Dysphagia - Swallowing Treatments

Normal Larynx

Behavioral Therapy

Behavioral Therapy are postural maneuvers or compensatory strategies that are implemented to insure a safe swallow.

For example, a HEAD TURN is implemented when it is found that a patient is numb on one side of their throat during a FEESST exam. By having the patient turn their head to the numb side, the area of the throat that is numb becomes narrowed so that incoming food gets directed towards the sensate side of the throat.

Types of Swallowing Behavioral Therapy include:

A. Postural Techniques

• Head Rotation to Weak Side or Strong Side - By rotating the head to the side of either motor or sensory weakness, the patient can eliminate the injured side of the pharynx from the food bolus path.
• Shaker Exercises - Another way to open the upper esophageal sphincter by having the patient lay flat on their back and, in a precise manner, slowly lift their chin to their chest.
• Chin Tuck - By placing the chin downwards toward the chest the patient: 

1. widens the vallecula to prevent bolus from entering airway 
2. puts the epiglottis in a more protective position 
3. narrows the laryngeal entrance

• place bolus in swallow position
• swallow while holding breath 
• cough after swallowing before inhaling (this clears any residue that may have entered the larynx)

Dietary Therapy
Pharmacotherapy
Surgery

A) Zenker's Diverticulectomy Three procedures have been described to treat a Zenker's diverticulum: diverticulectomy, diverticulopexy, and peroral endoscopic division of the party wall between the diverticulum and the esophagus. Diverticulectomy is usually selected for treating large diverticula in otherwise healthy patients. It involves an open-neck operation where the(Zenker's) hernia sac is identified and isolated. The sac is then resected its neck, taking care not to compromise the esophageal lumen by resecting too much mucosa, and closing the pharyngotomy with a watertight closure. A cricopharyngeal myotomy is performed as close to the posterior midline as is possible to minimize risk to the recurrent laryngeal nerves; the myotomy consists of dividing the entire circular cricopharyngeus muscle. Diverticuloplexy, combined with cricopharyngeal myotomy, is preferred by some surgeons for dealing with small diverticula or large diverticula in high-risk patients. The sac is isolated and tacked with permanent suture to the prevertebral fascia, such that the mouth of the sac is in a dependent position. Diverticulopexy avoids a pharyngotomy, reducing the risk of a pharyngocutaneous fistula or injury to the recurrent laryngeal nerves. Endoscopic peroral division of the party wall between the sac and the esophagus was first described by Dohlman in 1960. He used a special double-lipped esophagoscope, inserting one lip into the sac and one lip into the esophagus. Electrocautery was used to divide the party wall, including the cricopharyngeus muscle. Dohlman's procedure fell into disfavor because of an unacceptably high complication rate and mortality from mediastinitis. More recently, with some modifications to Dohlman's original technique such as utilization of an operating microscope and a laser, the endoscopic approach has gained acceptance, especially for very ill patients in whom an open procedure might pose greater risks. B) Cricopharyngeal Myotomy Dysphagia as a result of abnormalities with the cricopharyngeus muscle may be ameliorated by selective use of cricopharyngeal myotomy. Cricopharyngeal myotomy may be either surgical or pharmacologic (botulinum toxin). In general, cricopharyngeal myotomy is primarily useful for true cricopharyngeal achalasia such as after vagus nerve injury at the base of the skull where pharyngeal motor function remains otherwise intact. Cricopharyngeal myotomy is contraindicated in conditions when there is impaired pharyngeal peristalsis or when significant reflux disease exists. Many disease entities where cricopharyngeal myotomy was thought to be useful in improving dysphagia, such as myopathy and brainstem stroke, may actually be of no benefit. C) Salivary Diversion Procedures Dysphagia severe enough to result in the threat or actual circumstance of food and saliva constantly soiling the airway typically requires aggressive management. Surgical procedures that divert or diminish the flow of food and saliva from the airway include vocal fold medialization, tracheostomy, laryngeal stents, reversible laryngeal closure procedures, laryngotracheal separation and total laryngectomy. The application of any one of these treatment modalities depends on several patient factors such as underlying disease process and overall health status of the patient. Patients who are aspirating regularly frequently become malnourished, which only exacerbates their underlying condition. Therefore, as measures are considered to prevent aspiration, alimentation through non-oral means should be implemented as well. Feeding gastrostomy or jejunostomy tubes, placed endoscopically (percutaneous endoscopic gastrostomy (PEG) or percutaneous endoscopic jejunostomy (PEJ), are excellent ways to aliment patients who are at high risk for aspiration as a result of severe dysphagia. Laccourreye O et al. Esophageal diverticulum: diverticulopexy versus diverticulectomy. Laryngoscope 1994.

