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The Institute for Voice and Swallowing Disorders at Phelps Memorial Hospital Center is committed to providing comprehensive diagnostic and therapeutic care to children and adults who experience voice and swallowing conditions.
Dr. Craig H. Zalvan, a Board Certified Laryngologist, is the institute’s Medical Director. The interdisciplinary team is comprised of highly trained, nationally recognized and specialized professionals. Sessions are provided in a safe and pleasant environment, using state-of-the-art technology.
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A swallowing problem, or dysphagia, is the unsafe and inefficient movement of foods and/or liquids from the mouth to the stomach.
Swallowing becomes unsafe when the food or liquid goes below the level of the vocal folds and enters the airway (trachea) to the lungs, rather than entering the esophagus. This is known as aspiration.
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Primary Structures Involved in Swallowing
Lips, teeth, tongue, cheeks, soft palate, pharynx, epiglottis, larynx, esophagus
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4 Phases of a Normal Swallow
- Oral Preparatory Phase: Food is manipulated in the mouth and chewed. The tongue mixes the food/liquid with saliva and forms it into a ball, called a bolus.
- Oral Phase: The tongue propels the bolus posteriorly to the back of the mouth, using a wavelike motion, into the pharynx (the area of the tonsils) and the soft palate (velum) elevates, to prevent material from entering the nasal cavity.
- Pharyngeal Phase: When the bolus touches the tonsils (anterior facial arches) it triggers the swallowing response. This causes the bolus to move posteriorly and down toward the esophagus. This phase is critical for preventing food, liquid, or other foreign material, from entering the airway, or from being aspirated. The following events act as a defense mechanism and take place simultaneously with the swallow:
- The tongue retracts toward the back of the throat
- The soft palate elevates to prevent food or liquid from escaping through the nose
- The true vocal folds close
- The false vocal folds close
- The epiglottis ( a leaf-like structure that inserts at the base of the tongue) flips back and covers the entrance to the airway
- The larynx (the structure which houses the vocal cords) elevates and extends outward to open the esophagus for safe bolus entry into the stomach.
All of these movements must occur in order to promote swallowing safety by preventing aspiration.
- Esophageal Phase: The bolus then moves through a circular, sphincter-like muscle called the cricopharyngeous into the esophagus and finally into the stomach. If esophageal involvement in the swallowing disorder is suspected, further objective evaluation can be done (see Modified Barium Swallow (MBS).
In the normal population, each of the first three phases takes approximately 1 second to complete and the last (esophageal) phase takes approximately 8-20 seconds to complete. However, we swallow differently for different consistencies, amounts and viscosities (thickness/density of the material). In the normal elderly population, you can expect the swallowing process to be slightly delayed and altered.
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Disorders commonly associated with Dysphagia
There are many medical conditions that may predispose a person to swallowing problems. Medical conditions can be broken down into 2 broad categories: neurological and structural.
Neurological conditions include:
- Brain Injury- stroke, closed head injury, brain tumor, cerebral palsy
- Progressive Neurological Diseases- Parkinson disease, ALS, MS
- Cognitive- Alzheimer’s disease, multi-infarct dementia
Neurological conditions affect swallowing because of decreases in motor (movement) function, sensory (sensation) function or both.
Motor function relates to the function of the person’s muscles.
Sensory function refers to the person’s ability to feel the food as it moves through his or her mouth and throat.
Structural disorders interfere with the swallow because of a mechanical dysfunction in the swallowing mechanism. These may include:
- Local Structural Problems- laryngectomy, head and neck tumors, tracheotomy, glossectomy
- Motility Disorders- scleroderma
- Mechanical Obstructions- peptic stricture, Barrett’s esophagus or esophageal cancer
Radiation and chemotherapy for head and neck cancers also have a detrimental effect on swallow function.
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Indicators of a Swallowing Problem
When dysphagia is suspected, the speech-language pathologist will evaluate a person to determine the severity of the dysphagia and to identify what aspects of the swallowing mechanism are affected.
