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dysphagia review

Major parts of the skull mastoid, styloid, zygomatic processes & arch
the first cervical vertebrae atlas
the second cervical vertebrae axis
Thryoid-larynx structures hyoid, thyroid, cricoid, trachea, epiglottis, arytenoids, corniculates
Important landmarks on thyroid cartilage lamina, prominence, superior/inferior cornu, oblique line
Area between the root of the tongue adn the epiglottis valleculae
Area just superior to the UES pyriform sinuses
opening into the airway vestibule (additus)
area between the false and true vocal folds ventricle
Description of oral prep stage Prepare food bolus in oral cavity, ends when bolus is gathered in a unit. Tongue moves laterally.
Parts of tongue Tip, blade, dorsum, BOT
Types of salivary glands parotid,submandibular, sublingual
Function of saliva maintain oral moisture, reduce tooth decay, assist in digestion, neutralizes stomach acid, triggered by chewing
Paired muscles & nerves used in chewing Temporalis, masseter, buccinator, pterygoid (all CN-V: trigeminal)
Sensory nerves involved in sublingual & submaxillary glands VII: Facial
Sensory nerves involved in parotid gland: IX: Glossopharyngeal
Nerves involved in mechanical pressure sensors, temperature change V: Trigeminal
Sensory nerve involved for taste in anterior 2/3 of tongue VII: Facial
Chemo-receptor nerves for taste in posterior 2/3 of tongue IX: Glossopharyngeal
Oral Stage description Tongue cradles bolus, presses edges against hard palate. Tongue propels bolus posteriorly. Posterior pharyngeal wall moves anteriorly. Hyoid bone begins to elevate adn move anteriorly. Velum elevates. Airway begins to close.
Extrinsic tongue muscles that cradle bolus Genioglossus, Hyoglossus, Styloglossus (all CN XII); and Palatoglossus: X, XI
Extrinsic tongue muscles that propel bolus posteriorly Digastric, Mylohyoid: V; Geniohyoid: XII
Muscle that elevates posterior tongue Palatoglossus: X
Muscles involved in velum elevation Palatopharyngeal, levator veli palatini: X, XITensor veli palatini: V
CN involved in airway closure (false & true vocal folds) X, recurrent branch
CN involvedin chemical & water respondent receptors X, superior laryngeal nerve
Pharyngeal phase description begins when bolus passes trigger point & enters larynx. Velum remains elevated, airway closed. Hyoid bone elevation & anterior position maintained. Pharynx shortens. Larynx moves 2-3 cm under tongue, epiglottis folds down over airway, UES opens
Muscles involved in elevation & shortening of pharynx as bolus arrives Palatopharyngeal: X, XI; Stylopharyngeus: IX
Muscles involved in pharyngeal wall moving anteriorly Superior: X, XI, Middle: X, Inferior: X, XI constrictors. Inferior=thyropharyngeus & cricopharyngeus
Esophagus description at rest closed muscular tube, 18-22 cm (8-10 inches), enters stomach through diaphragmatic arch, UES & LES make superior & inferior boundaries
Peristalsis contracted movement that delivers bolus from proximal to distal esophagus (3-10 seconds)
Esophageal stage description Peristalsis occurs. First contractile wave is strongest. Secondary signals LES to open.
Muscle make-up of the esophagus Upper 1/3: striated muscle: CN X from NAMiddle 1/3: mixed striated & smoothLower 1/3: smooth: CN X from dorsal motor nucleus
What makes up the swallow center/central control of swallow? Nucleus Tractus Solaritus and Nucleus Ambiguous: located in medulla of brainstem
What is the NTS? nucleus of the solitary tract, part of Swallow center. Integrates sensory info. of touch, sense, taste, afferent input from CN: V, VII, IX, X; afferent info from cardiovascular & respiratory brainstem nuclei, transfers sensory info. to NA.