B. Compensatory Strategies

• Effortfull Swallow - The patient is instructed to bear down, or to squeeze hard with all of their head and neck muscles while swallowing.
• The Supraglottic Swallow - Four step maneuver, inhale and hold breath (this closes the vocal folds)
• The Supra - Supraglottic Swallow - The patient follows the same procedure as with the supraglottic swallow but additionaly he/she  bears down while holding his/her breath. 
• Mendelsohn Maneuver - A technique that opens the upper esophageal sphincter. The patient is instructed to hold the thyroid cartilage up for several seconds. In this way, the larynx is kept tilted forward and elevated, thereby allowing the upper esophageal sphincter to relax.

You can learn more by watching a video with the swallowing strategies presented by a clinician-

http://www.youtube.com/watch?v=UgkRVD-LvjY&feature=endscreen&NR=1

During the FEESST test  it may become evident that certain types of food cause the patient to cough or choke, but other foods do not. During the FEESST exam the various food volumes and consistencies are used until it is determined which combinations allow the patient to swallow easily and safely.

Pharmacotherapy is therapy when certain medications may be prescribed which can help the patient swallow safely.

Depending on the results of the swallowing evaluation, certain medications may be prescribed which can help the patient swallow safely

A)  Mucolytic agents: Medications that thin-out thick secretions. Sometimes patients have very thick phlegm and mucus that makes it difficult for patients to swallow. Mucolytics can thin thick secretions so that they could be more readily expectorated and coughed.

B) Anti-acid medications: Swallowing problems are sometimes due to untreated, or insufficiently treated, acid reflux disease. The acid causes swelling in the throat which can contribute to swallowing difficulties. Under those circumstances, anti-acid medication is prescribed in order to help alleviate the throat swelling that may be contributing to the swallowing problem.

The surgical management of the patient with dysphagia primarily depends on the etiology of the dysphagia. The more common etiologies of dysphagia that lend themselves to surgical correction are described.

References:

1. Dohlman G, Mattsson O. The endoscopic operation for hypopharyngeal diverticulum. A roentgen cinematographic study. Arch Oto Head Neck Surg 1960. 
2. Ian Overbeek JJM. Meditation on the pathogenesis of hypopharyngeal (Zenker's) diverticulum and a report of endoscopic treatment in 545 patients. Ann Otol Rhinol Laryngol 1994.
3. Wisdom G, Blitzer A. Surgical therapy for swallowing disorders. Oto Clin NA 1998.
4. Pou AM. Surgical treatment of swallowing disorders: Cricopharyngeal myotomy in Carrau RL, Murray T (eds.) Comprehensive Management of Swallowing Disorders. Singular Publishing Group, Inc. San Diego, CA 1999.
5. Stevens KM, Newell RC. Cricopharyngeal myotomy in dysphagia. Laryngoscope 1971; 81: 1616-1620.
6. Lebo CP, Sang K, Norris FH. . Cricopharyngeal myotomy in amyotrophic lateral sclerosis. Laryngoscope 1976.
7. Calcaterra TC, Kadell BM, Ward PH. Dysphagia secondary to Cricopharyngeal muscle dysfunction: surgical management. Arch Otolaryngol Head Neck Surg 1975. 
8. Netterville JL, Stone RE, Luken ES, Civantos FJ, Ossoff RH. Silastic medialization and arytenoid adduction, a review of 116 procedures: the Vanderbilt experience. Ann Otol Rhinol Laryngol 1993.
9. Eliachar I, Nguyen D. Laryngotracheal stent for internal support and control of aspiration without loss of phonation. Otolaryngol Head Neck Surg 1990.
10. Castellanos PF. Method and clinical results of a new transthyrotomy closure of the supraglottic larynx for the treatment of intractable aspiration. Ann Otol Rhinol Laryngol 1997. 
11. Biller HF, Lawson W. Total glossectomy. Arch Otolaryngol Head Neck Surg 1983.
12. Lindeman RC, Yarington CT, Sutter D. Clinical experience with the tracheoesophageal anastomosis for intractable aspiration. Ann Otol Rhinol Laryngol 1976.
13. Cannon CR, McClean WC. Laryngectomy for chronic aspiration. Am J Otolaryngol 1982.

