Mechanical Swallowing Disorders. Mechanical Disorders Secondary to: Muscle loss Loss of motor and/or...
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Transcript of Mechanical Swallowing Disorders. Mechanical Disorders Secondary to: Muscle loss Loss of motor and/or...
Mechanical Swallowing Disorders
Mechanical Disorders
Secondary to: Muscle loss Loss of motor and/or sensory innervation Peripheral structure loss
Oral Pharyngeal Esophageal
Frequently associated with cancerous processes
Clinical Manifestation
Can overlap with those observed in neurogenic dysphagia Sialorrhea Impaired mastication Collection in the oral cavity and pharynx Increased swallowing transit time Delayed swallow initiation Reduced pharyngeal peristalsis aspiration
Differential Diagnosis
Acute Inflammation Non-specific reactions to injury of the
oropharyngeal tissue Fungal Bacterial Viral Chemical Traumatic
May not be the primary cause of dysphagia, rather exacerbates an underlying compromise
Differential Diagnosis
Herpes Simplex Viral
Round lesions Lips Pharynx Buccal mucosa
Palatal and pharyngeal ulcers may cause pain during swallowing
Differential Diagnosis
Ludwig’s Angina: Most typical type of infection to impact swallowing Symptoms
Massive tongue swelling and displacement Red, tender floor of mouth May extend posteriorly and result in epiglottis Muffled voice Swelling in the suprahyoid area
Complications Asphyxia Aspiration pneumonia Lung abscess Tongue necrosis
Differential Diagnosis
Ludwig’s Angina (con’t); Treatment
IV antibiotics Surgery Drainage Airway maintenance
Condition is typically related to: Dental management
Abscess Post extrication infection
Ludwig’s Angina
Lingual Tonsillitis
Pts complain of pain in the throat in the medial pharynx Lump in the throat
Indirect laryngoscopy Examine the base of the tongue and pharynx Confirm diagnosis
Epiglotitis
Inflammation of the supraglottic structures Can result in acute respiratory stress
Airway obstruction Symptoms
Pain Dysphagia Respiratory difficulty Drooling stridor
Pharyngitis
Red inflammation of the oropharyngeal area Viral Bacterial May precede cold symptoms Dysphagia Mild fever Streptococcal- most common bacterial form
Untreated can lead to rheumatic fever
Streptococcal Pharyngitis
Lateral pharyngeal Space Infection
May be secondary to primary tonsillitis or pharyngitis Anterior presentation
Dysphagia Trismus High fever Mandibular swelling/hardening Systemic toxicity Bulging of the lateral pharyngeal wall
Lateral pharyngeal Space Infection (con’t) Anterior presentation
Treatment: Antibiotics Surgical drainage Airway management
Posterior presentation Sepsis Edema and swelling of the epiglottis Edema and swelling of the larynx Dyspnea Can lead to secondary infections
Sudden death syndrome myocarditis
Retropharyngeal and Prevertebral Infections Infections that occur in the
pharyngoesophageal wall and spine Retropharyngeal
Secondary to adjacent abscess or cervical trauma
Prevertebral Secondary to osteomyelitis
Infected hemotomas following vertebral fracture Complications
Meningitis Spontaneous rupture of the larynx
Fungal Inflammation
Candidiasis: most common (Thrush) Soft, white lesions frequently on the tongue Seen in immunosuppressed, debilitated pts Long-term antibiotic tx Those receiving irradiation tx Differ from leukoplakia
Can be scraped away http://www.ghorayeb.com/TongueGeographic
.html http://www.visualdxhealth.com/adult/oralCand
idiasisThrush.htm
Chemical Agents
Exposure to chemicals Can present as red or white lesions
Throat lozenges Excessive use = decreased sensation
Aspirin Gargles Lye ingestion
Most severe chemical burn Chemotherapy
Painful ulcerations
Pharyngoesophageal Diverticulum
Zenker’s diverticulum: weakness in muscle fibers that result in a “pouch” in which material can collect. Above or below the cricopharyngeal muscle Must be large to result in dysphagia symptoms
Regurgitation Halitosis Fullness Weight loss Nocturnal cough with aspiration
Zenker’s Diverticulum
Dysphagia Associated with Cancer