What is the NA? Part of swallow center. Integrates and coordinates motor output to the swallowing muscles via CN: V, VII, IX, X, XI, XII
What areas does the NTS communicate with? Hypothalamus, sensory motor strip in parietal lobe, precentral cortex, lateral postcentral gyrus, SMA, limbic forebrain, cerebellum
Transfer time of bolus from oral cavity to pharynx (liquids) .05-1 second
Transfer time of bolus (liquids) from oral cavity to stomach less than 5 seconds
What are the 6 valves that create high and low pressure? lips, velum, tongue, false & true vocal folds, UES, LES
Describe the mechanism of the UES opening Mechanical traction: posterior tongue retraction, hyoid bone elevation, hyoid bone elevates the thyroid & cricoid, bolus is driving force, brainstem disinhibition
List the 5 mechanisms of airway protection during swallowing airway closure, laryngeal elevation, tongue base retraction, epiglottis inverts, vallecular spaces
Describe the airway closure protective mechanism true and false vocal folds adduct, laryngeal additus narrows
Describe the laryngeal elevation protective mechanism larynx raises and tilts under BOT
Describe tongue base retraction protective mechanism posterior tongue action deflects bolus from airway
Describe the inverted epiglottis protective mechanism Rising larynx & thryoepiglottic ligament contraction allows epiglottis to fold over the laryngeal additus
Describe the vallecular space protective mechanism Bolus is divided and channeled around airway
Describe how valves create a series of positive and negative pressures during the pharyngeal phase BOT & pharyngeal constrictors put positive pressure on bolus as it flows into negative pressure in pharynx, negative pressure aids in UES opening
Describe how valves create a series of positive and negative pressures during the esophageal phase Peristalsis applies positive pressure, esophagus is a negative pressure...
Describe the apneic period. Airway closure period. No respiration. Duration increases as bolus volume increases. 75% of normal swallows begin w/exhalation & followed by continued exhalation. Dysphagic pts. more likely to interrupt inhalation to swallow.
Describe normal variations in swallowing regarding volume. Larger bolus volumes preceded by inhalation. Small bolus (5ml)-oral phase followed by pharyngeal phase. Large bolus (10-20 ml): simultaneous oral & pharyngeal phase. BOT & pharyngeal wall movement occur later.
Describe normal variations in swallowing regarding viscosity. Pressure of tongue & pharyngeal walls increase. Volume functions increase in duration (velar closure, laryngeal closure, UES opening)
What 4 major steps do all normal swallows include? Oral propulsion of bolus into teh pharynx, airway closure, UES opening, BOT & pharyngeal wall propulsion to move bolus from pharynx into esophagus
What is the purpose of screening? Provide indirect evidence that pt. has a swallowing disorder. Determine if pt. is a normal swallower, or exhibtits symptoms of oral stage dysfunction, at risk for aspiration & if further ax is needed
What does a screening involve? 15 minutes or less. Chart review, brief observation of pt. (gurgly voice, coughing, drooling, infrequent swallowing, throat clearing, breathing difficulty)
What are some indicators for a full evaluation in infants, children, DD, dementia pts? Rejects food, food selectivity, gagging, open mouth during eating
What are the basic components of the Clinical Swallow evaluation? Medical history: pt, family, caregiver interview; Oral Motor exam: structures, function; Observation of swallowing: dry swallow, liquids (not always included)
What things would you look at when reviewing a pts. chart? current/past medical problems, medications, hx of swallowing disorder, airway device placement, oral nutrition (consistencies), non-oral nutrition, notes regarding ability to follow directions, cognition/behavior, neuro disease/psych/cancer.
What should you do when you first walk into the room during a CSE? Check their respiratory status-rate at rest--if there is distress postpone eval. Is saliva being swallowed during inhalation, exhalation? Timing of cough-respiration-cough coordination. How long can pt. hold breath? Nasal or mouth breather?
What are some questions you would ask the patient? When did the swallow problem begin? Has it gotten worse slowly or rapidly? Are some foods/liquids more difficult? What happens when you try to swallow? Does food stick anywhere? Do you cough or choke? When/
What are some signs and symptoms of dysphagia? pt. complains of difficulty swallowing, difficulty placing food in mouth, inability to control food/saliva, coughing before/during/after swallow, recurrent pneumonia, weight loss, gurgly voice, increased secretions after swallow, can't recognize food
When would a CSE be ordered? For any pt. referred for an ax of suspected swallowing problem, 1st step for dx & tx process, provides info. regarding symptoms, determines readiness for further testing
What are some advantages of CSE? Compared to VFSS is less invasive, less taxing on frail pts, more ecological eval. in a more typical setting
Limitations of CSE can't visualize entier alimentary tract, can't provide definitive info (where pt. is aspirating, why pt. is aspirating), not a substitute for "gold standard" VFSS
What is silent aspiration? Pt. does not exhibit signs/symptoms of aspiration. Over 50% of pts. who aspirate do not cough.