Dysphagia - Feeding & Swallowing Disorders in Infants & Children

Children with feeding and swallowing difficulties (also called dysphagia) are at risk for malnutrition, dehydration, and respiratory problems. Infants and children with feeding and swallowing problems are a diverse group, ranging from premature babies to teenagers. Parents are often the first to notice a feeding problem.

Check my other post:

Dysphagia and Swallowing Therapy and Treatment, Diet and Liquid Consistency

http://slpzone.blogspot.com/2012/04/dysphagia-and-swallowing-therapy-and.html

“The best practice for swallowing is swallowing” – Dysphagia in Children and Adults

https://slpzone.blogspot.com/2020/05/the-best-practice-for-swallowing-is.html

Causes of feeding and swallowing problems

• Prematurity
• Cerebral palsy
• Autism
• Head and neck abnormalities
• Muscle weakness in the face and neck
• Gastroesophageal reflux
• Multiple medical problems
• Respiratory difficulties
• Medications that may cause lethargy or decreased appetite
• Problems with parent-child interactions at mealtime

Symptoms

Children with feeding and swallowing problems present with a wide variety of symptoms, depending on the nature and cause of their disorder. Typical symptoms include:

• Poor feeding
• Difficulty chewing
• Difficulty drinking from a bottle or cup
• Difficulty breast feeding
• Refusing food or liquid
• Coughing or choking while eating or drinking
• Excessive drooling and food spilling from the mouth
• Liquid leaking out the nose
• Gagging
• Vomiting during meals
• Increased congestion during meals
• Increased fussiness or crying during meals
• Accepting only certain types of food (only pureed foods or only crunchy foods)
• Poor weight gain
• Frequent respiratory infections or pneumonia (may occur when food or liquid is aspirated into the airway, rather than swallowed effectively)

Evaluation and Diagnosis of Feeding and Swallowing Disorders

If you suspect that your child is having difficulty eating, contact your pediatrician right away. Your physician will examine your child and address any medical reasons for the feeding difficulties, including the presence of reflux or metabolic disorders. The pediatrician may refer you and your child to a feeding team or speech-language pathologist who specializes in treating children with feeding and swallowing disorders. The SLP will discuss your concerns and observe your child while they eat. The SLP may also conduct an instrumental assessment of your child's swallowing ability. This involves having your child eat and drink foods and liquids mixed with barium while watching them on an x-ray. This procedure is typically called a modified barium swallow (MBS) and is conducted in a radiology office. Sometimes a different instrumental assessment will be completed, which involves having a lighted scope inserted through the nose so your child's swallow can be observed.

If a feeding team is involved, which may include the speech language pathologist SLP, an occupational therapist OT, a physical therapist PT, a physician or nurse, and a dietitian, your child's posture, self-feeding abilities, medical status, and nutritional intake will also be examined. The team will then make recommendations on how to improve your child's feeding and swallowing.

You can watch 

normal swallow - animation

https://www.youtube.com/watch?v=4FMnXz6o2vI

X-Ray swallow -

http://www.youtube.com/watch?v=PwVreNrTKBw&feature=related

abnormal swallow

https://www.youtube.com/watch?v=mvAKyuI_nUE

Learn about basic of videofluoroscopy of swallowing

http://www.youtube.com/watch?v=-wmt6HlLduY&feature=related

Treatment

Based on the results of the feeding evaluation, the SLP or feeding team may recommend any of the following:

• Medical intervention, as needed
• Direct feeding therapy designed to meet your child's individual needs
• Nutritional changes
• Postural or positioning changes (different seating, etc.)
• Behavior management techniques
• Desensitization to new foods or textures
• Food temperature and texture changes
• Referral to other disciplines, such as psychology or a dentist

If feeding therapy with an SLP is recommended, the focus of intervention may include:

