Contents. Preface Acknowledgments

Transcription

1 00_Murry_FMi-xiv 2/22/06 1:50 PM Page v Contents Preface Acknowledgments ix xiii I. INTRODUCTION TO AND EPIDEMIOLOGY OF SWALLOWING DISORDERS 1 Introduction 3 Need for Early Intervention 5 Epidemiology 7 Summary 12 Study Questions 13 References 15 II. III. STRUCTURE AND FUNCTION OF THE SWALLOWING MECHANISM 17 Introduction 19 The Normal Swallow 19 Sphincters 26 Cranial Nerves Involved in Swallowing 27 Central Neural Control 29 Summary 31 Study Questions 32 References 32 THE ABNORMAL SWALLOW: CONDITIONS AND DISEASES 35 Introduction 37 Neurological Disorders 44 Conditions Found in Critical Care Patients 54 Esophageal Disorders 55 Infectious Diseases 65 Medications 66 Neoplasms 70 Swallowing Disorders Following Radiation Therapy 71

2 00_Murry_FMi-xiv 2/22/06 1:50 PM Page vi vi CLINICAL MANAGEMENT OF SWALLOWING DISORDERS Autoimmune Disorders and Diseases 73 Summary 77 Study Questions 78 References 79 IV. SWALLOWING DISORDERS ARISING FROM SURGICAL TREATMENTS 81 Introduction 83 Anterior Cervical Spinal Surgery (ACSS) 83 Head and Neck Surgery 85 Skull Base Surgery 86 Floor of the Mouth Surgery 88 Partial Glossectomy 88 Palate Surgery 89 Lip Surgery 89 Mandibular Surgery 89 Oropharyngeal Surgery 89 Hypopharyngeal Surgery 90 Tracheotomy 90 Zenker s Diverticulum 93 Summary 95 Study Questions 95 References 96 V. EVALUATION OF SWALLOWING DISORDERS 97 Introduction 99 Case History and Clinical Evaluation of Swallowing 101 Instrumental Tests of Swallowing 112 Instrumental Assessment and Predicting Aspiration 131 Summary 132 Study Questions 133 References 134 VI. NONSURGICAL TREATMENT OF SWALLOWING DISORDERS 137 Introduction 139 Compensatory Swallow Therapy 140 Rehabilitative Swallow Therapy 150 Prosthetic Management of Swallowing Disorders 156 Physical and Environmental Adjustments 162 Summary 164 Study Questions 164 References 166

3 00_Murry_FMi-xiv 2/22/06 1:50 PM Page vii CONTENTS vii VII. SURGICAL TREATMENTS OF SWALLOWING DISORDERS 169 Introduction 170 Vocal Fold Medialization 170 Palatoplexy 177 Surgical Closure of the Larynx 177 Gastrostomy 180 Tracheostomy 180 Summary 183 Study Questions 183 VIII. NUTRITION AND DIETS 185 Introduction 186 Properties of Liquids and Foods 187 Oral Nutrition and Dysphagia Diets 196 Nonoral Diets 200 Malnutrition and Dehydration 204 Nutrition in the Aging Population 205 Summary 207 Study Questions 208 References 209 IX. THE RELATIONSHIP BETWEEN VOICE AND SWALLOWING DISORDERS 211 Introduction 212 Diagnosis 213 Instrumentation 215 Personnel 217 Facilities 218 Case Studies from Voice and Swallowing Centers 218 Summary 228 References 228 Glossary 229 Appendix 1: Reflux Symptom Index 245 Appendix 2: Reflux Finding Score 246 Index 247

4 01_Murry_Pgs1-16 2/22/06 1:50 PM Page 3 INTRODUCTION TO AND EPIDEMIOLOGY OF SWALLOWING DISORDERS 3 INTRODUCTION The general definition of dysphagia is simply difficulty in swallowing. When someone cannot swallow at all, the term aphagia, or inability to swallow anything, is used. The terms dysphagia and aphagia include difficulty swallowing saliva, liquids, foods and medications of all consistencies. Dysphagia may also include such problems as foods or liquids sticking in the throat or regurgitation of swallowed liquids or foods. Swallowing difficulties may arise from mechanical problems of the swallowing mechanism, neurological disorders, gastrointestinal disorders, or loss of organs due to surgery or traumatic injury. Consequences of Swallowing Disorders Swallowing disorders, even when subtle, eventually take a toll on quality of life. Because eating is a natural part of social interaction, daily nutrition, and general health, the importance of normal swallowing cannot be overstated. Swallowing disorders affect quality of life in a number of ways. Aspiration This is a condition in which foods or liquids or oropharyngeal secretions pass into the airway below the level of the true vocal folds. This happens occasionally to most people; but in the absence of injuries to the muscles or nerves of swallowing, most people have the ability to sense the food or liquid in the airway and cough it out. When there is an injury or damage to the swallowing mechanism and aspiration is frequent or extensive, the risk of lung infections, dehydration, and malnutrition increases and the enjoyment of eating diminishes; thus, quality of life diminishes also. Aspiration Pneumonia When pulmonary infection results from acute or chronic aspiration of fluids, foods, or oral secretions from the mouth, or from fluids rising from the stomach, aspiration pneumonia develops. This is a potentially life-threatening condition and requires significant medical attention. Dehydration Dehydration is the state when there is not enough water in the body to maintain a healthy level of fluids in the body s tissues.

