Overview of Ch. 7

*Swallowing Disorders- Oral Cancer

*Typical Tumor Locations

*Hard palate

*Soft palage

*Alveolus, floor of the mouth, tonsil, and anterior faucial pillar

*Lateral tongue

*Base of tongue

*Oral Cancer

*Primary treatment modalities

*Surgical resection

*Radiotherapy with or without chemotherapy

*Rehab Needs

*Oral cancer patient experience changes in

*Salivary flow

*Speech, swallowing post-treatment

*Intraoral sensory loss

*Decreased tongue and jaw range of motion

*Rehab Needs

*Oralpharyngeal Cancer patients experience changes in

*Reduced Tongue base movement

*Pharyngeal wall motion

*Velopharyngeal function

*Rehab Needs

*After Radiotherapy to the Oral cavity and Orpharynx patients will experience either immediately or within a year after radiotherapy

*Reduced saliva flow- these are permanent

*Swelling in the mouth

*Sores in the mouth

*Reduced speed of tongue movement

*Delay in oral transit time

*Delay in triggering the swallow

*Can benefit from the Super-supraglottic swallow and Mendelsohn maneuver

*General Principles with Oral Cancer Patients

*Counseling before treatment

*Patient education before treatment

*Start preparatory oral motor exercises to build strength

*Direct therapy when cleared by surgeon

*Usually start with a nasogastric tube

*Videofluroscopic swallow examination

*Begin oral feedings with appropriate diet

*Swallowing Disorders-

Laryngeal CancerOverview of Ch. 8

*Treatment options

*Tumor Staging

*TNM classification system

*60% occur in the glottic area

*35% occur in the supraglottic area

*5% occur in the subglottic area

*Tumor management

*Surgical

*Radiotherapy

*With or without chemotherapy follow up

*Rehab Needs

*After Radiotherapy, patients may experience

*Hoarseness- temporary

*Minimal Saliva flow changes

*Rarely report swallowing problems immediately

*With high doses of radiotherapy and chemotherapy patients may experience significantly reduced laryngeal elevation and reduced pharyngeal wall motion

*Sometimes these changes may not be noticed until years later

*General Principles with Laryngeal Cancer

Patients

*Counseling prior to treatment

*Patient education prior to treatment

*For radiation management- can begin tongue range of motion, tongue base and laryngeal elevation exercises before treatment

*Postoperative treatment will depend on patient’s functional capacity after surgery and the extent of the surgery

*General Principles with Laryngeal Cancer

Patients

*Direct treatment and exercises can begin postoperatively when cleared by the surgeon

*Videofluoroscopic swallowing examination should be completed before feeding orally.

*Begin appropriate diet as patient progresses

*Swallowing Disorders- Neurologic

ImpairmentsOverview of Ch. 9 and 10

*Lesions of Brainstem

*Significant oropharyngeal swallow impairment

*Medulla houses the major swallowing centers

*Unilateral lesions-

*functional oral control,

*delayed trigger of swallow

*weak pharyngeal swallow

*Reduced laryngeal elevation

*Reduced opening of upper esophageal sphincter

*Residue in pyriform sinus and pharyngeal wall

*Treatment

*Thermal-tactile stimulation to improve the trigger of the swallow

*Head rotation to the damaged side

*Mendelsohn maneuver

*Range of motion exercises for laryngeal elevation

*Cricopharyngeal myotomy

*Subcortical Stroke Lesion

*Affect motor and sensory pathways to and from the cortex

*Mild delays in oral transit time

*Mild delays in triggering pharyngeal swallow

*Aspiration before the swallow

*Treatment to focus on

*Thermal tactile stimulation for trigger of swallow

*Range of motion of larynx and tongue base

*Cerebral Cortex Lesions

*Anterior left hemisphere

*Apraxia of swallow

*Delay in initiating the oral swallow

*No tongue motion in response to presentation of food

*Mild oral transit delays

*Mild delays in triggering pharyngeal swallow

* Treatment can focus on

* Increasing bolus taste

* Increasing pressure of the spoon on tongue

* Thermal-tactile stimulation

* Allowing them to feed themselves

*Cerebral Cortex Lesions

*Right Hemisphere

*Mild oral transit delays

*Moderately delay in triggering pharyngeal swallow

*Delayed laryngeal elevation

*Aspiration before the swallow

*Therapy can focus on

* Chin down posture

* Thermal tactile stimulation

* Supraglottic or super-supraglottic maneuver

* Range of motion exercises to improve laryngeal elevation

*Closed Head Trauma

*Can be complex due to various types of neurologic injuries the patient sustained during the accident

