Swallowing Disorders: Neurogenic. Presentation of Neurogenic Disorders Acute Injury Conditions...
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Transcript of Swallowing Disorders: Neurogenic. Presentation of Neurogenic Disorders Acute Injury Conditions...
Presentation of Neurogenic Disorders
Acute Injury Conditions occur suddenly Some recovery expected
Degenerative Conditions Gradual deterioration over time
Established Diagnosis
CVA Cortical (cortex)
R or L hemisphere Subcortical Brainstem
Hemorrhage Cancerous Process
Tumor growthMay be an initial sign
Traumatic Brain Injury
Clinical Manifestations
Oral/Pharyngeal symptoms Decreased awareness/sensation Drooling Impaired mastication Trouble with initiating a swallow Nasal regurgitation Coughing Choking Difficulty moving bolus through the pharynx Difficulty with secretions Throat clearing Gurgly voice
Clinical Manifestations
Esophageal Symptoms Sticking in the chest Regurgitation Heartburn Chest discomfort Globus sensation Chronic sore throat
Rule of thumb Poor timing/coordination Decreased awareness Increased risk of silent aspiration
Secondary Complications
Weight loss Malnutrition Dehydration Laryngospasm Bronchospasm Aspiration (pneumonia) Asphyxia Loss of appetite, desire to eat Social withdrawal
Dysphagia with Diagnosis
Review all symptoms Esophageal Structural Neurological
Know the symptoms well enough for differential diagnosis
Comprehensive evaluation must be completed
“Silent” Symptoms
Pt compensates for difficulty Cough reflex is reduced or absent Cognitive impairment
Specific Neurologic Diagnoses
Many symptoms occur in more than one type of neurologic disease process or insult
Cerebrovascular Accident (CVA) Right hemisphere CVA
Characteristics Left pocketing/weakness Poor insight Neglect Impulsivity Silent aspiration Reflex delay 3-5”
Treatment Positioning Liquid/diet modification Tray/meal set-up Oral motor exercises; TTS; maneuvers Longer recovery time vs. L CVA
Cerebrovascular Accident (CVA) Left hemisphere CVA
Characteristics Right pocketing/weakness Oral motor apraxia; swallow apraxia Reflex delay 2-3” Silent aspiration Reduced comprehension
Decreased ability to follow treatment strategies Treatment
Positioning Liquid/diet modification Oral motor exercises Multimodality input to facilitate comprehension Increase pressure with spoon; TTS
Cerebrovascular Accident (CVA) Brainstem CVA (low – medullary)
Characteristics Significant impairment; May affect swallow centers of the brain Significant reflex delay 10-15” or absent reflex Reduced laryngeal elevation TVF paralysis Pharyngeal paresis Compromised respiration Fatigue UES dysfunction
Treatment Usually return to po intake (eating out of mouth) within 3 weeks Exercise for weakness Positioning
Head turn to weaker side (while swollowing) Mendelsohn maneuver (swallow and hold laryx up) Liquid/diet modifications Thermal stimulation
Cerebrovascular Accident (CVA) Brainstem CVA (high – pontine)
Characteristics Hyperspasticity Delayed or absent swallow reflex Unilateral pharyngeal wall paresis Decreased laryngeal elevation
Treatment Similar to previous slide Massage prior to exercises/feeding trials may
be helpful
Cerebrovascular Accident (CVA)
Subcortical CVA Characteristics
3-5” delay in OTT and pharyngeal reflex Decreased laryngeal elevation
Treatment 3-6 weeks recovery time TTS Exercises for oral ROM, BOT, and laryngeal
movement
Cerebrovascular Accident (CVA)
Multiple CVAs (can lead to vascular dementia) caused by multiple strokes Characteristics
Delayed pharyngeal reflex Reduced laryngeal closure Pharyngeal weakness Decreased attention and language comprehension
Treatment Similar to other treatments for CVAs, depending
on exact disorders
Traumatic Brain Injury
Characteristics Decreased level of arousal Impulsivity Cognitive deficits Decreased sensation Weakness of the oral-motor structures Abnormal oral reflexes (Abnormal reflex such as ,biting and
sucking, rooting relex) Delayed swallow reflex Decreased laryngeal elevation Tolerate prolonged aspiration
Treatment Compensations Diet/hydration modification Thermal stimulation; exercises for oral muscles Longer period of spontaneous recovery; assess yearly
Guillain-Barre
Characteristics Rapid onset paresis – tracheostomy – vent Generalized weakness of oral and pharyngeal
musculature Recovery slow Respiration unstable
Treatment Gentle ROM and resistance exercises Increase effort with improvement – slowly! Supraglottic swallow; Mendelsohn maneuver
Progressive Neurologic Disease Amyotropic lateral sclerosis
Characteristics Progressive weakness
Oral, pharyngeal, laryngeal, and respiratory Progression of symptoms
Aspiration Tongue fasciculations VPI
Nasal regurgitation Treatments
Counsel regarding long-term feeding options Diet/liquid modification Controversy regarding tx
Progressive Neurologic Disease Parkinson’s Disease
Characteristics Progressive disease Marked variability in med cycles Weak oral motor muscles Delayed initiation Reduced pharyngeal contraction High percentage of silent aspiration in later stages.
Treatments Manipulation of drug cycles Diet/liquid modification Enteral feeding options
Progressive Neurologic Disease Multiple Sclerosis
Characteristics Periods of exacerbation/remission Symptoms vary dependent upon site of lesions
Treatments Typically necessary during periods of
exacerbation Compensatory strategies
Postural Behavioral
Diet/liquid modification
Progressive Neurologic Disease
HIV-AIDS Characteristics
Weakness of the laryngeal elevators and other oral motor structures
Pharyngeal weakness Treatments
Compensatory strategies Postural
Diet/liquid modifications Advise on long-term feeding options
Progressive Neurologic Disease
Myasthenia gravis: Characteristics
Rapid fatigue Can affect all phases of the swallow
Treatment Frequent small meals Compensatory strategies
Overcome short-term symptoms
Progressive Neurologic Disease Huntington’s Chorea
Characteristics Choreiform movements Difficulty with coordinated movements of
manipulating and moving a bolus Increased risk of aspiration/airway obstruction
Treatment Modified diet/hydration Positioning stabilization