5 01_Murry_Pgs1-16 2/22/06 1:50 PM Page 4 4 CLINICAL MANAGEMENT OF SWALLOWING DISORDERS Even in an otherwise healthy person, lack of adequate water intake can lead to dehydration. For patients with neurological impairments who may be at risk for aspiration when swallowing liquids, fluid intake may require constant monitoring. Other factors such as medications that have dehydrating side effects, as discussed in chapter 3, conversely may impact one s ability to swallow. For example, when there is not enough natural saliva in the mouth, chewing becomes more difficult, food does not easily form a bolus, and particles may break apart and require multiple swallows. Malnutrition Malnutrition results from inability to ingest food safely, the reluctance to eat, or fear of eating or drinking due to past swallowing problems, or the inability to digest or absorb ingested nutrients. Once a person is unable to ingest food safely, his or her ability to maintain health decreases. This is especially important for patients who are recovering from extensive surgeries, strokes, or other debilitating diseases that will require long-term rehabilitation. Once malnutrition develops, its treatment may be as important as any other part of the rehabilitation process. Recovery from malnutrition has been shown to help in the overall rehabilitation process, leading to improvement in the patient s quality of life. Weight Loss There is a great preoccupation with weight loss in our society. Extensive weight loss, either induced or without reason, requires attention. Significant weight loss is associated with loss of muscle mass, which may produce weakness severe enough to change the daily activities of an individual. When unplanned weight loss develops, a swallowing disorder should be suspected. Weight loss should not be so extensive that it affects quality of life nor should it continue beyond normal weight ranges. The Impact of Swallowing Disorders on Quality of Life General Health The inability to swallow correctly may lead to a decline in general health. The decline may be slow or rapid and usually, but not always, is associated with other diseases. For individuals with systemic diseases, such as Parkinson s disease, diabetes mellitus, or high blood pressure, disorders such as gastroesophageal reflux, syndromes such as Charcot-Marie-Tooth, or autoimmune disorders,

6 01_Murry_Pgs1-16 2/22/06 1:50 PM Page 5 INTRODUCTION TO AND EPIDEMIOLOGY OF SWALLOWING DISORDERS 5 the concomitant dysphagia increases the severity of the primary problem. With the onset of dysphagia, the body s ability to cope as well with the primary disease is diminished. Moreover, the primary disease may be exacerbated by the dysphagia. Psychological Well-Being Eating is a social function as well as a nutritional necessity. When an illness or disease is further compounded by dysphagia, the natural social functions in which food plays a role are limited. The person with a swallowing disorder can no longer participate seamlessly in the social interactions that surround meals. Financial Well-Being The financial impact caused by dysphagia can be significant if there is a need for special foods, supplemental feeding, or primary enteral or parenteral feeding, dysphagia therapy, special gadgets and appliances to aid in the preparation of meals, and the need for others to assist with feeding. Some or all of these expenses may be paid for by insurance; however, the costs of all dysphagia-related management issues may be substantial and may continue for extended periods of time, straining the financial condition of the patient, his or her family, and the economic welfare of the patient s society. 1 Limitations brought by insurance capitation or personal financial abilities often compromise ideal rehabilitation strategies. The true financial impact of dysphagia remains unknown, as research has not yet determined the total cost of such major events such as aspiration pneumonia and hospital readmissions nor the cost-benefit ratio for the early identification and management of swallowing disorders. Conventional wisdom suggests that early intervention may prevent extensive comorbidities that result from the interaction of swallowing disorders with other diseases or disorders; clinical research will ultimately lead to the confirmation of methods of dysphagia rehabilitation. NEED FOR EARLY INTERVENTION Not everything that counts can be counted. Dennis Burket as quoted in Kitchen Table Wisdom, R.N. Remen

7 01_Murry_Pgs1-16 2/22/06 1:50 PM Page 6 6 CLINICAL MANAGEMENT OF SWALLOWING DISORDERS There is limited, albeit strong and intuitively right, evidence that the diagnosis and treatment of dysphagia is efficacious from the standpoint of significantly reducing aspiration pneumonia. Most of the evidence that exists is based on studies of stroke patients although, as pointed out in chapter 7, there is also evidence derived from research on patients undergoing treatment for cancers of the head and neck. The limited evidence available suggests that, in the acute care setting, dysphagia management is accompanied by reduced pneumonia rates. Furthermore, the use of a complete clinical swallowing examination appears to be cost-effective. 2 Others have found dysphagia management to be useful in the rehabilitation of swallowing disorders in other populations. Wasserman et al have shown that, with accurate reporting of clinical swallowing examination information, an early aggressive treatment program is efficacious in reducing the length of hospital stay in patients undergoing major surgery for head and neck cancer. 3 Additionally, development of valid screening procedures, such as the scale developed by Foster and colleagues, may offer further basis for early treatment of patients with dysphagia. 4 They administered a dysphagia screening instrument to 299 inpatients and found that the scale provided a means for targeting patients for early swallowing assessment and intervention. More recently, McHorney and colleagues presented early versions of the two quality of life assessments to determine the need and value of treating swallowing disorders. 5 The SWAL-QOL is a validated 44-item tool that assesses 10 quality-of-life concepts. The SWAL-CARE, is a 15-item tool that assesses quality of care and patient satisfaction. The scales identify patients with oropharyngeal dysphagia from normal swallowing subjects and are sensitive to differences in dysphagia severity. The SWAL-QOL and SWAL-CARE may ultimately help clinicians to identify and focus on patients who are in critical need of treatment and to determine treatment effectiveness. For what groups of patients might the SWAL-QOL and SWAL-CARE be most useful? In what groups might its use be limited? Currently, the lack of control groups, the undefined effects of diseases, and lack of long-term follow-up data limit the statements that can be made on the true effects of early dysphagia intervention. The lack of prospective, controlled, randomized research should not suggest that swallowing programs using the clinical swallowing examination or other programs such as the modified barium swallow (MBS) or the flexible endoscopic evaluation of swallowing (FEES) should not be continued. On the contrary, stud-