How can you recognize a swallowing problem? The following are signs/symptoms of a swallowing disorder:
- Decreased cognition, awareness and/or perceptual status
- Severe dysphonia – breathiness, harshness or hoarseness
- Wet, gurgly vocal quality after swallowing
- Reduced volitional cough
- Coughing or choking during or after eating
- Reduced/ poor laryngeal elevation
- Poor posture
- “Messy eating” – can’t keep food in mouth or has increased secretions or drooling
- Slow or effortful eating
- Food left in mouth after swallow
- Sensation of food sticking in throat or discomfort during swallowing
- Oral or nasal regurgitation or reflux
- Loss of appetite/refusal to eat a particular food consistency
- Unexplained weight loss
- History of one or more aspiration pneumonias
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Outcomes of Swallowing Problems
- Inadequate nutrition/ hydration
- Weight Loss
- Decreased quality of life
- Aspiration – which can lead to aspiration pneumonia
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What is Aspiration Pneumonia?
It is an infection and inflammation of the lung following an aspiration event or chronic aspiration. It results from an infectious accumulation in the lungs.
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Candidates for a Swallowing Evaluation
Swallowing evaluation is appropriate for anyone who has a complaint of difficulty swallowing; pain when swallowing food, liquid or medication; choking during meals; a history of one or more of the above related disorders; and/or a sudden change in swallow function following an acute event such as, a change in medication, trauma or surgery.
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Types of Evaluations
Sometimes a person can silently aspirate, which happens when food or liquid enters the lungs but the person is not aware. In those cases, the person may be referred for a Modified Barium Swallow (MBS) study or a Fiberoptic Endoscopic Evaluation of Swallowing and Sensory Testing (FEES/ST).
Modified Barium Swallow Study
The MBS can provide detailed information about the safety of a person’s swallow. The MBS is conducted in a radiology suite in the presence of a radiologist. The person is tested with various food and liquid consistencies to determine choices for oral intake. For this test, the food is mixed with a contrast material, called barium, which makes it visible on the x-ray. The person is x-rayed as he or she eats each food consistency. Unlike a static x-ray, which reflects one single instant in time (like a chest x-ray), and is viewed as a photograph, the MBS is a moving x-ray that records the swallow from the oral-preparatory phase to the esophageal phase. The recording of the test can be reviewed at a later date for comparative purposes or to determine progress from receiving a form of swallowing therapy.
The Modified Barium Swallow serves several important functions in the diagnosis and management of swallowing disorders.
- It allows the clinician to directly visualize the swallow in order to determine whether there is laryngeal penetration (pooling or stasis of swallowed material above the level of the vocal folds) or aspiration.
- It provides the clinician with information regarding the safest consistencies for the person to eat and drink.
- It helps to determine therapeutic strategies for improving swallowing safety.
Fiberoptic Endoscopic Evaluation of Swallowing & Sensory Testing (FEESST)
FEESST is an alternative test to the X-ray test of swallowing that uses a specifically designed endoscope in order to assess both the SENSORY and MOTOR components of the swallow.
FEESST is a two-part test. The first part of the test assesses sensation in the larynx in order to elicit an airway protective reflex (the Laryngeal Adductor Reflex). The second part of the test involves giving food to the person (with green food coloring mixed in) and tracking where the food travels in the throat region.
Velopharyngeal closure, anatomy of the base of the tongue and hypopharynx, abduction and adduction of the vocal folds, pharyngeal musculature and the person’s ability to manage his/her own secretions are assessed.
Benefits of FEESST:
- Immediate results including dietary recommendations.
- Office procedure.
- No anesthetic
- Portable capabilities.
- Non-radioactive alternative to MBS studies
- Facilitates the development of a specialized therapy program by identifying which swallowing therapies are most useful for the specific impairment(s) noted during the exam.
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The information obtained from clinical assessments and MBS and FEESST studies are used to make recommendations regarding food consistencies, the way food is eaten or the way a person is fed.
Type of food: A diet will be prescribed to meet the person’s needs for safe swallowing. Consistencies of liquids can range from thin to thickened. Solids can be regular, chopped, ground or pureed.
The way food is eaten: The speech pathologist may recommend that the person use therapeutic postures and/or maneuvers to increase swallow safety.