What is some typical equipment used in a CSE? flashligh, tongue depressor, gloves, small laryngeal mirror, feeding apparatus, food & liquid of different consistencies, emesis basin, tissue/towels, suction, gauze, lemon juice, sugar water, saline
What are some challenges of a medical/case history? Dysphagia is often a long-standing disorder so pt. is adept ast compensating; med. record does not document clear pic. of dysphagia, dysphagia is a symptom of other medical disorders
What should be asked during medical hx interview? Chief complaint, pt. perception, character of complaint, course of complaint, ADLs, previous tx, questions about each stage of swallow, ask qeustions about neuro. disease
What are some other risk factors for dysphagia? side effects of medication, bacterial/viral/fungal infections, toxins, diabetes Mellitus, respiratory diseases, esophageal diseases
What areas are assessed during an oral motor exam? mandible, lips, tongue, velum, reflexes
How do you check a gag reflex? Use a tongue depressor/mirrow. check dorsum, velum, faucial pillars, PPW. Gag reflex is indication of airway protection. Clinically significant is absent on one side but not other.
What do you do when incorporating liquids/solids into a CSE? Dysphagia hand shake, phonate ah immediately after swallow-check for wet voice quality. Have swallow multiple times...check for wet voice quality.
Define pocketing. solids/liquids in oral sulci after swallow
Define residual. solids/liquids in valleculae or pyriform sinuses...aka pooling.
How do you check for residual in the sinuses? Have pt. turn head. For valleculae: lift chin up & hold for 3 seconds, then check for wet voice quality. In pyriforms: turn chin to right, check for wvq, turn chin left, check for wvq.
What are some aspiration indicators? Wet voice, cough, throat clearing, expectoring material.
What are some maneuvers/postures to check with patient? head back, chin tucked, head turned, head tilted. Techniques: food placement, supraglottic, super supraglottic, effortful, Mendelssoh...check for wvq after each attempt.
Define pneumonia: infection of alveoli as opposed to bronchi, bronchioles, or upper airway. Occurs in all ages, especially very young & old.
What are the 4 types of pneumonia? Bacterial, Viral, Mycoplasma, Fungal
What are the 3 ways pneumonia is acquired? Community, Nocosomial, Aspiration
Describe Community acquired pneumonia. most common, less than 5 days after hospitalization, pts. at risk include smokers, ETOH, lung disease, recent viral illnesses including flu. Typical: abrupt, atypical: more gradual. Tx: antibiotics, hospitalization, pneumonvax
Describe Nosocomial Pneumonia occurs in medical & surgical ICUs. VAP is sbtype of NP. Occurs 48 hours or more after admittance, not caused by pts. condition.
Describe Aspiration Pneumonia Deposition of foreign matter into airway or distal airway. Prandial=food/liquid entering while swallowing. Non-prandial: foreign matter enters due to regurgitation/vomit/reflux.
Where is Aspiration Pneumonia most likely to occur? Right lung, lower right lobe #3.
What are some serious pulmonary complications of AP? lung abscess, lung necrosis, empyema, adult respiratory syndrome, death
What contributes to adequate bronchopulmonary clearance? cough, airway cilia network, interstitial lympatics, alveolar macrophages, local immunoglobulins
What are some risk factors for aspiration pneumonia? health status, dependent feeders, tube feeding: reflux, regurgitation, oropharyngeal secretions
What are some chief determinants in aspiration pneumonia? frequency in aspiration, character of aspirate: volume/acidity, chemical composition, presence of particluate matter, food, bacteria,
Define asphyxiation: foreign material occludes airway, often fatal. Heimlich or tracheotomy.
Define chemical pneumonitis: aspiration of significant amounts of gastric contents or foreign material (drowning)
Define aspiration pneumonia occurs as direct result of aspiration, generally from oropharynx or stomach
Describe aspiration before the swallow Occurs prior to pharyngeal initiation due to disturbance of sensory mechanism, results in disruption or delay of pharyngeal swallow initiation, airwa not protected. Tx: work on oral/pharyngeal phase.
Describe aspiration during the swallow: Weak or rigid suprahyoid muscles fail to lift hyoid & thyroid, inadequate post. tongue movement, disurption to valves, incomplete glottis closure, bolus volume too larege, inadquate pressure generation
Describe aspiration after the swallow # 1 cause of AP, inadequate bolus propulsion force (decreased BOT-pharyngeal wall contact), reduced pharyngeal peristalsis, reduced UES opening, regurgitation
What are some ways to prevent aspiration? Dx via VFSS to identify optimum bolus variables, implementation of compensatory techniques & maneuvers, good oral hygiene, monitor feeding tube placement, reflux precaustions, antibiotics, vocal fold augmentation/medialization
What is the purpose of the diagnostic procedure? Determine the nature or cause of swallow disorder, determine timing of aspiration/penetration, determine tx options, determine effectiveness of swallow modifications
When do you do an instrumental exam? Pt. is alert & stable, pharyngeal disorder is expected, done prior to PEG placement, to document prognosis or positive/negative change in pts. condition, after swallow maneuvers have been mastered, pt. had a TIA
When is an ultrasound used? to study oral stage. Lingual & oral compensations can be easily visualized.