8 01_Murry_Pgs1-16 2/22/06 1:50 PM Page 7 INTRODUCTION TO AND EPIDEMIOLOGY OF SWALLOWING DISORDERS 7 ies such as that by Odderson, Keaton, and McKenna 6 provide strong arguments for continued early intervention in dysphagia. These investigators looked at pneumonia rates before and after initiating a bedside swallow evaluation program in a hospital setting. Aspiration pneumonia rates in stroke patients were substantially reduced after the program was initiated compared to rates recorded before the program. Additional research is needed to provide further evidence for clinical swallowing examination programs as well as for programs that rely on instrumental diagnosis of the swallowing problem. To this end, it is important for programs in dysphagia intervention to include a data acquisition format that offers an opportunity to assess their contribution to reduction of hospital stays and readmissions due to swallowing-related problems. EPIDEMIOLOGY Dysphagia can be caused by many different disorders, including natural aging, neurological diseases, head injury, degenerative diseases, systemic diseases, autoimmune disorders, neoplasms, and infections. Treatment modalities such as surgery, radiation therapy, and medications can also lead to dysphagia. Chronic reflux laryngitis, a condition that is often overlooked, may also interfere with normal swallowing. Patients with head or neck cancer have a variable presentation. They often have significant dysphagia at the time of initial presentation; and their swallowing function often suffers as a result of the treatment, although some deficits improve with time. Patients with Parkinson s disease suffer from dysphagia that becomes more severe as the disease progresses. Because of these varied and often compounded etiologies, it may not be possible to ascertain the true incidence of any particular category of swallowing disorder. In addition, no single test is 100% accurate for diagnosing dyphagia. Swallowing disorders also may arise as comorbidities of other disorders or as precursors to more significant diseases and disorders. Moreover, the incidence of swallowing disorders may vary depending on the type of diagnostic evaluation. Table 1 1 shows the incidence of oropharyngeal dysphagia in patients who exhibited aspiration during videofluoroscopic examination. 7 If all the tests for examination of swallowing are considered, the true incidence of swallowing disorders may be substantially higher. When the swallowing disorder accompanies other medical conditions, the primary condition may be affected by the swallowing disorder. Conversely, a swallowing disorder may be the symptom of another neurological disease or condition requiring treatment. Thus, the exact incidence of swallowing disorders remains unknown.

9 03_Murry_Pgs /22/06 1:50 PM Page 37 THE ABNORMAL SWALLOW: CONDITIONS AND DISEASES 37 INTRODUCTION Swallowing is a complex activity requiring the interaction of sensory and motor mechanisms as described in Chapter 2. A normal swallow consists of two discrete events, airway protection and bolus propulsion. Neural impulses from cortical and subcortical pathways integrate motor and sensory data to the muscles of the oral cavity, pharyngeal, and laryngeal structures. The muscles of the oral and pharyngeal regions transfer data to the brainstem reticular formation, medulla, and frontal cortex via the facial, glossopharyngeal, and vagus nerves. A safe swallow entails the timely interaction of the muscles of mastication, which are innervated by the trigeminal nerve, and the pharyngeal and laryngeal muscles, which are controlled by the efferent and afferent fibers of the glossopharyngeal and vagus nerves. Additional muscular innervation of the strap muscles of the swallowing mechanism by the ansa hypoglossi and ansa cervicalis aids in the complex motion of swallowing. A more detailed description of the muscular actions and neuromuscular control of these actions can be found in Aviv and Murry. 1 Damage to any of the nerves involved in swallowing or to the corresponding areas of the central nervous system (brainstem, medulla, cortex) affects swallowing. Thus, normal swallowing involves an intact nervous system. Many conditions can disrupt the muscular actions of a normal swallow at any point along the pathway leading to the stomach. In addition, conditions of the bolus in the stomach may affect the transit of these boluses that have not yet arrived in the stomach. Prior to reaching the stomach, the bolus must pass along a lumen that is shared with the respiratory pathway. Each swallow involves the interruption of breathing, protection of the airway, and then the return of respiration once the bolus is safely beyond the laryngeal inlet. Airway protection during normal swallowing is brought about by the three-tier closure of the laryngeal sphincter. This includes closure of the true vocal folds and the arytenoids (ie, the glottis), the false vocal folds, aryepiglottic folds, and the epiglottis (ie, supraglottis). The superior and anterior motion of the larynx caused by the contraction of the suprahyoid muscles opens the posterior cricoid space and moves the larynx superiorly to a protected position beneath the base of the tongue. Following the swallow, normal subjects resume respiration activities with exhalation. 2 When airway protection is incomplete or delayed, penetration of the bolus and even aspiration of the bolus may occur. Kendall et al 3 showed that, in most subjects, the arytenoidsepiglottic approximation occurs before the bolus reaches the upper esophageal sphincter; but, in some cases, it may occur after but the

10 03_Murry_Pgs /22/06 1:50 PM Page CLINICAL MANAGEMENT OF SWALLOWING DISORDERS delay is never greater than 0.1 second. They also noted no delay of the supraglottic closure in normal elderly patients. It is clear that any condition that results in failure of the glottic sphincter to close in a timely and appropriate way may allow food or liquid to enter the airway. Although the neuromuscular pathogenesis is beyond the scope of this book, we will outline the most common conditions associated with a disordered swallow in adults. In this chapter, we introduce the terms, penetration, aspiration, and aspiration pneumonia as their understanding is important to the remainder of the chapter. Penetration. Penetration is defined as the entry of bolus contents into the larynx to a level that does not extend beyond the true vocal folds. Figure 3 1 shows an example of penetration obtained during transnasal flexible endoscopy. Aspiration. Aspiration is the entry of material into the airway below the true vocal folds. Aspiration can occur before, during, or after the swallow. These may be termed preprandial, prandial, or postprandial aspiration. Table 3 1 summarizes Mendelsohn s classic review of the nature of prandial aspiration. 4 Figure 3 2 shows aspiration. A portion of the food is below the vocal folds and has not yet been expelled. Figure 3 1. Endoscopic view of aspiration of liquid during a Flexible Endoscopic Evaluation of Swallowing.