• Strengthening the muscles of the mouth
• Increasing tongue movement
• Improving chewing patterns
• Increasing tolerance of different foods or liquids
• Improving sucking /drinking ability
• Coordinating the suck-swallow-breathe pattern (for infants)
• Altering food textures and liquid viscosity to ensure safe swallowing
• Other interventions depending on your child's specific needs

Swallowing strategies for dysphagia 

A. Compensatory Strategies
- Supraglottic Swallow
- Effortfull Swallow
- Mendelsohn Maneuver
- The Supra-Supraglottic Swallow

B. Postural Techniques
- Head Rotation To Weak Side
- Head Rotation To Strong Side
- Head Back/ Chin Up
- Chin Tuck

Watch video with the swallowing strategies presented by a clinician - 

http://www.youtube.com/watch?v=UgkRVD-LvjY&feature=endscreen&NR=1

  

Management hints of gastro-oesophageal reflux 

1. Keep your baby upright for at least 30 minutes after a feed. 
2. Use a baby sling; which keeps your child upright, while your hands are free. Avoid baby slumping. 
3. Try elevating the head of the cot/bassinet. 
4.  Consider using a dumm. 
5. Avoid vigorous movements or bouncing a baby. 
6. The best time to lay your baby on the floor is when baby's tummy is empty, i.e. before feeding. 
7. Change nappy before feeding. Take care to elevate baby's head and shoulders. Avoid lifting legs too high. Turn to the side if possible. 
8. Avoid any tight clothing around the waist, such as tight nappies, elastic waistbands. 
9. Avoid overfeeding – if baby vomits, wait until the next feeding rather than feeding your baby again. 
10. If a baby is bottle-fed, it may be worthwhile to try AR (anti-reflux) or hypoallergenic formula.
11.  Offer a spoonful of thickened milk (formula or breastmilk) following the feed. 
12. If breastfeeding, in your diet avoid foods that can aggravate reflux, e.g. citrus, tomato, fatty foods, spicy foods, chocolate and carbonated drinks. 
13. Some reflux children may suffer from food sensitivities, and may need dietary restrictions (or the mother may consider an elimination diet). If you suspect foods may be responsible for your child's condition, it is essential to discuss this with your health care provider. Do not change your or your child's diet before seeking medical advice. 
14. Contact a reflux support organisation for further information and support. The support groups can offer the emotional support you may need.

Oral-Motor Exercises

Rules to follow for a success

Try to apply and look for a triumph. Good Luck!

Make exercises fun as much as possible!

Modify environment by minimizing distractions!

Sit behind a child, the way you both face a mirror!

Make sure your child is in comfortable, supported position!

Explain what you are doing in a simple, narrative way!

Provide exercises for short periods of time!

Don’t do all learned exercises at the same session!

Provide exercises before each meal not during a mealtime!

Pause to allow time to swallow any saliva that may have accumulated!

Don’t attempt swallowing if your child has a cold!

Stop if your child becomes distressed at any time!
Be patient!

 

Exercises to develop and improve oral sensitivity and muscle tone

1. First, before you approach the child’s face verbally explain what are you going to do and what for.
2. Use slow, firm strokes over the hands, arms, shoulders, neck with rough texture (e.g. towel, etc.)
3. Next start at the sides of the face, forehead, chin, gradually working towards the centre of the face.
4. Massage the cheeks using circular movements, particularly around the mouth.
5. Using thumb and index finger press the top and bottom lips firmly together. Hold for a while and release.
6. Stroke firmly downwards on the area between the nose and top lip while using your finger to push the bottom lip upwards.
7. Using 2 fingers pull the top lip down, starting under the nose and working towards the top of the lip (without touching the lip itself).
8. Do the same for the bottom lip, working from the chin to the lip. Support the jaw if necessary.
9. Gradually introduce stronger flavors at mealtimes:

a.       Using seasoning (curry, garlic, etc.)

b.      Introducing organic chips of different flavor (vinegar, pepper, etc.) and dips (mayonnaise, ketchup, etc.)

c.       Offering tangy, bitter flavored fruits or yoghurts (kiwi, lemon, grapefruit, cranberry, etc.)