In order for the person to benefit from these interventions, he or she must be able to understand the reason for the intervention, follow 2-3 step directions, remember them throughout the meal or be thoroughly supervised.
Compensatory Strategies may include: postures, positions, maneuvers and changes in feeding style.
Most Common Postures/Positions:
- Chin Tuck – The chin is tucked to the chest during the swallow
- Head Rotation – The head is turned toward the weaker side during the swallow
- Head Tilt – The head is tipped to the unimpaired side.
- Head Back – The head is tilted back during chewing
Most Common Maneuvers:
- Hard Swallow – Effortful swallow
- Double Swallow – Two swallows per bolus
- Supraglottic Swallow – Chew, hold your breath, swallow, clear your throat, swallow again
- Mendelsohn Maneuver – Hold your larynx (Adam’s apple) up for as long as possible during and after the swallow.
How a person is fed:
Sometimes a person’s cognitive status prevents him or her from using therapeutic postures and/or maneuvers. These persons may require being hand-fed.
- Food placement: Food may need to be placed in a particular part of the mouth to facilitate chewing, forming a bolus and moving the food back.
- Quantity: Some people may require small bites and/or sips (1 teaspoon at a time) to ensure they are able to safely chew and swallow food and liquids.
- Speed: Some people may require extra time between bites to swallow what is in their mouth before taking the next bite
- After meals: A person with a swallowing impairment may need to have their mouth checked after meals for any pocketing of food in the gums, cheeks, tongue, or roof of the mouth
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Swallowing therapy is performed by the Speech-Language Pathologist (SLP) up to five times per week. It may include any of the techniques described above to improve the safety of the person’s swallow. These techniques may also be performed in conjunction with the therapies listed below.
Physiotherapy/Oral Motor Exercises:
- Exercises specially designed to focus on specific striated muscle groups such as the lips, cheeks and tongue
- Exercises should increase in repetition and/or duration
- Focus should be on strength first, then improving range of motion (ROM) and coordination
- If the patient does not have strength, it will affect ROM and coordination
- The Iowa Oral Performance Instrument (IOPI) objectively measures and targets the tongue and lips to develop strength and endurance.
- Surface Electromyography, or sEMG, measures electrical activity of muscles. As muscles contract, microvolt level electrical signals can be measured from the skin’s surface. Electromyography is the study of muscle activity through the measurement of these electrical signals. An SLP may use surface EMG, during a therapy session, to more accurately evaluate muscle function and activity and as biofeedback for the patient when attempting an exercise or maneuver.
- Neuromuscular Electrical Stimulation (NMES) for muscle re-education of the swallowing mechanism. NMES is known as “E-Stim” or “Vital Stim™®” therapy. This therapy involves the use of electrical impulses applied externally to elicit a physiological response. It is a form of surface/transcutaneous electrical stimulation where the electrodes are placed on the surface of the skin (at the submandibular triangle/ suprahyoid-infrahyoid muscle area) and impulses transmit through the tissue to the peripheral nerves and elicit an action potential. In other words, E-stim is an external stimulus that tells your nerves to tell your muscles to move (re-education of the muscles)
What is the underlying principle?
- “If you don’t use it…you lose it” During an inactive period the brain adapts to the inactivity as being the normal function. For example, if the muscles work at 20%, the brain believes that is the highest level at which it can work.
- E-stim helps the muscles to readapt and reestablish potential
Why NMES for dysphagia?
- Maintains and strengthens muscle mass during inactive periods (e.g., when a patient is not able to eat by mouth and muscles weaken)
- Maintain/gain ROM for increased laryngeal elevation or to increase airway closure
- Facilitates voluntary control (e.g., stimulates the ease of performing swallow maneuvers such as the Mendelsohn maneuver)
- Increases oral and pharyngeal sensory awareness (e.g., increases pharyngeal sensitivity to residue)
- Reduces effects of spasticity-reduce spasticity and then re-educate muscle movement
- More expedient/quicker return of function
- Able to reach populations who were not able to respond to traditional therapy methods (e.g., NPO/PEG patients, dementia)
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The Institute for Voice & Swallowing Disorders
777 North Broadway
Sleepy Hollow, NY 10591
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