11 03_Murry_Pgs /22/06 1:50 PM Page 39 Table 3 1. Classification of Prandial Aspiration Aspiration Before the Pharyngeal Stage most common type in central neurological disease due to loss of bolus control during oral phase or to delayed pharyngeal swallow conservative management: thicken the diet, neck flexion during deglutition, supraglottic swallow, effortful swallow, thermal stimulation surgical management: horizontal epiglottoplasty, tongue-base flaps, laryngeal suspension Aspiration During the Pharyngeal Stage least common type of aspiration due to vocal palsy, paresis, or incoordination conservative management: vocal adduction exercises surgical management: augment the paralyzed vocal cord Aspiration After the Pharyngeal Stage due to inhalation of uncleared residue at the laryngeal inlet conservative management: thinning the diet, alternating liquids, liquid wash, Mendelson maneuver, head rotation surgical management: translaryngeal resection of the cricoid lamina, cricopharyngeal myotomy or Botox injection, laryngeal suspension, laryngotracheal separation From Mendelsohn M. New concepts in dysphagia management. J Otolaryngol. 1993;22(Suppl 1):9. Figure 3 2. Endoscopic view of aspiration. The bolus is partially below the vocal folds and has not yet been expelled. 39

12 03_Murry_Pgs /22/06 1:50 PM Page CLINICAL MANAGEMENT OF SWALLOWING DISORDERS Factors that influence the tolerance to aspiration include volume, frequency, and type of the aspirate, depth of aspiration (ie, tracheal or pulmonary), oral hygiene, pulmonary reserve, ability to expectorate the aspirate, and immune function of the host. These factors and their interaction with the neuromuscular system of the host are extremely variable. Thus, the definition of what constitutes significant aspiration should be individualized. Pulmonary syndromes that are related to aspiration are shown in Table 3 2. They include: (a) chemical pneumonitis, (b) bacterial infection, and (c) acute airway obstruction. 5 Aspiration Pneumonia. Aspiration pneumonia is a condition resulting from the entrance of foreign materials, usually foods, liquids, or vomit into the bronchi of the lungs with resultant infection. Table 3 3 describes the two types of bacterial infections associated with pneumonia. 5 Patients may present with a wide spectrum of aspiration syndromes prior to the development of aspiration pneumonia. Multiple risk factors for Table 3 2. Pulmonary Conditions Related to Aspiration 1. Acute respiratory distress syndrome (ARDS): Interstitial and/or alveolar edema and hemorrhage, as well as perivascular lung edema. It may be caused by aspiration of acid refluxate. 2. Lipid (lipoid) pneumonia: Aspiration of oil-based liquid, such as mineral oil given as a laxative, oil-based nasal spray, or contrast material. In unconscious patients, especially those requiring mechanical ventilation, fever, hypoxia, and excessive tracheal secretions may suggest pneumonia. For patients requiring mechanical ventilation, placement in a semirecumbent position and active suction of the hypopharynx may reduce the risk of aspiration. 3. Aspiration pneumonia: Aspiration pneumonia is usually polybacterial and is associated with a high morbidity and mortality. It is usually found in dependent pulmonary lobes. 4. Chronic pneumonitis: Some patients do not develop a radiographic consolidate that could be diagnosed as a pneumonia, but present with purulent, foul-smelling bronchorrhea, low-grade spiking fever, and varying degrees of respiratory compromise. A prominent bronchial pattern may be present in the chest radiogram. Adapted from Falestiny MN, Yu VL. Aspiration pneumonia. In: Carrau RL, Murry T, eds. Comprehensive Management of Swallowing Disorders. San Diego, Calif: Plural Publishing, Inc; in press:385.

13 03_Murry_Pgs /22/06 1:50 PM Page 41 THE ABNORMAL SWALLOW: CONDITIONS AND DISEASES 41 Table 3 3. Bacteriology of Aspiration Pneumonia Community Acquired Anaerobes Fusobacterium nucleatum Peptostreptococus spp Bacteroides melaninogenicus Other Bacteroides spp Aerobes Micro-aerophilic streptococci Streptococcus viridans Moraxella catarrhalis Eikenella corrodens Streptococcus pneumoniae Haemophilus influenzae Nosocomial-Acquired Anaerobes Fusobacterium nucleatum Peptostreptococcus spp Bacteroides spp Aerobes Staphylococcus aureus Enterobacteriaceae Escherichia coli Klebsiella spp Enterococcus spp Citrobacter freundii Acinetobacter lwoffii Pseudomonas aeruginosa Adapted from Falestiny MN, Yu VL. Aspiration pneumonia. In: Carrau RL, Murry T, eds. Comprehensive Management of Swallowing Disorders. San Diego, Calif: Plural Publishing, Inc; in press: aspiration are listed in Table Technically known as bronchopneumonia, aspiration pneumonia may consist of one of three distinct types: Pneumonitis or pulmonary inflammation in its early stages results in a low-grade fever. Extended periods of aspiration lead to more severe symptoms such as fatigue, productive cough with colored phlegm, and even unconsciousness secondary to hypoxia. Lung abscess is an accumulation of pus that has been contained by a surrounding inflammatory process. Radiologically, it appears as a spherical-looking area with an air-fluid level often resembling a lung mass. Empyema is pus in the pleural space. If left untreated, empyemas produce destructive changes resulting in rupture of the pleural walls. Aspiration pneumonia may be initially difficult to identify and diagnose even with invasive studies. Patients present with nonspecific pulmonary symptoms such as cough, wheezing, or shortness

