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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) [email protected] 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 Pressure generation and bolus transit during the pharyngeal stage of swallowing Swallowing mechanism as a closed system (McConnel) BACK TO BASICS 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 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 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 Contributing factors that could be present: Metabolic encephalopathy Confusion/Lethargy AGE/Sarcopenia NEURO DIAGNOSES 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 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 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 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 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 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” 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) “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) Ambulation Status Activity Level/Spunk Nutritional Status Independence with ADL’s i.e.: feeding CLINICAL EXAMINATION: LET’S THINK ABOUT: ACTIVITY LEVEL AND ATTITUDE Support System Permanent Residence CLINICAL EXAMINATION: SOCIAL/CAREGIVER / LIVING SITUATION 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 Nectar thick Honey thick Thickeners available: natural foods (i.e.: applesauce) Corn starch type: Thick it Xanthan gum type (gel)(simply thick) THICK LIQUIDS 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 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 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 Logemann: Instrumental Exam indicated when pharyngeal stage dysphagia is suspected What happens when access to Instrumental examinations is limited? THE INSTRUMENTAL EXAM 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 Mendlesohn Maneuver Shaker Exercises Masako Maneuver Supraglottic Swallow Effortful Swallow Huck and Spit TREATMENT/TECHNIQUES Head turn to weak side Chin tuck (cut out cup, straw) Lean to strong side TREATMENT/POSITIONS Alternate liquids/solids (liquid flush) Double swallow (dry swallow) Add texture Extra sauces and gravies (moisteners) Caloric enhancement TREATMENT/MISC. 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 The best exercise for swallowing is SWALLOWING! AND SWALLOWING SOMETHING! QUALITY OF LIFE AS WELL AS PATIENT SAFETY ARE KEY AND REMEMBER! PATIENT’S RIGHTS RIGHT TO SAY NO CLOSE COOPERATION WITH MEDICAL TEAM PATIENT ADVOCACY AND REMEMBER!