Nonsurgical Management of Swallowing Disorders
Shaum S. Sridharan
Cathy L. Lazarus
Milan R. Amin
Swallowing disorders refer to any dysfunction in the complex cascade of normal deglutition. It is the task of the clinician to not only investigate the site of dysfunction, but also to try to help rebalance the system to prevent symptoms of dysphagia and aspiration pneumonia. This chapter provides a comprehensive overview of medical and rehabilitative modalities in the management of swallowing disorders. With the proper identification of the underlying reason(s) for dysphagia, appropriate therapy can be initiated by physicians and speech and language pathologists.
Treatment for oropharyngeal dysphagia should be based on a thorough instrumental assessment of oropharyngeal swallowing, including the modified barium swallow (MBS) procedure (1,2,3,4). This radiographic procedure, also known as a Videofluoroscopic Swallow Study (VFSS), involves giving a patient specific bolus types of various volumes and consistencies (calibrated bolus volumes of liquids, cup sips, pudding, and masticated consistencies, as appropriate) and examining their effects on the swallow. The radiographic examination provides a view of the oropharyngeal anatomy and allows the clinician to identify any abnormalities of the oropharyngeal swallow. The radiographic study should identify the patient’s physiologic swallow disorders, rather than merely symptoms of the disorders, such as penetration (material in the airway entrance), aspiration (material below the vocal folds), and residue (food remaining in the oral cavity, valleculae, pharyngeal wall, pyriform sinuses). Appropriate treatment strategies cannot be determined until the physiologic swallow abnormalities (such as reduction in tongue base posterior motion, reduction in laryngeal elevation, and anterior motion) have been identified.
Once the anatomic and/or physiologic swallow disorders have been defined on fluoroscopy, the clinician determines the effects of rehabilitative strategies on the patient’s swallow. The goal of the rehabilitative strategies is to improve swallow safety (i.e., elimination of aspiration) and efficiency (i.e., improving the speed of the swallow and reducing the amount of residue within the oral cavity and pharynx). These strategies can be compensatory in nature, including postures and sensory augmentation, or can be direct treatment techniques designed to alter swallow physiology, including swallow maneuvers. Some patients are able to begin or resume some type of oral diet using the postures that demonstrated success on fluoroscopy. Others may require use of swallow maneuvers during meals. Some patients, however, exhibit swallow function that is so impaired as to preclude an oral diet. The treatment strategies will be based on the patient’s oropharyngeal anatomy and abnormal swallow physiology. In addition, the strategies employed will be determined by the patient’s medical diagnosis, including the patient’s overall medical condition, mental status, cognitive ability, motivation level, and speech/language ability. Thus, treatment planning begins at the time of the diagnostic procedure. The report of the VFSS should identify the symptoms of the swallow disorders, the physiologic swallow disorder, the rehabilitative strategies tried on fluoroscopy and their effects, and the specific treatment plan.
COMPENSATORY TREATMENT PROCEDURES
Compensatory treatment techniques are designed to redirect the bolus flow through the oral cavity and pharynx. They are techniques that are designed to eliminate aspiration, one of the symptoms of dysphagia, but are not designed to alter the swallow physiology. These techniques can be implemented by caregivers, and, therefore, are useful for patients of all ages and cognitive levels. Compensatory treatments include: (a) postures; (b) heightening sensory input; (c) modifying bolus volume and speed of feeding; (d) modifying food viscosity/texture, and (e) intraoral prosthetics.
Postures
Postures alter the flow of the bolus through the oral cavity and pharynx (Table 58.1). Chin tuck posture is used when the pharyngeal swallow (i.e., pharyngeal motor response) is delayed and aspiration occurs before the swallow triggers (1). This posture widens the vallecular space, creating a space for liquids and food to catch in the valleculae during the delay. Chin tuck posture also narrows the airway entrance, with closer approximation of the arytenoids to the epiglottic base and is useful for patients who demonstrate reduced airway closure (5). The tongue base is situated closer to the posterior pharyngeal wall (PPW) during chin tuck posture, providing additional airway protection by deflecting the bolus more posteriorly during the swallow (1,6,7). In addition, for those patients with reduced tongue base posterior motion, resulting in poor bolus clearance past the tongue base and residue on the tongue base, valleculae, and pharyngeal wall, chin tuck posture improves bolus clearance within this region, resulting in reduced upper pharyngeal residue (7). This technique has been found useful in eliminating aspiration in neurologically impaired and in surgically treated head and neck cancer patients (8,9,10).