When is cervical ausculatation used? Used to listen for inhalation, exhalation, moment of swallowing, secretions before, during, and after swallow. Useful in training Mendelsohn maneuver.
When is manometry used? Combines pressure sensors along with videofluoroscopy to determine pressure of bolus and relaxation of UES. Primarily used in research, to examine esophagus transit time.Lead 1: BOT, Lead 2: Pharynx, Lead 3: UES, Lead 4: Esophagus
What is scintigraphy and when is it used? Radioactive substances are administered and the radiation emitted is measured. Bolus can be visualized but not anatomy. Amount of aspiration & residue can be quantified.
What is EMG? Electromyography. Electrodes pasted on skin, measures timing and relative strength of muscle contraction, used for biofeedback for effortful swallow and Mendelsohn manuever
When is a CT/MRI used? to image anatomical structures
Describe FEES: Flexible endoscopic evaluation of swallowing Involves passing a very thin flexible fiberoptic tube through nose to obtain view directly down throat. Tube does not go down throat-but light shines.
What are some advantages of FEES? positiioned above velum which shows VP closure, great view of pharyngeal anatomy, residual clearly observed. Used to assess & train swallowing maneuvers, test intact pharyngeal sensation, can observe vocal folds without radiation exposure
What are some disadvantages of FEES? No visualization of oral phase, swallow not observable, unable to assess penetration vs. aspiration, possible discomfort/intolerance
What are some contraindications for FEES? Cardiac arrhythmias, respiratory distress/arrest, bleeding disorders, agitated/agressive pts, pts. w/movement disorders, pts. w/deviateed nasal septums, hx. of vasovagal response (losing consciousness)
What is an esophagram? X-ray showing how the barium moves through the esophagus and into the stomach.
What are some advantages of FEES over MBS? can see airway closure by vocal folds, arytenoid movement, amount & location of secretions, pharyngeal & laryngeal sensitivity, residue in valleculae, pyriforms, coordination of breathing & swallow, if pt. gets fatigued over course of meal, altered anato
What are some advantages of MBS over FEES? closure at entrance to airway btw. epiglottis & arytenoids, tipping of epiglottis, movement of bolus during swallow, aspiration during swallow, movement of bolus in esophagus, effect of mendelsohn manuever
What is the purpose of the Dx procedure? determine nature/cause of disorder, timing of aspiration/penetration, tx options, effectiveness of swallow modifications
Describe MBS/VSS/VFSS/cookie swallow enables examination of bolus prep. efficiency, transport & airway protection. Shows underlying anatomical and/or physiological reasons for dysphagia.
What are some outcomes of MBS? 25% go from NPO to full oral intake, 50 % can begin partial oral intake.
What are some guidelines for MBS? Prepare in advance per pt. needs, be systematic in bolus placement, types of materials, volumes, order of bolus presentation, order of interventions introduced, keep in the NG tube
Define symptom Observation, related to swallowing disorders that casued them. Symptoms alert clinician that pts. swallowing is disordered.
Why is it important to understand radiographic symptoms? SLPs are the expert (not radiologist), critical to dx of disorder, critical for determining tx
What are some things you be observing w/the bolus during an MBS? Transit time, efficiency of bolus movement, safety of bolus movement
What things do you look for in the oral & pharyngeal anatomy & physiology in an MBS? anatomical integrity & range of motion (ROM)
Residue on the dorsum of the tongue indicates... decreased tongue strength
Residue on the BOT indicates... decreased BOT retraction
Residue on PPW indicates... decreased peristalsis
Residue in valleculae indicates... decreased BOT retraction
Residue in pyriform sinuses indicates... decreased UES opening due to decreased hyoid-laryngeal elevation
meta-analysis of multiple well-designed studies 1A (strongest)
well-designed randomized control studies 1
well-designed non-randomized control studies (quasi experients) 2
observational studies w/controls (retrospective studies, time-series studies, case-control studies, cohort studies w/controls) 3
Observational studies without controls 4
Expert opinion weakest level of evidence
Created by: berta



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