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
). 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.
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
). 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
). 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
). 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
). 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
Disorder Seen on MBS
Impaired or delayed glottic closure; delayed triggering of the pharyngeal motor response
Breath hold improves glottic closure before and during the swallow
Impaired airway entrance closure
Super supraglottic swallow
Effortful breath hold facilitates arytenoid anterior motion to epiglottic petiole and maintains early airway entrance closure
Reduced tongue base posterior motion
Effort increases tongue base posterior motion
Reduced motion of the pharyngeal constrictors
Masako (tongue-hold) maneuver
Slightly anterior position of tongue base results in compensatory increase in anterior motion of pharyngeal constrictors
Reduced laryngeal motion and reduced cricopharyngeal opening
Increases extent and duration of laryngeal elevation, resulting in increased width and duration of UES opening
Effort improves timing and coordination of muscular events during pharyngeal swallow