Dysphagia Compensations

Postural techniques

Head back:
What- Patient places head backward
When- Fluroscopy shows inefficient oral transit (reduced posterior propulsion of bolus by tongue) but good airway protection
Rationale- Uses gravity to clear the oral cavity from the bolus
Chin down posture:
What- Touching the chin to the neck
When- Try this technique when fluroscopy shows a delay in triggering the pharyngeal swallow (Bolus passes the ramus of the mandible, but the pharyngeal swallow does not trigger). This is also helpful if the patient has reduced tongue base retraction, and or reduced airway entrance closure.
Rationale- It widens the valleculae to prevent the bolus from entering the airway; narrows the airway entrance; pushes the epiglottis posterior; pushes the tongue base backward, closer to the pharyngeal wall

Head turn to damaged side:
What- Patient turns his head to the weak/damaged side
When- Unilateral pharyngeal wall impairment or vocal fold weakness.
Rationale- Places extrinsic pressure on thryroid cartilage, thus increasing adduction when there is a vocal fold weakness. It twists the pharynx and closes the damaged side of the pharynx so food wll pass down the normal side

Head tilt to stronger side:
What- Patient tilts head to side that is strong and without weakness
When- Unilateral oral and pharngeal weakness on the same side (residue in mouth and pharynx on same side)
Rationale- Directs bolus down stronger side

Other Modifications
Volume and speed of food presentation. Patients with a delay in pharyngeal triggering may benefit from a larger bolus. Patients with a weakened pharyngeal swallow that requires two or three swallows per bolus, may result in a collection of food in the pharynx and aspiration.

Diet changes
This should be the last compensatory strategy examined. This should only be done if all other compensatory strategies and postural strategies are ineffective or the patient is unable to follow the directions. Liquids may need to be thickened if the patient is showing aspiration on thin liquids. A patient may also have to be on a puree diet secondary to inability to masticate adequately.

National Dysphagia Diet Levels:

Dysphagia I

Dysphagia II

Dysphagia III

Regular

Improving Oral Sensory Awareness

Patients include those with apraxia, agnosia for food, reduced oral sensation, delayed onset of the oral swallow, or delayed triggering of the pharyngeal swallow.

Techniques:

• Using downward pressure on the spoon against the tongue when presenting food
• Present different temperature bolus
• Present a sour bolus
• Present a larger volume of bolus
• Present a bolus requiring chewing
• Thermal or tactile stimulation- rubbing the faucial arches to aid in triggering a swallow

Measure effectiveness by the duration of time from command to swallow until initiation of the oral stage of swallow, oral transit time, and pharyngeal delay time.

Swallow Maneuvers:

Supraglottic swallow- Perform a supraglottic swallow maneuver when there is reduced or late vocal fold closure.

The patient is told to take a breath and hold it while swallowing and then coughs after the swallow. This results in the voluntary closure of the vocal folds before, during and after the swallow.

Supersupraglottic swallow-  This is for reduced closure of the airway entrance.  The super-supraglottic swallow technique closes the entrance to the airway at the level of the arytenoid cartilages. The patient follows the same procedure as with the supra-glottic swallow, but “bears down while holding his breath.”

Effortful swallow-This increases the tongue driving force by causing exaggerated retraction of the tongue. This helps to get food past the valleculae.  The effort increases posterior tongue base movement.

The patient is directed to squeeze hard with his throat and neck muscles during the swallow.

The patient is told to pay attention to the way the thyroid cartilage (Adam’s apple) goes up and down during swallowing. Then he learns to use muscles to keep the larynx elevated for several seconds after the swallow. This should facilitate the opening of the cricopharyngus muscle.

Thermal Stimulation (Logemann, 1989,1997)

Evidence regarding the efficacy of this procedure is mixed, but it is commonly used. Logemann (1989) has promoted the use of this technique.

Thermal stimulation involves tapping or rubbing the patient’s anterior faucial pillar with an iced dental mirror. In each treatment “set” the tapping/rubbing is done about five times. As immediately as possible after a set is completed the patient is instructed to swallow and may be given a small amount of liquid through a straw, even carbonated. The extra stimulation provided by the iced mirror is supposed to somehow alert the nervous system, allowing the swallow response to occur more rapidly.

Logemann (1989) recommends doing thermal stimulation three times per day. She suggests stimulating only the anterior faucial pillar on the patient’s good side.

Swallowing Exercises:

Swallowing exercises have some degree of evidence to aid in improving swallowing of patients with dysphagia.

More information coming soon…..

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Jacob P, Kahrilas PJ, Logemann JA, Shah V, Ha T: Upper esophageal sphincter opening and modulation during swallowing. Gastroenterology 97:1469-1478, 1989

Cook IJ, Dodds WJ, Dantas RO, Massey BT, Kern MK, Lang IM, Brasseur JG, Hogan W J: Opening mechanism of the human upper esophageal sphincter. AmJ Physiol 257:G748-G759, 1989.

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Tags: compensations, diet change, dysphagia treatment, effortful, Mendelson maneuver, supraglottic, swallow exercise, swallow maneuver, thermal stimulation