TABLE 58.1 RATIONALE FOR USE OF COMPENSATORY POSTURES TO IMPROVE SWALLOW FUNCTION | ||||||||||||||||||||||||||||||
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The head back posture is useful for those patients who demonstrate difficulty propelling the bolus out of the oral cavity into the pharynx, as frequently observed in oral cancer patients and dysarthric patients with impaired tongue mobility (1). This posture allows gravity to propel the bolus into the pharynx. This posture, however, should be used with caution, since patients may aspirate more easily, particularly on thin liquids. Voluntary airway closure techniques, described below, are useful in protecting the airway during use of this posture. Patients with fairly severe pharyngeal phase swallow disorders should not use this posture.
The head rotation posture is useful for those individuals who demonstrate unilateral muscular disorders. For example, patients with unilateral pharyngeal weakness typically demonstrate residue on the weak side of the pharynx. Patients will benefit from head rotation to the weaker side, since this posture effectively closes off the weaker side and allows the bolus to clear through the pharynx and pyriform sinus region on the undamaged side (1). This posture is also useful for those patients with reduced cricopharyngeal opening, which can result in pyriform sinus residue that can enter the airway after the swallow (11,12). Head
rotation is also useful for those patients who are aspirating during the swallow due to vocal cord paralysis or following hemilaryngectomy. The patient rotates the head toward the paretic/surgical side, improving glottic closure (1,9). Combinations of postures are frequently used, particularly head rotation and chin tuck. These are particularly effective for those individuals who demonstrate a unilateral pharyngeal weakness as well as reduced airway closure (1,9).
rotation is also useful for those patients who are aspirating during the swallow due to vocal cord paralysis or following hemilaryngectomy. The patient rotates the head toward the paretic/surgical side, improving glottic closure (1,9). Combinations of postures are frequently used, particularly head rotation and chin tuck. These are particularly effective for those individuals who demonstrate a unilateral pharyngeal weakness as well as reduced airway closure (1,9).
Side-lying posture is used when pharyngeal clearance is reduced, resulting in residue that enters the airway after the swallow (1,2). In this posture, the patient is lying down on his side with his head propped up slightly. Residue will still be present after the swallow when using this maneuver, but the residue will remain on the lateral pharyngeal wall and will be cleared on subsequent dry swallows.
Head tilt posture is useful when a patient exhibits a unilateral oral and/or pharyngeal weakness (1,2). The head is tilted toward the unimpaired or stronger side, to allow the bolus to clear the oral cavity and pharynx on the stronger side. This posture is useful after hemiglossectomy and also for patients who are dysarthric with hemiparesis of the tongue, as this posture allows for improved oral control and propulsion of the bolus into the pharynx, resulting in improved oral phase swallow functioning. Head tilt is also useful to improve clearance of the bolus through the pharynx for those patients with unilateral pharyngeal paresis or paralysis (Table 58.1).
Sensory Enhancement Techniques
Therapy techniques that utilize sensory enhancement are helpful for those patients who have reduced sensory awareness, delayed initiation of lingual activity (often seen in patients with oral apraxia), and delayed triggering of the pharyngeal swallow. These techniques involve providing a preswallow sensory stimulus to improve initiation of lingual activity and/or triggering of the pharyngeal swallow. These techniques can include downward pressure on the tongue with a spoon, introducing boluses with other tastes, such as sour, or changing temperature and texture of the bolus (1,2,13,14). Carbonated boluses have been found to improve the oropharyngeal swallow, specifically, reducing pharyngeal transit time, percent pharyngeal residue, and aspiration (15). Another technique includes the use of thermal/tactile stimulation to improve triggering of the pharyngeal swallow (16,17). Slightly larger bolus volumes may provide increased sensory input and may result in improved oral initiation, as can boluses that require chewing. A slightly firmer bolus (i.e., pastes vs. liquids) can have the same effect.
Modifying Bolus Volume and Speed of Feeding
The ideal volume of food or liquid that will initiate triggering of the pharyngeal swallow will vary among patients. In addition, for those patients who demonstrate pharyngeal phase motility disorders resulting in pharyngeal residue, two to three repeat dry swallows are often needed to clear the pharynx. Thus, often taking smaller bolus volumes and eating at a slower pace, allowing time to reswallow to clear residue will reduce the risk of aspiration in these patients.
