Midterm sample questions
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| List 6 defining attributes of the current view of rehab. | process; restoration; effectiveness; enabling & facilitating; learning & teaching; autonomy
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| What can we do with clients? | change in: swallow; health status; functional status; quality of life; cost of treatment
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| List the muscles with their cranial nerve responsible for hyolaryngeal elevation. | CNV-trigeminal-mylohyoid & ant.digastric; CNVII-facial-styloid & post.digastric; CNXII-hypoglossal-hyoglossus & geniohyoid
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| List the muscles with their cranial nerve responsible for airway protection & clearance. | CNX-vagus-intrinsic laryngeal
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| What cranial nerve branches are involved in protecting the airway above the vocal cords? | CNX-vagus-superior laryngeal branch sensory receptors detect material
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| What cranial nerve brances are involved in protecting the airway below the vocal cords? | CNX-vagus-recurrent laryngeal branch sensory receptors detect material
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| Explain the process of airway protection with an emphasis on the sensation. Provide details. | the bolus approaches the oropharynx - sensory receptors induce cough with penetration of laryngeal vestibule. Airway closes; PES opens; reflex inhibition of breathing
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| What is the 'typical pattern' of respiratory/swallowing integration? | inhale-begin exhalation-swallow apnea (hold breath)-continue exhalation
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| Explain 'lingual motility' and the interdependence of swallowing movements. | Early stage modifications can influence entire patterned response ex: events in the oral swallow determine events in the rest of the swallow
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| How can swallowing movements be variable? | by peripheral sensory input depending on the characteristics of the bolus
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| Which neuromuscular events can we control? | laryngeal elevation and vocal fold closure
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| Which neuromuscular events are involuntary? | pharyngeal peristalsis & UES relaxation
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| Describe the neuromuscular characteristics of UMN and compare with LMN. | UMN -spasticity; bilateral lesion; loss of intellectual capacity=poor judgment rate and amount LMN - flaccid; unilateral lesion; aphonia can't adduct VF and can't protect airway
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| What is the traditional view of what triggers the pharyngeal swallow? | stimulation of the anterior faucal arch region
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| What is the current view of what triggers the pharyngeal swallow? | stimulation of both: deep muscle receptors in the base of the tongue AND superficial muscle receptors within the pharynx
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| What is the current view on location of bolus to generate "trigger"? | "delayed swallow" concept reconsidered; position of bolus at onset of swallow reveals 'risk of penetration' and not 'length of delay'.
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| Describe the experiment that supports the current view of swallow trigger and the result. | normal college students were examined with endoscopy while they ate burgers and fries. The majority of swallowing was initiated AFTER the bolus had entered the HYPOpharynx
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| List the valves for swallowing. | lips; glossopalatal; palatal; ariepiglottal; false VF; true VF; PES
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| How is pressure generated in swallowing? | Positive pressure is generated by the tongue base pushing the bolus into the oropharynx. Negative pressure is g.b. the PES opening & hyolaryngeal elevation and forward movement that creates a space and sucks the bolus into it.
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| What are the modifiable events making up the 'patterned response' of swallowing? | sensory information during oral swallow ex: viscosity, temperature, taste, smell, and tactile information
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| How does the PES open? | relaxation - neurological control traction - movement away from post. pharyngeal wall due to hyolaryngeal excursion
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| What happens if the PES/UES malfunctions? | Can lead to residue in the piriform sinus and possible post swallow aspiration
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| What causes aspiration? | material falls into the larynx below the VF due to abnormal swallowing or altered level of consciousness
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| What causes pneumonia? | Inflammation of the lungs and bronchial tubes caused by aspiration or inhaling material. The greater the acidity the greater the lung injury.
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| What factors are more likely to predict if pneumonia will result from aspiration? | dependency for feeding (19 times more likely); dependency for oral care & number of decayed teeth (6-8 times more likely)
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| How does the lower airway mechanism maintain pulmonary hygiene? | Trap, Cough & Clear
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| Why is a swallowing exam with an inflated cuff useless? | The airway is blocked. You need airflow to be normal for coughing, throat clearing, speaking and you need to assess airway protection and leakage.
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| What are the crucial steps necessary to do a swallowing exam on a person with a tracheostomy tube? | Get medical clearance to deflate the cuff.