*Delay in triggering pharyngeal swallow is most common

*Can present with multiple oral and pharyngeal disorders

*Cognitive difficulties such as impulsiveness and inability to recall or follow compensatory strategies can impact treatment

*Closed Head Trauma

*Treatment

*Are responsive to postural changes

*Range of motion exercises

*Enhanced sensory input

*Swallowing maneuvers may be too difficult

*Can work with family members and caregivers in providing cueing and thermal tactile stimulation

*Can progress very slowly or quickly depending on brain function

*Cervical Spinal Cord Injury

*Without a head injury

*Delay in triggering pharyngeal swallow

*Reduced laryngeal elevation and anterior movement

*Reduced upper esophageal sphincter opening

*Reduced tongue base motion

*Unilateral or bilateral pharyngeal wall dysfunction

*Many require a tracheostomy tube for airway management

*Cervical Spinal Cord Injury

*Treatment

*Cervical Bracing and Anterior Cervical fusion can impact swallow function and ability to use exercises, compensatory strategies, or postural changes

*Cerebral Palsy

*Oral dysfunctions

*Inability to hold material in a cohesive bolus

*Difficulty with mastication

*Disorganized lingual movements

*Treatments include

*Oral motor exercises

*Thermal-tactile stimulation

*Diet changes

*Alzheimers

*Initially- agnosia for food- they cannot visually recognize food as food

*As it progresses- apraxia for both feeding and swallowing- difficult using utensils to feed themselves- difficult to initiate the oral stage of swallowing

*Holding food in mouth and not swallowing

*Decreased tongue motion for chewing

*Delay in triggering pharyngeal swallow

*Reduced laryngeal elevation

*Alzheimers

*Reduced oral intake which significantly impacts nutrition and hydration

*Treatment

*Sensory enhancement prior to placing food in mouth

*Diet changes

*Modify volume/rate of food

*Amyotrophic Lateral Sclerosis

*Progressive disease

*Predominantly corticobulbar involvement

*Begins with reduced tongue mobility

*Decreased mastication

*Lip closure is reduced

*Delayed triggering of pharyngeal swallow

*Treatment

*Thermal tactile stimulation

*Diet changes

*Parkinson’s Disease

*Oral Phase

*Repetitive anterior-posterior rolling pattern in lingual propulsion of bolus

*Decreased mastication and management of bolus

*Pharyngeal Phase

*Delay in triggering pharyngeal swallow

*Tongue base motion reduced

*Pharyngeal wall contraction reduced

*Laryngeal elevation and closure are reduced

*Aspiration after the swallow

*Parkinson’s Disease

*Treatment

*Medication management

*Active range of motion exercises for tongue, lips

*Laryngeal elevation exercises

*Effortful swallow

*Mendelsohn maneuver

*Effortful breath-hold

*Falsetto exercises

*Multiple Sclerosis

* Lesions from the cortex to the brainstem to the cranial nerves

*Can present with various swallowing disorders

*Hypoglossal nerve- lingual control of bolus, chewing, and oral transit time is reduced

*Vagus nerve-reduced tongue base movement, pharyngeal wall movement and delayed trigger of the swallow

* Treatment

* Medication management

* Enhanced sensory input

* Thermal-tactile stimulation

*Myasthenia Gravis

*Biochemical changes in the myoneural junction

*Fatiguing of involved musculature with repeated use

*Tongue musculature or velar function affected

*Backflow of food into the nasal cavity

*Decreased mastication

*Treatment

*Compensatory swallow management strategies

*Exercises may only contribute to fatigue

*Diet changes

*Muscular Dystrophy

*Prolonged contraction and difficulty in relaxation of involved muscles

*Muscles of mastication

*Upper esophageal sphincter opening

*Aspiration due to inability to pass through upper esophageal sphincter

*Rheumatoid Arthritis

*Affects cricoarytenoid joint

*Restricts arytenoid movements which adduct vocal folds

*Residue collects in airway entrance

*Aspiration after the swallow

*Treatment

*Medication

* Introduce compensatory strategies

*May need diet changes until inflammation is eliminated

*Chronic Obstructive Pulmonary Disease

*Poor Respiratory and Swallowing coordination

*Difficulty with airway closure

*Aspiration during the swallow

*Treatment

*Compensatory strategies to conserve energy

*Postural changes

*Diet changes

*Sensory enhancement procedures