14 03_Murry_Pgs /22/06 1:50 PM Page CLINICAL MANAGEMENT OF SWALLOWING DISORDERS Table 3 4. Aspiration: Risk Factors Altered level of consciousness: Head trauma Coma Cerebrovascular accident acute stage Metabolic encephalopathy Seizure disorders General anesthesia Alcohol intoxication Altered drug states Excessive sedation Cardiopulmonary arrest Gastrointestinal dysfunction: Scleroderma Esophageal stricture Gastroesophageal reflux Laryngopharyngeal reflux Erosive esophagitis Zenker s diverticulum Tracheoesophageal fistula Esophageal cancer Hiatal hernia Pyloric stenosis/gastric outlet obstruction Enteral feeding Pregnancy Anorexia/bulimia Iatrogenic: Prolonged mechanical ventilatory support Tracheotomy Anticholinergic drugs Miscellaneous: Obesity Neck malignancies Medication overdosages Postsurgical: Skull base Head and neck Thyroid carcinoma Supraglottic laryngectomy Major oropharyngeal resection Carotid endarterectomy Anterior spinal fusion Adapted and revised from Pou AM, Carrau RL. Skull base surgery. In: Carrau RL, Murry T (eds.). Comprehensive Management of Swallowing Disorders. San Diego, Calif: Plural Publishing, Inc; in press: of breath (hypoxia). Chest radiographs most commonly show a consolidation of the dependent lobes of the lungs. In stroke patients, the overall debilitation, malnutrition, dehydration, and other systemic problems that accompany or precede the stroke increase the risk of aspiration pneumonia after the stroke. Other risk factors often present in patients with a stroke, as well as with head-and-neck cancer patients include poor oral hygiene with bacterial overgrowth and loss of sensory awareness, which may occur after other prolonged illness or degradation of pulmonary function even after the acute event has been stabilized.

15 03_Murry_Pgs /22/06 1:50 PM Page 43 THE ABNORMAL SWALLOW: CONDITIONS AND DISEASES 43 The following conditions include the most important groups of patients that are predisposed to aspiration pneumonia. Altered mental status: Nearly 70% of patients with altered mental status, regardless of the underlying disease, aspirate possibly because of the inability to protect the airways and/or the lack of coordination between breathing and swallowing. Prolonged mechanical ventilation: Patients requiring prolonged mechanical ventilation and patients with a tracheostomy are especially at risk for aspiration. These patients suffer from desensitization of the pharynx due to the presence of the tube and the loss of the afferent-efferent reflexes that coordinate the separation of the airway from the foodway at the time of swallowing. Aspiration pneumonia can occur after only 2 weeks on mechanical ventilation, and nearly 85% of these patients show aspiration during flexible endoscopic evaluation of swallowing or videofluoroscopy. Gastroesophageal reflux: Acute findings in acid aspirationinduced lung injury include mucosal edema, hemorrhage, and focal ulceration followed by the development of focal necrosis and diffuse alveolar hyaline membrane formation. Subsequent capillary leakage, bronchorrhea, and diminished lung compliance result in severe pulmonary failure and compromised gas exchange. Gastroesophageal reflux is discussed in great details in a later section of this chapter. Neuromuscular disorders: These patients lose motor and sensory function of the upper aerodigestive tract, leading to a variety of disorders affecting cognition, coordination of reflexive actions, and loss of sphincteric and propulsive mechanisms. Upper aerodigestive tract tumors: Most of these patients experience some swallowing difficulty, either from the mechanical effects of the tumor, its interference with the sphincteric mechanism of the larynx, or anatomical and functional changes produced by surgery, radiation therapy, and chemotherapy. Their swallowing problems are not limited to the time of treatment or shortly after treatment. Surgery, radiation, and/or chemotherapy can result in long-term changes in bolus propulsion, ability to close the airway, and motility disorders of the esophagus. The remainder of this chapter reviews the most common conditions and diseases that may require assessment and treatment of a swallowing disorder.

16 03_Murry_Pgs /22/06 1:50 PM Page CLINICAL MANAGEMENT OF SWALLOWING DISORDERS NEUROLOGICAL DISORDERS Dysphagia caused by neurological injuries and diseases is usually the end result of an impaired integration of the sensorimotor components of the oral and pharyngeal phases of swallowing. The onset and progression and severity of the primary disease, and therefore its symptoms, may be sudden or may result from a slow progressive degeneration of neuromuscular systems. A recent review of the advances in sensorimotor control of the swallowing mechanisms suggests that many of the reflexive laryngeal functions associated with swallowing are controlled by the brainstem. 7 These functions are thought to control the integration of respiration and swallowing. 7,8 Table 3 5 lists the more common neurological disorders causing dysphagia as identified by Perlman and Schulze- Delrieu 9 and by Coyle, Rosenbek, and Chignell. 10 Evaluation of the patient with unexplained dysphagia should include the taking of a careful history, a workup that includes magnetic resonance imaging of the brain and brainstem, serology for muscle enzymes, thyroid screening, vitamin B12 levels and anti-acetylcholine receptor antibodies, and electromyographic nerve conduction studies. In certain cases, muscle biopsy or cerebrospinal fluid examination may also be necessary. These tests are often coordinated with a neurologist experienced in dysphagia. The following pages describe neurogenic conditions that have a significant incidence of swallowing disorders. Amyotrophic Lateral Sclerosis (ALS) Amyotrophic lateral sclerosis has an incidence around 2 per 100,000. Men are affected slightly more frequently than women, with a disease onset around age 60, although it presents a bimodal distribution with a subpopulation of patients presenting in their fourth decade. Diagnosis of ALS requires the presence and progression of lower motor neuron and upper motor neuron deficiency. Upper limb muscles are affected more frequently than lower limb muscles. Bulbar muscles may be affected, leading to significant prominent dysarthria and dysphagia. Bulbar involvement in ALS is associated with a worse prognosis because of the higher risk of pulmonary aspiration and malnutrition. It is important to monitor the weight of the dysphagic patients and their nutritional status. This will identify the patients in need of a percutaneous endoscopic gastrostomy (PEG). The use of gastrostomy tubes in patients with ALS is controversial and full of philosophical implications. It is recognized, however, that if a gastrostomy tube is to be considered, it should be at a time when the patient is not yet impaired by malnutrition.