Bolus Consistency (Diet) Changes
Eliminating specific food consistencies is the last resort in compensatory diet modification. It is often unpleasant for the patient to be told that thin liquids must be eliminated from the diet. However, if other compensatory or direct therapy strategies do not eliminate aspiration or improve swallow efficiency, certain consistencies must be eliminated from the diet. In general, if a patient demonstrates reduced oral tongue control, delayed triggering of the pharyngeal swallow, or reduced airway closure, thin liquids might need to be eliminated, whereas slightly thicker consistencies would be indicated. For those patients who demonstrate reduced lingual strength or reduced bolus clearance through the pharynx, the latter impairment due to reduced tongue base posterior movement, reduced pharyngeal wall contraction, reduced hyo-laryngeal elevation and anterior motion, and cricopharyngeal dysfunction, thinner bolus consistencies are indicated, such as thin and thick liquids.
Intraoral Prosthetics
Intraoral prosthetics can help compensate for anatomic deficits, such as resection of a portion of the tongue, resection of part or all of the soft palate, neurologic damage that results in reduced lingual range of motion, or neurologic damage that results in palatal paresis. A palatal lift aids in velopharyngeal closure by lifting the paralyzed soft palate. A palatal obdurator seals off the velopharyngeal port for those patients who undergo soft palate resection, preventing material from entering the nasopharynx and improving intraoral pressure (18,19). A palatal augmentation prosthesis lowers the palatal vault for those patients who have undergone oral cancer resection. This prosthesis allows the remaining lingual tissue to contact the augmentation so that the tongue can control, seal, and propel a bolus of food through the oral cavity. A palatal augmentation prosthesis can benefit patients who have had a significant portion of the oral tongue resected, resulting in improved transport of the bolus through the oral cavity and reduced oral residue (19,20). The speech-pathologist works collaboratively with the maxillofacial prosthodontist to construct the prosthesis. For patients undergoing oral cancer surgery, construction of the prosthesis should begin 4 to 6 weeks postoperative. For those patients undergoing radiotherapy, construction typically begins at least 6 to 8 weeks after completion of treatment. In those patients with total glossectomy, the palatal augmentation prosthesis is typically fairly large because the augmentation portion needs to be
near the remaining muscles comprising the floor of mouth in order to assist with bolus control and clearance through the oral cavity. Additional swallow exercises are provided and should be practiced with the prosthesis in place to maximize its use for swallowing and speech.
near the remaining muscles comprising the floor of mouth in order to assist with bolus control and clearance through the oral cavity. Additional swallow exercises are provided and should be practiced with the prosthesis in place to maximize its use for swallowing and speech.
THERAPY PROCEDURES
Direct therapy procedures are designed to change the swallow physiology by altering specific components of the oral and/or pharyngeal phases of swallowing. These can include exercises to improve or increase muscle strength, range of motion, and control. They can also improve the sensorymotor integration of the swallow or alter the timing and coordination of various aspects of the swallow (1,21,22).
RANGE OF MOTION, RESISTANCE, AND CONTROL EXERCISES
Exercise programs are designed to improve function of the target muscle or muscle groups to improve swallow physiology. Range of motion exercises are designed to increase range of the target muscle (23,24) and can include the jaw, lips, oral tongue, tongue base, pharyngeal constrictors, larynx, and hyoid-related musculature. They are often prescribed for head and neck cancer patients and stroke patients with dysarthria and dysphagia. They are also prescribed for those patients with dysphagia due to generalized weakness and deconditioning, particularly older patients who have been hospitalized for prolonged periods. Changes in the timing, coordination, and degree of muscle activity for swallowing occur with normal aging and with bolus volume and viscosity (5,13,25,26,27,28,29,30,31,32,33,34) and can place older, medically debilitated patients at risk for developing swallowing problems. Tongue range of motion exercises have been found to improve swallow function, specifically, oropharyngeal swallow efficiency in surgically treated oral cancer patients (23). Lingual range of motion exercises have also been prescribed for patients with progressive neurologic impairment, such as Parkinson disease (PD), multiple sclerosis (MS), and amyotrophic lateral sclerosis (ALS). However, it is commonly believed that tongue range of motion and strengthening exercises are not indicated for these patients, as active lingual exercise programs are thought to fatigue the muscles, resulting in poorer function for speech and swallowing. There are little data, however, to refute or support this theory.
Strengthening exercises involve active resistance to increase muscle strength and often target the tongue, lips, jaw, and suprahyoid muscles. Tongue strength has been found to be reduced in the elderly healthy population (35,36,37) and in patients with stroke, traumatic brain injury, ALS, PD, and oral cancer treated with radiotherapy (35,38,39,40,41,42). Lingual strengthening/resistance exercises have been found to increase tongue strength in young and elderly healthy individuals (43,44) and have been found to improve tongue strength and swallowing function in the stroke population (45).
