow: Dysphagia

Copyright 2006 by Pearson Education, Inc.

Copyright 2006 by Pearson Education, Inc.

Prevalence and Incidence

Copyright 2006 by Pearson Education, Inc.

II. How is Dysphagia Classified?

Copyright 2006 by Pearson Education, Inc.

III. Defining Characteristics of

SLP manages oral preparatory, oral, and

Copyright 2006 by Pearson Education, Inc.

Oral Preparatory Phase

Likely causes: head and neck cancers,

Copyright 2006 by Pearson Education, Inc.

Oral Phase Dysphagia

Copyright 2006 by Pearson Education, Inc.

Pharyngeal Phase Dysphagia

Copyright 2006 by Pearson Education, Inc.

Esophageal Phase Dysphagia

Copyright 2006 by Pearson Education, Inc.

Interruption in blood supply to brain, resulting in

Traumatic brain injury

Copyright 2006 by Pearson Education, Inc.

Amyotrophic lateral sclerosis:

Copyright 2006 by Pearson Education, Inc.

Many patients with cancers of the mouth,

Copyright 2006 by Pearson Education, Inc.

Surgical management: full or partial

Copyright 2006 by Pearson Education, Inc.

IV. How is Dysphagia Identified?

Need to achieve a balance between

Copyright 2006 by Pearson Education, Inc.

Consultation with the SLP

Copyright 2006 by Pearson Education, Inc.