17 05_Murry_Pgs /22/06 1:41 PM Page 99 EVALUATION OF DYSPHAGIA 99 INTRODUCTION The evaluation of swallowing encompasses the case history, the clinical or bedside swallow examination, and the instrumental examination. Recently, several patient self-assessment tools have also been proposed to quantify quality of life and specific aspects related to swallowing symptoms. In many assessment protocols, the case history and bedside swallow evaluation (BSE) are combined. Each aspect of the swallow evaluation is designed to address the issues of: (1) swallow safety, (2) nutritional status, (3) continuation or possible modification of present diet, (4) need for specialized treatments, (5) referrals for additional tests based on the results of the specific swallow evaluation or the patient s general behavior and (6) establishment of a medical diagnosis and/or pathogenesis for the swallowing disorder or the need for further assessment. Patient Self-Assessment The SWAL-QOL and SWAL-CARE are two outcomes tools to assess the swallowing quality of life and quality of care that patients determine themselves. 1 The original assessment tool was exceptionally long (93 items); it is now reduced to 44 items in the SWAL-QOL and 15 items in the SWAL-CARE versions. These are pencil and paper tools that patients can respond to prior to treatment, at various times during treatment, and after treatment. The SWAL-QOL consists of several subscales, all of which exhibit reliability and reproducibility. Moreover, the scales differentiate patients with normal swallowing from patients with oropharyngeal swallowing dysfunction. Unlike other tests of swallowing that may be specific to an underlying disorder, such as radiation injury or surgical treatments, the SWAL-QOL can be used with any patient who has a swallowing disorder. The MD Anderson Dysphagia Inventory (MDADI) is a multiple scale assessment of patients responses to swallowing quality of life following treatment for head and neck cancer. The MDADI consists of global, emotional, functional, and physical subscales, all with internal consistency and high reliability. Findings by Chen et al 2 indicate that the MDADI is a valid test of swallowing function when compared with the Medical Outcomes Study 36-Item Short Form Health Survey. In their original work, Chen and his colleagues found that patients with primary tumors of the oral cavity and oropharynx had significantly greater swallowing disability with an adverse impact on quality of life compared to patients with

18 05_Murry_Pgs /22/06 1:41 PM Page CLINICAL MANAGEMENT OF SWALLOWING DISORDERS tumors of the larynx and hypopharynx. Recently, Gillespie et al demonstrated the usefulness of the MDADI in comparing QOL outcomes after treatments for head and neck cancer. 3 Patients who received chemoradiation for various oropharyngeal cancers demonstrated better emotional and functional subscale scores than patients who underwent surgery and postoperative irradiation. The Reflux Symptom Index (RSI) is a 10-question patient selfassessment that quantifies a patient s reflux symptoms (Apendix 1). 4 The RSI has been validated using 24-hr ph-metry and has been found to be a valid index of reflux severity. Gastroesophageal reflux (GER) and laryngopharyngeal reflux (LPR) are highly associated with dysphagia and when treated maximally, the reduction of GER or LPR results in improvement in swallow function. Screening Tests Prior to instrumental evaluation, and in some settings in place of the complete BSE, the use of a dysphagia screening test may be appropriate. This is usually done by a speech-language pathologist but may also be done by other core providers trained in the procedure. Two such screening tests are the Burke Dysphagia Screening Test (BDST), 5 and the acute screening test proposed by Odderson et al. 6 The BSDT consists of seven items (this is discussed fully in chapter 3). If the patient has one or more of the items listed in the test, he or she is referred for an instrumental evaluation. The screening items are: (1) bilateral stroke, (2) brainstem stroke, (3) history of pneumonia in the acute stroke phase, (4) cough during a 3-oz water swallow, or cough associated with feeding, 5 failure to consume one-half of meals, 6 prolonged time required for feeding (more than 30 minutes when the time prolongation is not caused by physical limitations), and (7) nonoral feeding program in progress. This screening procedure coupled with that of Odderson et.al was found to be highly valuable in identifying stroke patients at risk for swallowing problems. The dye test also known as the blue dye test, may be used to determine the presence of aspiration in a tracheotomized patient. A few drops of methylene blue or vegetable coloring are placed in the mouth, the tracheotomy cuff is deflated, and the tracheotomy tube is deep suctioned for secretions that may have been resting on or above the level of the cuff. The patient s tracheotomy tube is deep suctioned again, looking for dyed material in the airway. The blue dye test, however, may not detect trace amounts of aspirated materials and, consequently, yield a false-positive result if the suction draws dyed secretions from the hypopharynx. In addition,