The pharyngeal squeeze maneuver is also designed to improve pharyngeal contraction for swallowing (46) In this maneuver, the patient says a forceful “eee” in order to effect increased pharyngeal muscle contraction. Change/improvement in pharyngeal constrictor motion when using this maneuver can be easily visualized with fiberoptic laryngoscopic examination
Lingual control exercises can improve bolus control for chewing (1,3). These exercises involve manipulation of material such as a piece of licorice within the oral cavity to work on bolus seal, lateral trafficking of the bolus, bolus retrieval from the teeth, and sealing and propelling the bolus posteriorly through the oral cavity.
The Shaker exercise is a strengthening exercise program to improve upper esophageal sphincter (UES) opening for swallowing (47,48). This rehabilitation exercise involves a program of head-raising to strengthen the suprahyoid muscles involved in UES opening. In healthy asymptomatic elderly individuals, the Shaker exercise program resulted in increased UES opening diameter and a decrease in hypopharyngeal intrabolus pressure (47). In dysphagic patients with reduced UES opening, the Shaker exercise program resulted in significantly increased UES opening, increased anterior laryngeal excursion, reduction of pharyngeal residue, and elimination of postdeglutitive aspiration (48). There is evidence that respiratory strength training can have a positive impact on swallowing by training expiratory, suprahyoid, and velar muscles. Sapienza (49) reported that respiratory strength training improved swallowing in dysphagic Parkinson patients, with a reduction in pharyngeal delay time, improvement in speed and extent of hyolaryngeal motion during the swallow. In addition, subsequent studies have shown improved respiratory driving pressure in PD and MS patients employing respiratory strength training (50). This could lead to improved vocalization and decreased rates of aspiration in neurologically impaired patients (51,52). There is also evidence that the Lee Silverman Voice Training (LSVT), a voice exercise program designed to improve voice and speech in the Parkinson patient, can improve swallowing, specifically, by improving oral transit times, triggering of the pharyngeal swallow, and reducing percentage oral residue (53). In addition, the LSVT program has been found to improve tongue strength and quality of life (54), as measured by the SWAL-QOL, a swallowing quality of life measure (55).
SENSORY-MOTOR INTEGRATION PROCEDURES
Thermal-tactile stimulation has been used as a preswallow alerting mechanism for the central nervous system. This technique involves rubbing the anterior faucial arches with a size 00 cold laryngeal mirror and instructing the patient to swallow (1). It has been found to improve triggering of
the pharyngeal motor response in patients with delayed triggering of the pharyngeal swallow (16,17). Thermal/tactile stimulation combined with a sour stimulus has been found to result in a similar reduction in swallow latency (56). This technique can be performed in isolation (i.e., dry swallows or.5mL amounts of water for those patients who are nonoral) or intermittently during meals, as appropriate.
the pharyngeal motor response in patients with delayed triggering of the pharyngeal swallow (16,17). Thermal/tactile stimulation combined with a sour stimulus has been found to result in a similar reduction in swallow latency (56). This technique can be performed in isolation (i.e., dry swallows or.5mL amounts of water for those patients who are nonoral) or intermittently during meals, as appropriate.
MANEUVERS
Maneuvers are designed to alter the physiology of the swallow, specifically, the pharyngeal phase, placing specific aspects of the pharyngeal swallow under voluntary control (Table 58.2). The supraglottic swallow is designed to improve airway closure before and during the swallow at the level of the glottis (2,57). Patients are instructed to hold their breath, swallow, and cough. The super supraglottic swallow is designed to improve airway closure before and during the swallow at the level of the airway entrance (i.e., laryngeal vestibule) and glottis (2,57,58). The super supraglottic swallow involves a tighter breath hold than that used with the supraglottic swallow and is designed to achieve arytenoid to epiglottic base contact for closure of the laryngeal vestibule (57,58). In patients having undergone supraglottic laryngectomy, the super supraglottic swallow is designed to achieve arytenoid to tongue base contact for vestibular closure. The patient is instructed to: (a) hold your breath very tightly while bearing down with the abdominal muscles, (b) swallow, and (c) cough. This maneuver has also been found to increase extent of laryngeal elevation during the swallow (22). Patients are often taught to exhale slightly before holding their breath tightly, as most individuals swallow during an exhalation, which may increase subglottic pressure during the swallow and reduce the risk of aspiration (59,60). The super supraglottic swallow maneuver requires a fair degree of cognitive functioning, attention, sequencing, and memory.
TABLE 58.2 RATIONALE FOR USE OF SWALLOW MANEUVERS TO ALTER SWALLOW PHYSIOLOGY AND IMPROVE SWALLOW FUNCTION | |||||||||||||||||||||
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The effortful swallow is designed to improve tongue base posterior motion during the swallow and improve pressures to clear the bolus past the tongue base (1,3,24
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