1. Dysphagia in the Neurologic and Head and Neck Cancer Patient
Karen Ball MPA MS CCC-SLP BCS-S
Speech Language Pathologist
Queens College,
City University of New York (CUNY)

2. Review normal swallow physiology (oral prep, oral stage, pharyngeal stage, esophageal stage)
What muscles are involved, neurological input (supra hyoid muscles, tongue, laryngeal, palatal, pharyngeal muscles)
Review cortical and peripheral input into the swallow (CNS/PNS, UMN/LMN)
Role of swelling (larynx post intubation, post anterior spine surgery, head/neck surgery)
Back to basics

3. Pressure generation and bolus transit during the pharyngeal stage of swallowing Swallowing mechanism as a closed system (McConnel)
Back to Basics

4. Pressure generation system
Oropharyngeal pressure pump
Tongue (piston)
Pharyngeal wall (chamber)
(tongue base applies pressure to bolus tail, pharyngeal contraction also applies force to the bolus, increasing velocity and propulsion of the bolus through the pharynx)
Pressure generation system

5. Pressure generation system
PE segment pump
Larynx
Hypopharynx
Anterior movement of the larynx opens the PE segment
Esophageal pressure sub atmospheric, opening PE segment releases this, bolus is drawn into esophagus
Pressure generation system

6. Neuro Diagnoses Acute Chronic Progressive
Combination (Patient with PD who is s/p CVA or TBI secondary to a fall)
Associated diagnoses:
Structural (osteophytes, diverticula, achalasia)
Diabetes
Physiological: (esophageal dysmotility, Gerd, LPR)
Psychological (anxiety, fear of choking)
Neuro Diagnoses

7. Neuro Diagnoses Contributing factors that could be present:
Metabolic encephalopathy
Confusion/Lethargy
AGE/Sarcopenia
Neuro Diagnoses

8. Neuro Involvement Muscle tone: (spasticity, flaccidity)
Muscle weakness/paralysis
Bradykinesia
Major muscles(muscular structures) affected:
Tongue (oral tongue, tongue base)
Cheeks
Velo pharyngeal complex
Pharynx
UES
Vocal folds
Suprahyoid muscles
Intrinsic laryngeal muscles
Neuro Involvement

9. H/N Cancer Diagnoses Location Staging (size)
Treatment (surgery, chemo/radiation, or combo) and response to treatment.
If surgery, how was the area of the resection reconstructed?
Presence of G-Tube and timing of placement.
H/N Cancer Diagnoses

10. Can change the mechanics of swallowing by altering the swallowing structures (surgery)
Can change the physiology of swallowing secondary to effects of Chemo/RT (fibrosis,)on the major muscles involved in swallowing.
Can change the desire to eat due to presence of sensory or taste changes or pain. Occasionally, fear can also contribute.
H/N Ca Treatment

11. A thorough, well thought out clinical exam is essential.
Clinician style
Conservative? i.e.: “afraid” of aspiration (thickens everyone’s liquids, recommends NPO continually).
Realistic? (Common sense)
Thoughtful? i.e.: quality of life essential
Empathetic? Involve the patient in the decision making.
Clinical Examination

12. The COUGH Indicative of airway protection Is cough secondary to ingestion of food or liquid? Nervous/anxiety provoked? (habit cough) Secondary to globus? Secondary to GERD/LPR? We all cough!!!!
Clinical Examination

13. Langmore, et al “Predictors of Aspiration Pneumonia: How Important is Dysphagia?” (Dysphagia, 1998)
189 Elderly subjects recruited from outpatient clinics, acute care wards, and nursing home from the VA Medical Center, Ann Arbor, MI
Given an oral/pharyngeal/esophageal swallowing assessment, feeding assessment, functional status assessment, medical assessment, oral/dental assessment.
Followed for up to 4 years for an outcome of verified “aspiration pneumonia”