10.  Introduce food of different temperature (ice-cream, popsicles, etc.)

11.  Gradually introduce sensory toys (textured teethers, etc.)

Exercises to develop and improve lip movements

 

1. Child will drink from a cup making very small sips.
2. Child will drink using straw (tight/round lip seal around the straw; straw has to be held just by lips, not deeply.)
3. Child will blow bubbles in the air, bubbles in the water using a straw, cotton wool balls across the table, whistles/party blowers, etc.
4. Child will make /oo/ sounds (imitating a ghost, owl, monkey, wind) and /ee/ sounds, like E-I-E-I-O in Old McDonald song, using exaggerated lip movements. You might need to gently push the lips from a tight stretched position (smile shape) to the round position (kiss shape).
5. Child will blow kisses. (You might need to gently push the lips from a tight stretched position  -smile shape to the round position - kiss shape. Put on some lip stick or face paint and make kiss marks on a mirror, tissue, paper etc.

Exercises to develop and improve jaw and tongue movements

1. When side-spoon-feeding your child, place spoon on the lower lip. Let the child to clean the spoon.
2. Over time place food at the sides of the mouth, between the teeth. This will encourage munching/sideward tongue movements.
3. To stimulate biting, munching and sideward tongue movements.

a.       Do exercises at times when your child is relaxed.

b.      Exercises should not be done at mealtimes.

c.       Place the item in the mouth, between the teeth, along the line of the jaw and ensure that it is not placed so as to stretch the lips. Do not place too far back in case your child gags.

d.      Place on the best side initially, than move to the other side.

e.       If the child is not munching, pull the item out slightly and gently or press down.

f.       When you feel your child is confident about biting skills, introduce food items. Initially use bite-and-dissolve foods (biscuits, snacks, etc.)

g.      If the child is not biting off the food, break it off for them while they are biting down on it. Do not force your child to take foods that their mouth is not ready.

h.      Over time, gradually introduce chewier foods in the same way.

Complementary Techniques in Education

Art and Music

Art and music are particularly useful in sensory integration, providing tactile, visual and auditory stimulation.

Music therapy is good for speech development and language comprehension. Songs can be used to teach language and increase the ability to put words together.

Art therapy can provide a nonverbal, symbolic way for the child with autism to express him or herself. 

Animal Therapy

Animal therapy may include horseback riding or swimming with dolphins. Therapeutic riding programs provide both physical and emotional benefits, improving coordination and motor development, while creating a sense of well-being and increasing self-confidence. 

Dolphin therapy was first used in the 1970s by psychologist David Nathanson. He believed that interactions with dolphins would increase a child's attention, enhancing cognitive processes.

In a number of studies, he found that children with disabilities learned faster and retained information longer when they were with dolphins, compared to children who learned in a classroom setting.

Hemisphere Dominancy - Hemispheric Lateralization

What doe's it mean?

A picture comes from http://www.lefthandersday.com/

Coordination of hearing - vision - kinesthetic movement

How to observe predominance (out of 10 tries):

1. Leg:
• kick a ball
• first step walking upstairs/downstairs
2. Hand:
• holding utensils
• holding marker/ pen/ pencil
• playing with toys, e.g. pushing car, hitting with hummer
3. Eye:
• looking into kaleidoscope
• looking through whole (paper 25x15cm with whole in the center)
4. Ear:
• turning head to an unexpected source of sound
• listening to whisper

A picture comes from http://www.thethinkingblog.com/2008/05/dual-mind-which-part-of-your-mind.html

What hemispheric lateralization tells us about?

The two hemispheres of the brain are specialized to perform certain tasks ("lateralization".) Language is localized in the left hemisphere, specifically Broca's and Wernicke's areas. Facial recognition is localized in the right hemisphere, specifically the fusiform gyrus.  Summarizing, the right brain is dominant for spatial abilities, face recognition, visual imagery and music. The left brain may be more dominant for calculations, math and logical abilities. The right side of the brain controls muscles on the left side of the body and the left side of the brain controls muscles on the right side of the body. Also, in general, sensory information from the left side of the body crosses over to the right side of the brain and information from the right side of the body crosses over to the left side of the brain. Therefore, damage to one side of the brain will affect the opposite side of the body. Most individuals show a preference toward using a dominant hand, eye and leg. The idea behind it is that left-brained people need to "develop" more "right-brain thinking" and vice-versa to take full advantage of the brain's capacity and to be more successful.