19 05_Murry_Pgs /22/06 1:41 PM Page 101 EVALUATION OF DYSPHAGIA 101 trace aspiration and delayed aspiration may not be reliably identified using this procedure. Alternatively, a Dextrostix may be used to detect the presence of glucose (ie, food) in the tracheal secretions. 7 Auscultation of the chest and cervical airway is done by placing a stethoscope over various parts of the airway. Placing the stethoscope gently on the lateral aspect of the larynx, and listening to the airflow during normal breathing, swallowing, and speech provides the listener with indirect evidence of penetration and/or aspiration. Although one may hear various sounds during respiration using the stethoscope, the examiner may also hear other sounds of respiration such as soft palate movement that do not reflect evidence of fluid in the airway. A trained observer/listener may find this screening tool useful in planning the types of materials to be swallowed during instrumental testing of the swallowing mechanism. CASE HISTORY AND CLINICAL EVALUATION OF SWALLOWING Case History Table 5 1 summarizes the critical components of the case history. Prior to any examination of the patient, the clinician should identify Table 5 1. Critical Components of the Clinical Case History Identify the chief complaint or define the current status Type of dysphagia: liquids, foods, pills Onset, progression Recent pneumonia and probable cause(s) Recent hospitalizations: reasons Associated symptoms: voice changes, weakness Present and past: illnesses, surgery, trauma Medications Trauma Social history/habits Family history Review of systems: pulmonary, cardiac, digestive, etc Adapted and revised from Carrau RL. Chapter 4. In: Carrau RL, Murry T, eds. Comprehensive Management of Swallowing Disorders. San Diego, Calif: Plural Publishing, Inc; in press:34 (Table 4 2).

20 05_Murry_Pgs /22/06 1:41 PM Page CLINICAL MANAGEMENT OF SWALLOWING DISORDERS the chief complaint or define the current status of the patient. A detailed history should account for the patient s current physical status, any neurologic diseases, recent surgeries, or sequelae from previous surgeries that may contribute to the dysphagia. The onset of the dysphagia should be documented and related to events such as acute or chronic illness, surgery, neurological changes, medicines, or trauma (physical or emotional). Based on the patient s input, family input, and medical records, the complexity of the problem should be estimated prior to testing the swallowing of liquids or foods. Time elapsed since oral feeding was stopped, anatomical changes to the swallowing mechanism, neurological status, and degree of alertness help to make those determinations. Clinical findings noted in the medical records should be considered. Common clinical findings that are associated with dysphagia and/or aspiration are shown in Table 5 2. It should be pointed Table 5 2. Common Clinical Findings in Dysphagic Patients Coughing/choking: swallowing food, liquid, or own saliva Frequent throat clearing: with or without a productive cough Multiple swallow pattern Wet vocal quality Edentulous Drooling Increased oral or pharyngeal secretions Cyanosis Shortness of breath Weight loss Bronchorrhea Increased time to consume meal Spiking Pulmonary infiltrate Resistance to eating or drinking Food sticking in mouth Changes in taste Difficulty in managing foods of specific textures or sensation Aberrant behavioral patterns when food is presented Adapted from Simonian MA, Goldberg AN. Chapter 52. In: Carrau RL, Murry T, eds. Comprehensive Management of Swallowing Disorders, San Diego, Calif: Plural Publishing, Inc; in press:368 (Table 52 2).

21 05_Murry_Pgs /22/06 1:41 PM Page 103 EVALUATION OF DYSPHAGIA 103 out that, even when the majority of these signs and symptoms are absent, swallow safety may still be an important issue. 8 Table 5 2 emphasizes observing the patient, reviewing the case history, and acquiring information from caregivers, all of which are important aspects of the bedside swallow examination. The clinician should find the answers to the following questions during the case history and clinical swallow evaluation (bedside swallow evaluation): 1. Is the patient currently eating by mouth or relying on nonoral feeding? 2. Is there a history of aspiration pneumonia? 3. Is there a risk of aspiration given the present nutritional status and diet? 4. What is the anatomical and functional status of the oral mechanism? 5. Is the patient thriving or maintaining his general health and nutrition status based on the current diet and method of eating? 6. Should the patient be referred for further evaluation of his or her swallowing based on the clinical evaluation of swallowing (bedside swallow evaluation)? 7. Is the patient cognitively capable of participating in instrumental testing and rehabilitation? 8. What changes in the treatment plan should be anticipated or planned given the outcome of the clinical evaluation of swallowing? Clinical Evaluation of Swallowing The clinical evaluation of swallowing (CES) provides a road map to the diagnosis and treatment of the swallowing disorder. The CES provides a preliminary assessment of the patient s current medical status, his or her needs for nutrition, and alerts the clinician to select the appropriate instrumental testing protocol. Depending on the status of the patient (eg, severe impairment from stroke or extensive trauma), a complete CES is sometimes not possible; nonetheless, the clinician should make an attempt to conduct as thorough a CES as possible. Even an incomplete CES provides important information regarding the patient s cognitive ability to