14. Results
Best predictors:
Dependent for feeding
Dependent for oral care
Number of decayed teeth
Tube feeding
>1 medical diagnosis
Number of Medications
Smoking
Langmore, et al “Predictors of Aspiration Pneumonia: How Important is Dysphagia?” (Dysphagia, 1998)

15. “Dysphagia was concluded to be an important risk for aspiration pneumonia, but generally not sufficient to cause pneumonia unless other risk factors were present as well”
Langmore, et al “Predictors of Aspiration Pneumonia: How Important is Dysphagia?” (Dysphagia, 1998)

16. Clinical Examination: Let’s think about: Activity Level and Attitude
Ambulation Status
Activity Level/Spunk
Nutritional Status
Independence with ADL’s i.e.: feeding
Clinical Examination: Let’s think about: Activity Level and Attitude

17. Clinical Examination: Social/Caregiver / Living Situation
Support System
Permanent Residence
Clinical Examination: Social/Caregiver / Living Situation

18. Does aspiration of food lead to aspiration pneumonia. J
Does aspiration of food lead to aspiration pneumonia??? J. Robbins has found that aspiration of thickened fluids is much more difficult to clear from the lungs than aspiration of thin liquids. MD thoughts essential at this juncture. How tolerant are they of aspiration. How much is too much? PS: we all aspirate/penetrate occasionally..does this mean we need to place ourselves NPO???
Aspiration

19. Thick liquids Nectar thick Honey thick
Thickeners available: natural foods (i.e.: applesauce)
Corn starch type: Thick it
Xanthan gum type (gel)(simply thick)
Thick liquids

20. You like. Hydration needs generally considered 64 oz
You like? Hydration needs generally considered 64 oz.. fluid per day Do most of us attain this??? Probably not with normal liquids Can we assume that patients will consume 64 oz. of thick liquids? (rarely)
Thick liquids

21. Pureed food You like? Hard sell to those who are cognitively intact….
We need to strive to maximize a patient’s desire when we recommend a diet level.
Consider taste, texture, caloric content.
How thick is it?
This can be a challenge if the patient is in the hospital or nursing facility. OR if the patient is not a cook!
Pureed food

22. MBS: Gold standard, able to evaluate all stages of swallow
FEES: View before and after the swallow. Views structures best, can assess secretion management
The Instrumental Exam

23. The Instrumental Exam Logemann:
Instrumental Exam indicated when pharyngeal stage dysphagia is suspected
What happens when access to Instrumental examinations is limited?
The Instrumental Exam

24. Careful, thoughtful clinical examinations can work!
Need to acknowledge some issues will not be able to be identified: (i.e.: Zenkers, osteophytes, esophageal motility, UES function)
You proceed as best you can with your excellent clinical judgement!
The Instrumental Exam

25. Treatment/Techniques
Mendlesohn Maneuver
Shaker Exercises
Masako Maneuver
Supraglottic Swallow
Effortful Swallow
Huck and Spit
Treatment/Techniques

26. Treatment/Positions Head turn to weak side
Chin tuck (cut out cup, straw)
Lean to strong side
Treatment/Positions

27. Treatment/Misc. Alternate liquids/solids (liquid flush)
Double swallow (dry swallow)
Add texture
Extra sauces and gravies (moisteners)
Caloric enhancement
Treatment/Misc.

28. Trends on the horizon Exercise Physiology
EMST (Expiratory Muscle Strength Training)
Sapienza (Aspire Products LLC) emst150.com
IPRO (Isometric Progressive Resistance Oropharyngeal Therapy) Robbins
(Swallowsolutions.com) (lots of info on website)
(relation of IOPI, MOST) Targets effects of Sarcopenia. Importance of understanding resistance training in the context of functional reserve
Trends on the horizon

29. And remember! The best exercise for swallowing is SWALLOWING! AND
SWALLOWING SOMETHING!
QUALITY OF LIFE AS WELL AS PATIENT SAFETY ARE KEY
And remember!

30. And remember! PATIENT’S RIGHTS RIGHT TO SAY NO
CLOSE COOPERATION WITH MEDICAL TEAM
PATIENT ADVOCACY
And remember!