Cancer Tumor Staging
Stage TNM System
I T1 N0 M0
II T2 N0 M0
III T3 N0 M0
T1 or T3 N1 M0
IV T4 N0 or N1 M0
Any T N2 or N3 M0
Any T any N M1
T = tumor size N = nodal status M = presence or absence of metastasis
Dysphagia Associated with Cancer
Constitute the largest group of people with mechanical disorders Organ(s) involved Adjacent structures Not the size of the lesion, rather the area that
is excised Sensation innervation
Oral lesions
Anterior tongue Floor of the mouth Submental structures Mandible Maxilla One or more of these structures may be
partially (or totally) removed http://www.ghorayeb.com/Pictures.html
Clinical Manifestations
Impairments in: Mastication Formation of the bolus Retention of the bolus Anteroposterior propulsion of the bolus Premature penetration of the bolus, or
particles of the bolus into the pharynx Impaired sequence of movements
Glossectomy
Partial or total glossectomy Interferes with the oral phases of deglutition
Even total glossectomy pts are able to eat Dependent upon the resection; if adjacent structures were
involved Age Preoperative health Size and position of primary tumor Lymph node involvement
1/3 glossectomy good prognosis Unless combined with mandibular resection
Usually oral candidates (PO trials) around 1month post surgery
Multiple Oral Structure Resection
Tongue, neck, floor of the mouth, and mandible Multiple structure resection involves varying symptoms
Mastication Bolus manipulation Bolus transit Posterior propulsion Protecting the airway
Surgery can result in scar tissue contractures, TMJ pain
Oropharyngeal Resections
Lesions involving the posterior tongue, soft palate, tonsils, superior and lateral pharynx.
Clinical manifestations Nasal regurgitation Aspiration PE segment dysfunction Impaired transit Altered pressure relationships
Use of reconstructive flaps No sensory/innervation
Partial Laryngectomy
Attempt to control malignant growth but preserve voice and deglutition Hemilaryngectomy
Unilateral resection of the TVF, VF, the ventricle, the SLN with preservation of the epiglottis
Mixed results in the literature
Partial Laryngectomy
Supraglottic laryngectomy Resection of both vestibular and aryepiglottic
folds and unilateral or bilateral transection of the SLNs
Immediate dysphagia symptoms postoperatively Varying results due to nonstandard definitions for
the procedure Resection without bilateral transection of the SLN
has good prognosis Extension of the resection of the resection results in
moderate to severe symptoms in approximately ½ of patients.
Partial Laryngectomy
Supraglottic laryngectomy Predictors for improved deglutition
Mobile tongue base Laryngeal elevation to the tongue base Resected hyoid Competent closure of the glottis.
Total Laryngectomy
Surgical separation of the respiratory and digestive tracts Still at risk for dysphagia
Postoperatively Malfunctioning CP (sphincter) Impaired pharyngeal function Recurrent neoplasm Stricture Fistulas
Irradiation procedures May negatively impact deglutition
Mixed results
Tracheoesophageal Puncture
Tracheoesophageal fistula that is surgically created either during or after the primary surgery
Implications for deglutition Aspiration saliva/food (two small or not fit correctly) Aspiration of voice prosthesis Stenosis Stoma/fistula infection Spasm Enlargement
TEP
Irradiation
Impaired saliva flow Implications for reduced saliva
Mucositis Inflammation of the mucosa
Dissipates following the termination of the tx
Osteoradionecrosis Mucosal destruction
Fibrosis Decreased blood flow
Can invade the bone
Irradiation
Trismus Fibrosis of mastication muscles
Loss of taste/appetite Effects of radiation
Decreased ability to taste, smell, chew, and swallow
Nausea Modified diet
Weight loss malnutrition
Miscellaneous Etiologies
Cervical Spine Disease Osteophytes – bony growth from spine
Nasogastric tubes Large vs. small bore Excess salivation Depressed cough reflex Laryngopharyngeal injuries GERD Tube placement
Tracheostoma tubes Limits laryngeal movement Still have larynx but can’t breath well.