http://faculty.washington.edu/chudler/split.html

Exercises to support hemispheric lateralization 

A picture comes from http://havefunwithpsychology.com/

Look for Veronica Sherborne exercises. This approach is based on the philosophy and theory of human movement created by Rudolf Laban (pioneer and founder of Modern European movement analysis) http://www.sherbornemovementuk.org/about-sherborne-developmental-movement.html

The parent will:

• build child’s self-esteem
• make child feel successful
• prompt child to finish activity

The child will:

• draw on lines (vertical up to down, horizontal in reading direction)
• copy after model
• assemble puzzle picture base on picture
• work on sound discrimination
• repeat rhythm/ music after a model
• look for differences in pictures
• play picture domino

Tongue Twisters Improve Communication Skills

What Are Tongue Twisters?

Tongue twisters are words, phrases, or sentences which are difficult to pronounce properly and result in fun and humor. Why is that? It is because of a varying combination of similar sounds in them. They can be very challenging as well as motivating. They can be also fun to learn. Evan adults want to repeat tongue twisters to impress the others.

What Can Tongue Twisters Help With?

• Language: The child learns meaning, synonyms, antonyms, or homonyms, correct form of the word and how to use it in context.
• Auditory Discrimination: The child listens and identifies correct or incorrect productions.
• Articulation: The child practices using articulators (lips, tongue, jaw), proper breath support and vocal cords.
• Fluency: The child practices a smooth rate and rhythm of speech by increasing mean length of utterance, and improving self-monitoring skills.

You Can Use Tongue Twisters In The Following Ways:

• Language: Have the child complete sentences, answer “Wh” questions, and identify regular and irregular past tense verbs, adjectives, and adverbs. You can also use the target words to teach or reinforce rhyming, synonyms, antonyms, and homonyms.
• Auditory Discrimination: The parent purposefully misarticulates a word(s) while saying the tongue twister. The child listens and identifies the incorrect productions.
• Articulation: Have the child practice using articulators and proper breathing to the microphone or in front of a mirror.
• Fluency: Give a model so the child can practice a smooth rate and rhythm of speech.

Examples Of Tongue Twisters For Kids

You can start with the one with the visual cues:

Which witch wished which wish?
Or
If two witches were watching two watches,
Which witch would watch which watch?

Which wristwatches are Swiss wristwatches?

A noisy noise annoys an oyster.

Six sticky sucker sticks.

Silly sheep weep and sleep.

If  Stu chews shoes, 

Should Stu choose the shoes he chews?

Then go to the one which rhyme:

Fuzzy Wuzzy was a bear,
Fuzzy Wuzzy had no hair,
Fuzzy Wuzzy wasn't very fuzzy,
was he?

Why do you cry, Willy?
Why do you cry?
Why, Willy?
Why, Willy?
Why, Willy? Why?

Whether the weather be fine
Or whether the weather be not.
Whether the weather be cold
Or whether the weather be hot.
We'll weather the weather
Whether we like it or not.

Continue with the one without rhyme:

She sells seashells by the sea shore. 

The shells she sells are surely seashells. 

So, if she sells shells on the seashore, 

I'm sure she sells seashore shells.

Peter Piper picked a peck of pickled peppers.

A peck of pickled peppers Peter Piper picked.

If Peter Piper picked a peck of pickled peppers,

How many pickled peppers did Peter Piper pick?

For more tongue twisters go to:

http://www.starfall.com/n/level-b/twisters/load.htm?f

http://www.indianchild.com/tongue_twisters.htm

http://tonguetwistersforkids.com/

http://learnenglishkids.britishcouncil.org/en/tongue-twisters

http://www.momsandkids.co.uk/kidstonguetwisters.tpl

Tongue Twisters in Speech Therapy

Since I’m a speech-language pathologist (SLP) I use the tongue twisters with my clients. I apply them exactly the way as presented above.

Here are the steps in the therapy:

1. I begin by saying the tongue twister completely so as to emphasize the targeted sound. Next, the child identifies the target sound. If I see that it is too difficult I help the child to do that. At last the child says the words, producing the target sound correctly.
2. Then the child says the tongue twister by either repeating after me, one line or phrase at a time, or by choral reading (reading the same thing at the same time).
3. When accuracy improves, I encourage the child to read a little faster. Each repetition of a complete tongue twister is a little faster than the one before. The child tries to keep the words from becoming “twisted.”