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| What are some general mechanical causes of dysphagia and esophagal stage disorders? | structural lesions; loss of muscle or sensation; bone spurs; Zenker's diverticulum; congenital web
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| In the neuranatomy of swallowing, what is the point of convergence? | The NTS - nucleus tractus solitarius
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| Where in the lower airway does ciliary action stop? | The TBL - terminal bronchi level
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| Define 'stasis'. | food and stuff sitting in the hypopharynx
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| What is 'dysphagia'? | A delay or misdirection of a food bolus or fluid as is moves from the mouth to the stomach
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| Describe 'PES'. | is a high pressure zone between the pharynx and esophagus; made up of the cricopharyngeus; upper esophagus, and lower inferior constrictor
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| What is the purpose of the laryngeal valve? | gatekeeper of the airway; primary protective function is cough
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| List three factors that may predict the likelihood of low grade chronic aspiration. Why? | poor respiratory support; shortness of breath; rapid breathing due to inhalation after swallowing
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| Variation in normal eating occurs due to what three reasons? | bolus characteristics; individual swallowing variation; motor equivalence
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| Define 'motor equivalence'. | Any motor goal can be accomplished in a number of different ways through activation of different combinations of muscles and joint movements.
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| Provide an example of motor equivalence. | Chewing - The only muscle with a predictable pattern is the masseter. All the other muscles act in concert as required.
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| List three ways to clear debris from the pharynx and describe. | Hawking clears the oropharynx; throat clearing clears the larynx and hypopharynx; coughing clears the lungs, trachea, larynx
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| Describe the ciliary action of the mucociliary escalator. | Outer mucous layer flows 1-2 cm/minute and brings up materials that were inhaled or aspirated with the wave-like action of all the little cilia
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| List ways a feeder can reduce aspiration. | feed slowly at a pace the client can handle; give smaller, more manageable bites; seat client at 90 degree angles; provide oral care after meals to prevent harmful bacterial colonization
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| Define 'pneumonia'. | acute inflammatory reaction as a result of bacteria or viruses in the lower respiratory system
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| What are the treatment considerations specific to the patient? | etiology; severity; history; disease trajectory; environmental factors
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| List a hierarchy for dysphagia treatment. | postural changes; increase sensory input; swallowing strategies; change food consistency
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| List characteristics of a medically fragile patient. | malnutrition; dementia; depression; incontinence; history of falls; one or more disease processes
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| Why is aspiration pneumonia called an 'opportunistic' disease? | because it develops in patients who are already seriously ill
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| What is the respiratory triad? | respiratory compromise - dysphagia - protein energy malnutrition - back to respiratory compromise - eventually to death
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| Contrast the traditional model with the current view of swallowing. | Before there were four distinct phases: oral prep, oral, pharyngeal, & esophageal Now it is seen as a complex series of overlapping and interdependent movements to get food from mouth to stomach.
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| What are the three neuro parts of the swallowing and respiratory systems? | sensors; central controller; effectors
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| What are the neuroanatomical divisions of the swallowing process? | Brainstem (NTS) reflexive and involuntary; subcortical sites (basal ganglia, white matter pathways); cortex
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| Why is the NTS so important? | It is the central pattern generator for both swallowing and breathing.
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| Why is the nucleus ambiguous (NA) so important? | It is where the motor response is organized for the 40 pairs of muscles for swallowing
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| What is the insular and cerebellar loop? | connections that plan sequential movements for swallowing and match these movements with bolus characteristics
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| List the oral structures. | lips, teeth, cheeks, mandible, hard palate, tongue (tip, blade, back), anterior faucial arches
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| List pharyngeal structures. | velum, tongue base, pharyngeal walls, epiglottis, UES
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| List pharyngeal crevices. | valleculae, piriform sinuses
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| List laryngeal structures. | true VFs; false VFs; ariepiglottic folds
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| Define 'swallowing'. | A complex series of movements and biomechanical forces which carry material from oral cavity through the pharynx and into the esophagus.
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| Contrast traditional view of swallowing with current view. | Before - brainstem controlled reflex Now - modifiable pharyngeal response
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| What swallowing events are under biomechanical control? | epiglottic tipping & PES opening
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| What cranial nerve innervates the PES? | CNX-Vagus
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| List some disorders that are associated with dysphagia. | Parkinsons, ALS, MS, dementia, Huntingtons
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| What is Xerostomia? | dry mouth
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| What is the gold standard of dysphagia assessment? | Videofluoroscopy
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| What structural divisions are associated with what risks for location of bolus at onset of swallow? | low: mouth to back of tongue med: back of tongue to hyoid bone high: hyoid bone to PES
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| What are some clinical markers of aspiration? | cough after swallow; wet voice; throat clearing; reddening of the face; difficulty breathing; OR sometimes nothing happens
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