Swallowing Disorders: Neurogenic

Presentation of Neurogenic Disorders

Acute Injury Conditions occur suddenly Some recovery expected

Degenerative Conditions Gradual deterioration over time

Established Diagnosis

CVA Cortical (cortex)

R or L hemisphere Subcortical Brainstem

Hemorrhage Cancerous Process

Tumor growthMay be an initial sign

Traumatic Brain Injury

Clinical Manifestations

Oral/Pharyngeal symptoms Decreased awareness/sensation Drooling Impaired mastication Trouble with initiating a swallow Nasal regurgitation Coughing Choking Difficulty moving bolus through the pharynx Difficulty with secretions Throat clearing Gurgly voice

Clinical Manifestations

Esophageal Symptoms Sticking in the chest Regurgitation Heartburn Chest discomfort Globus sensation Chronic sore throat

Rule of thumb Poor timing/coordination Decreased awareness Increased risk of silent aspiration

Secondary Complications

Weight loss Malnutrition Dehydration Laryngospasm Bronchospasm Aspiration (pneumonia) Asphyxia Loss of appetite, desire to eat Social withdrawal

Dysphagia with Diagnosis

Review all symptoms Esophageal Structural Neurological

Know the symptoms well enough for differential diagnosis

Comprehensive evaluation must be completed

“Silent” Symptoms

Pt compensates for difficulty Cough reflex is reduced or absent Cognitive impairment

Specific Neurologic Diagnoses

Many symptoms occur in more than one type of neurologic disease process or insult

Cerebrovascular Accident (CVA) Right hemisphere CVA

Characteristics Left pocketing/weakness Poor insight Neglect Impulsivity Silent aspiration Reflex delay 3-5”

Treatment Positioning Liquid/diet modification Tray/meal set-up Oral motor exercises; TTS; maneuvers Longer recovery time vs. L CVA

Cerebrovascular Accident (CVA) Left hemisphere CVA

Characteristics Right pocketing/weakness Oral motor apraxia; swallow apraxia Reflex delay 2-3” Silent aspiration Reduced comprehension

Decreased ability to follow treatment strategies Treatment

Positioning Liquid/diet modification Oral motor exercises Multimodality input to facilitate comprehension Increase pressure with spoon; TTS

Cerebrovascular Accident (CVA) Brainstem CVA (low – medullary)

Characteristics Significant impairment; May affect swallow centers of the brain Significant reflex delay 10-15” or absent reflex Reduced laryngeal elevation TVF paralysis Pharyngeal paresis Compromised respiration Fatigue UES dysfunction

Treatment Usually return to po intake (eating out of mouth) within 3 weeks Exercise for weakness Positioning

Head turn to weaker side (while swollowing) Mendelsohn maneuver (swallow and hold laryx up) Liquid/diet modifications Thermal stimulation

Cerebrovascular Accident (CVA) Brainstem CVA (high – pontine)

Characteristics Hyperspasticity Delayed or absent swallow reflex Unilateral pharyngeal wall paresis Decreased laryngeal elevation

Treatment Similar to previous slide Massage prior to exercises/feeding trials may

be helpful

Cerebrovascular Accident (CVA)

Subcortical CVA Characteristics

3-5” delay in OTT and pharyngeal reflex Decreased laryngeal elevation

Treatment 3-6 weeks recovery time TTS Exercises for oral ROM, BOT, and laryngeal

movement

Cerebrovascular Accident (CVA)

Multiple CVAs (can lead to vascular dementia) caused by multiple strokes Characteristics

Delayed pharyngeal reflex Reduced laryngeal closure Pharyngeal weakness Decreased attention and language comprehension

Treatment Similar to other treatments for CVAs, depending

on exact disorders

Traumatic Brain Injury

Characteristics Decreased level of arousal Impulsivity Cognitive deficits Decreased sensation Weakness of the oral-motor structures Abnormal oral reflexes (Abnormal reflex such as ,biting and

sucking, rooting relex) Delayed swallow reflex Decreased laryngeal elevation Tolerate prolonged aspiration

Treatment Compensations Diet/hydration modification Thermal stimulation; exercises for oral muscles Longer period of spontaneous recovery; assess yearly

Guillain-Barre

Characteristics Rapid onset paresis – tracheostomy – vent Generalized weakness of oral and pharyngeal

musculature Recovery slow Respiration unstable

Treatment Gentle ROM and resistance exercises Increase effort with improvement – slowly! Supraglottic swallow; Mendelsohn maneuver

Progressive Neurologic Disease Amyotropic lateral sclerosis

Characteristics Progressive weakness

Oral, pharyngeal, laryngeal, and respiratory Progression of symptoms

Aspiration Tongue fasciculations VPI

Nasal regurgitation Treatments

Counsel regarding long-term feeding options Diet/liquid modification Controversy regarding tx

Progressive Neurologic Disease Parkinson’s Disease

Characteristics Progressive disease Marked variability in med cycles Weak oral motor muscles Delayed initiation Reduced pharyngeal contraction High percentage of silent aspiration in later stages.

Treatments Manipulation of drug cycles Diet/liquid modification Enteral feeding options

Progressive Neurologic Disease Multiple Sclerosis

Characteristics Periods of exacerbation/remission Symptoms vary dependent upon site of lesions

Treatments Typically necessary during periods of

exacerbation Compensatory strategies

Postural Behavioral

Diet/liquid modification

Progressive Neurologic Disease

HIV-AIDS Characteristics

Weakness of the laryngeal elevators and other oral motor structures

Pharyngeal weakness Treatments

Compensatory strategies Postural

Diet/liquid modifications Advise on long-term feeding options

Progressive Neurologic Disease

Myasthenia gravis: Characteristics

Rapid fatigue Can affect all phases of the swallow

Treatment Frequent small meals Compensatory strategies

Overcome short-term symptoms

Progressive Neurologic Disease Huntington’s Chorea

Characteristics Choreiform movements Difficulty with coordinated movements of

manipulating and moving a bolus Increased risk of aspiration/airway obstruction

Treatment Modified diet/hydration Positioning stabilization

Cerebral Palsy

Characteristics Abnormal oral reflexes Difficulty with cohesive bolus hold Disorganized A-P tongue movement Delayed triggering of pharyngeal reflex

Treatment Oral exercises TTS Diet changes May need chronic/ long-term therapy