22 05_Murry_Pgs /22/06 1:41 PM Page CLINICAL MANAGEMENT OF SWALLOWING DISORDERS follow instructions and to cooperate during the testing and rehabilitation process. Detecting the presence of penetration and aspiration is an important part of the CES as health status and recovery are dependent on adequate nutrition and safe swallowing. Several investigators have examined the sensitivity and specificity of the CES for predicting aspiration. McCullough, Wertz, and Rosenbek examined 60 stroke patients and found that the CES was not highly predictive of which patients subsequently aspirated during the modified barium swallow examination. 8 Ramsey and colleagues found that the CES had highly variable specificity and sensitivity and also concluded that was inadequate for detecting silent aspiration. 9 Peruzzi and colleagues compared the use of a bedside dye test to videoflouroscopy studies of swallowing in 20 consecutive patients with tracheostomy and found that the videofluoroscopic exam was significantly better at detecting aspiration than the bedside dye test. 10 Clinical Evaluation of Swallowing with Pulse Oximetry A more recent approach to increase the sensitivity and specificity of the clinical evaluation of swallowing for detecting aspiration is the use of pulse oximetry. Pulse oximetry is based on the principle that reduced and oxygenated hemoglobin exhibit different absorption characteristics to red and infrared light emitted from a finger or ear probe. It is noninvasive, simple, and may be used as a continuous or continual test to measure oxygen desaturation of arterial blood as a result of aspiration. Although this test does not provide the diagnostic information to formulate treatment plans, its use as a complement to the CES may help to detect the presence and possibly the severity of aspiration. Some advocate the use of pulse oximetry as a well-tolerated and inexpensive option to endoscopy and videoflouroscopy. 11 Its use is advocated for patients who cannot be transferred, patients whose cognition is suspect and or who cannot tolerate instrumental testing, or patients in nursing homes where radiological or endoscopic examinations are not available. Thus, pulse oximetry added to the CES offers an alternative to a group of patients who might otherwise receive only a clinical evaluation of swallowing at bedside and no further tests. Lim et al found that combining the CES with pulse oximetry before and after drinking 50 ml of water, a test they called the bedside aspiration test, its sensitivity increased to 100% and its specificity was almost 71%. 12 They concluded that the bedside aspi-

23 05_Murry_Pgs /22/06 1:41 PM Page 105 EVALUATION OF DYSPHAGIA 105 ration test was a suitable screening test to identify acute stroke patients at risk for aspiration and in need of further evaluation and management. These results were similar to those of Smith et al who studied 53 acute stroke patients at bedside using pulse oximetry. By comparing bedside screening using pulse oximetry with modified barium swallow assessments, they detected 86% of their subjects who were potential aspirators or penetrators and who required follow-up testing and management. 13 Despite the limitations of the CES, in patients who cannot be tested more thoroughly or when instrumental evaluations are not available, CES may be the only basis for the decision to begin, continue, or suspend oral feeding. Adding pulse oximetry to the clinical evaluation of swallowing appears to increase the ability to detect aspiration. Pulse oximetry combined with the clinical evaluation of swallowing may be considered as an important first step in the diagnostic process despite its caveats. 14 Silent Aspiration The clinician must always be aware of the possibility of silent aspiration. This is the penetration of food, liquid, or saliva to the subglottic area without the elicitation of a cough. It has been estimated that silent aspiration may be as high as 40% in patients with dysphagia, and it is not generally identifiable during the CES. However, a history of pneumonia, a weak or absent cough, changes in body temperature after eating, and a voice that has a wet hoarse quality suggest the possibility of silent aspiration. Additionally, the use of sensory testing, as described below provides an estimate of sensory awareness, which may be a clinical indicator that the patient is a silent aspirator. 15 Oral, Pharyngeal, and Laryngeal Examination A thorough examination of the oral, laryngeal, and pharyngeal structures should include an assessment of lip closure, tongue strength, and mobility, facial symmetry, voice, and volitional cough quality and strength. Table 5 3, modified from Daniels, McAdam, Brailey, and Foundas, 16 provides a comprehensive orderly approach to the oropharyngeal examination and can be done at bedside. Clinicians, even those with extensive experience in oral examination, may profit from this structure as it provides an orderly approach to assessing muscular function related to the cranial nerves that are important for swallowing.

24 05_Murry_Pgs /22/06 1:41 PM Page 106 Table 5 3. The Oropharyngeal Examination at Bedside Name Diagnosis Mandible (CN V) Symmetry on Extension Date Strength Lips (CN VII) Symmetry: Rest Retraction Protrusion Strength Nonspeech Coordination: Repetitive Movement Alternating Movement Speech Coordination: Repetitive (/p,w/) Alternating (/p-w/) Tongue (CN XII) Symmetry: Rest Protrusion Lateralization Elevation: Yes/No Lateralization: Yes/No Fasciculations: Yes/No Strength Nonspeech Coordination: Repetitive Movement Alternating Movement Speech Coordination: Repetitive (/t,k/) Alternating (/t-k/) Alternating Movement (/pataka/) Multisyllabic Word Repetition (tip top, baseball player, several, caterpillar, emphasize) Conversation: (speech, voice, coordination characteristics) Laryngeal Function: Isolated Movement (/i-i-i/ on one breath) Alternating Movement (/u-i/) Buccofacial Apraxia; Blow out the candle Lick an ice cream cone Lick milk off your top lip Sip through a straw Kiss a baby Velum (CN IX, X, XI) Symmetry: Rest Elevation Coordination: Repetitive Movement (/a/) Appearance of Hard Palate Dentition Reflexes (CN, IX, X, XI) Gag (Abnormal:Yes/No) Swallow (Cough: Yes/No) (Voice Change: Yes/No) Additional information c/o Facial Numbness or Tingling: Yes/No Light Touch Dysphonia: Yes/No (mild, moderate, severe) Dysarthria: Yes/No (mild, moderate, severe) Breath Support Resonance Volitional Cough (Abnormal: Yes/No) Clinician Date 106 Adapted with permission from Daniels SK, McAdam CP, Brailey K, Foundas AL. Clinical assessment of swallowing and prediction of dysphagia severity. Am J Speech Lang Pathol. 1997;6(4):17.