Dysphagia Swallowing Disorder. Presented by: Angie Dubis Bohn Compiled by: Nehal Kothari. Anatomy of Normal Swallow. Oral structures: Lips: Swallowing begins as soon as food is put in mouth. Help in stripping food off the spoon and retaining bolus in mouth.
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DysphagiaSwallowing Disorder Presented by: Angie Dubis Bohn Compiled by: Nehal Kothari
Anatomy of Normal Swallow Oral structures: • Lips: Swallowing begins as soon as food is put in mouth. Help in stripping food off the spoon and retaining bolus in mouth. • Teeth: Process of mastication. Chewing and grinding the food. • Cheeks: Performs flattening action. • Tongue: Moves bolus from side to side.
Stages of Swallowing • A. Oral Stage • B. Pharyngeal Stage • C. Esophageal Stage • Oral Stage: • Oral Prep and Oral transit • Oral Prepinvolves reduction of bolus via mastication. Salivary glands produce saliva which is mixed with bolus during reduction. • Cheeks flatten and holds the bolus in contact with teeth. • Tongue and jaw movements are coordinated to keep the food between the teeth.
Oral Transit • Bolus is medialized on the back of the tongue. • Soft palate elevates. • Lips and cheek muscles contract. • The posterior tongue depresses. • Remaining of the tongue presses against the hard palate. • Bolus is propelled towards the throat (pharynx).
Pharyngeal Stage • Anatomical Structures: • Larynx • Pharynx • Two tubes in throat: Trachea (wind pipe) and Esophagus (food pipe) • Physiology: • Swallow reflex is triggered at the faucial arches. • To prevent nasal regurgitation, velopharyngeal closure is achieved. • Complete closure of true vocal folds. • Retroversion of the epiglottis. • Contraction of pharyngeal constrictors and laryngeal elevation takes place. • Larynx protects the airway.
As bolus moves from pharynx, it divides with appx. ½ flowing down each side of pharynx (throat). These 2 portions join together at the opening of esophagus.
Changes following stroke • Oral structures: • Lip weakness: Anterior loss of bolus. Loss of food. Difficulty in holding the bolus in mouth. • Tongue weakness: Difficulty with process of mastication and bolus transit. Residue may remain in oral cavity. Pre mature spill over may occur too. • Cheeks weakness: Difficulty with retaining food in the mouth. May result in pocketing of food on the weak side. • Reduced Oral Sensitivity: Food is not felt in the mouth and may be lost earlier in the oral cavity and aspirated before swallow. • Jaw weakness: May affect the adult rotary chewing pattern.
Changes following stroke • Weakness of throat: Laryngeal muscles may not be strong enough to move up and down. Epiglottis does not completely fall down. Material enters the airway. May result in choking or coughing Aspiration. • Disorders that may affect pharyngeal stage are: • Delayed or absent swallow reflex • Inadequate velum closure resulting in nasal regurgitation • One sided weakness of pharynx • Reduced peristalsis • Reduced laryngeal elevation and closure • Cricopharyngeal dysfunction
Reduced Sensitivity: Body fails to get the signal fast enough and food remains in airway, putting the person at risk for aspiration. • 40% of the people present with silent aspiration following stroke. Owing to reduced sensitivity, no cough reflex is triggered. One figures out the underlying problem only once pneumonia develops.
Esophageal Stage • Cricopharyngeus muscle relaxes. Allows food to pass into esophagus (food pipe). This food pipe connects to the stomach. • In the esophagus, 3 peristaltic movements occur and aid in passage of food to the stomach.
A represents food bolus and B indicates marked presence of upper air in the esophagus inferior to food bolus.
Conditions that can affect esophageal transit • Lax Cricopharyngeus muscle • Reduced esophageal peristalsis • Partial or total esophageal tumors: • Barret’s esophagus: • Normal tissue covering is replaced due to prolonged reflux and severe damage to the covering or tissue of esophagus. • Esophageal web • Achalasia: Failure to relax
Recap of Stages of Swallowing Initial stages of eating and swallowing under voluntary control. This means that it is governed by the brain.
Oral Stage Once food enters the mouth the teeth break it down into smaller and smaller pieces. This has the dual function of making the food easier to swallow and increasing the surface area of food on which the saliva can act. The tongue, lips and cheeks assist the teeth in the process by allowing the food to be "rolled" around the oral cavity. The mechanical action described above produces a softened bolus of food which is now ready to be swallowed. The correct biological term for swallowing is deglutition.
Pharyngeal Stage The picture shows the voluntary stage of deglutition. Here the bolus is pushed into the upper part of the pharynx (known as the oropharynx) by the action of the tongue. The pharyngeal stage of deglutiton is stimulated when the bolus enters the oropharynx. This stage of swallowing is mainly due to a reflex response.
Recap pf Pharyngeal Stage • This sets off muscular contractions in the pharynx. The soft palate closes off the nasopharynx. The vocal cords in the larynx are moved up and towards the front of the throat thus closing it off to the passage of food. This is extremely important in preventing food from entering the airway.I am sure we have all experienced the unpleasant feeling of food or drink going the "wrong way"!! • Another effect of the process is to widen the opening of the oesophagus thus making the passage of the bolus along the alimentary canal easier.
Recap • As the bolus pushes it's way into the oesophagus it automatically pushes the epiglottis downwards further closing off the airway.
Recap of Esophageal Stage • The bolus then enters the esophagus and the final stage of swallowing begins. • This final stage is known as the esophageal stage of deglutiton.
Animation of the whole process • http://greenfield.fortunecity.com/rattler/46/images/swallow.gif
Understanding the process through MBS images • Summary:
What can we do? • Diet Modifications • To maintain nutrition and ensure safety during swallowing. • Remember ! different facilities may use different names for these diet levels. • Level I: Puree • Level II: Mechanical Soft • Level III: Advanced • Regular diet
Level I • Puree Diet: • Homogenous, very cohesive, pudding-like, requiring very little chewing ability. • Examples: Apple Sauce, Pudding, Smooth mashed potato, Pureed scrambled eggs and cheese.
Level II • Cohesive, moist, semi-solid. • Requires some chewing ability. • Ground or minced meats with fork-mashable fruits & vegetables. • Excludes most bread products, crackers, and other dry foods.
Level III • Soft solid. • Requires more chewing ability. • Easy-to-cut meats, fruits, vegetables. • Excludes hard, crunchy fruits & vegetables, sticky foods, very dry foods. Soft bread Cake
Regular Diet • Any solid textures Carrot Corn Bagel Chips Nuts
Liquids • Thin: water, coffee, tea, soda, ices or anything that will liquefy in the mouth within a few seconds. • Nectar-Like: thickened to nectar consistency such as apricot or peach nectar • Honey-Like: thickened to honey consistency • Spoon Thick: thickened to a pudding consistency
Thickening Liquids • Thickening liquids can be achieved using modified food starch thickeners (a powder that is added to the liquid). The problem with this method of thickening is that the final product is not always the consistency prescribed. • There is much room for staff error using powdered thickeners, but if staffing is not an issue, it is a less expensive method. There are now many thickening packets available too. The advantage of using that they do not alter the consistecy of the liquid after a while.