Dysphagiain

Pseudobulbar palsy

PHINOJ K ABRAHAMIInd MOTh Student

All India Institute of Physical Medicine & Rehabilitation, (AIIPM&R) Mumbai

Dysphagia in Pseudobulbar Palsy

◦ Bulbar and Pseudo bulbar Palsy

◦ Dysphagia- Definition

◦ Anatomy of Pharynx

◦ Swallowing Process

◦ Types of dysphagia

◦ Causes of dysphagia

◦ Clinical assessment of dysphagia

◦ Treatment of Dysphagia

Overview

2

Bulbar Palsy◦ Is caused by bilateral lower motor neuron lesion

affecting the nerves supplying the bulbar muscles of the jaw, face, palate, pharynx & larynx.

C/F◦ Impaired speech and swallowing◦ Speech develops a nasal quality due to escape of

air through nose.◦ Paralysis of affected muscles, and tongue appears

wasted.

Bulbar & Pseudobulbar palsy

3

Pseudo bulbar palsy (Supra nuclear bulbar palsy)◦ Pseudo bulbar palsy results from damage to cortico motor

neuron pathways innervating the bulbar musculature◦ It is resulting from an upper motor neuron lesion.

Pattern of involvement 1. Unilateral upper motor neuron lesion

This produce only transient weakness of many of muscles supplied by the cranial nerves. E.g., in stroke hemiplegia

2. Bilateral damage to the corticobulbar tracts This causes persistent weakness and spasticity of the

muscles supplied by the bulbar nuclei.

Bulbar & Pseudo bulbar palsy cont..

4

Presentation

◦ Tongue - paralysed, no wasting initially and no fasciculations; "Donald duck" speech; unable to protrude

◦ Palatal movements absent◦ Dribbling persistently◦ Facial muscles - may also be paralysed◦ Reflexes - exaggerated e.g. jaw jerk◦ Nasal regurgitation may be present◦ Dysphonic◦ Dysphagic◦ Emotional lability may also be present◦ There may also be neurological deficits in the limbs e.g.

increased tone, enhanced reflexes and weakness.

Pseudo bulbar palsy cont…

5

Causes◦ Cerebrovascular events e.g. bilateral internal capsule infarcts

◦ Demyelinating disorders e.g. multiple sclerosis

◦ Motor neurone disease◦ High brainstem tumours◦ Head injury◦ Neurosyphilis

Complications◦ Poor nutrition◦ Psychological dysfunction◦ Progression of underlying disease

Prognosis◦ This depends on the underlying cause.

Pseudo bulbar palsy cont…

6

Dysphagia, a Greek word that means disordered eating, is difficulty in eating as a result of disruption of the swallowing process. (Braddom p535)

Dysphagia is defined as a condition in which an individual has had an interruption in either eating function or the maintenance of nutrition and hydration (Buchholz, D)

Difficulty with eating which may include one or more of the following Chewing food swallowing solids and/or liquids coughing or chocking when eating food sticking in the throat or chest

(ASHA)

Dysphagia-definition

7

Anatomy of Pharynx

Tongue

8

Anatomy of Pharynx cont…

9

The Four phases of Swallowing

Oral Preparatory Phase Oral Phase Pharyngeal Phase Esophageal Phase

These 4 phases are dynamic and overlapping.

In general, they allowed food and liquid to

move from the mouth into the stomach

smoothly & Safely. (ASHA)

The Swallowing Process

10

Eating is anticipated

Food is brought to the mouth

◦ Bitten off

◦ Taken from the utensil

Food is chewed and mixed with saliva

Liquids are sipped or sucked through a

straw

Oral Preparatory Phase

11

The food is collected Sealed between the roof of the mouth & the tongue The tongue moves the food back with a stripping wave in

to the back of the throat (pharynx) This begins the actual swallow For the successful execution of this phase we need,

◦ Intact lip closure◦ A mobile tongue◦ Functional muscles of mastication

Oral Phase

12

Soft palate elevates◦ Preventing food from escaping into the nose

Tongue base moves back to contact pharyngeal wall

Larynx (voice box) moves up and forward Epiglottis (top part of larynx) is tilted down

and back to guide the food past the airway.

Pharyngeal Phase

13

Breathing momentarily stops

Vocal cord comes together to further protect

airway

Muscles of the pharynx contract

◦ Moves the food towards the esophagus

◦ Upper esophageal sphincter relaxes

Food passes in to the esophagus.

Pharyngeal Phase cont…

14

Duration : 0.6 sec Aspiration is most likely to occur in this

phase Protection from laryngeal penetration and

aspiration is afforded in several ways;

◦ By folding of the epiglottis over the laryngeal opening

◦ By closure of vocal cords◦ By elevation and anterior displacement of larynx

Pharyngeal Phase cont…

15

Esophageal Phase• Peristalsis moves the

food through the esophagus

• The lower esophageal sphincter relaxes to allow the food to passes into the stomach• Duration: 6-10 sec

16

FLUROSCOPIC IMAGING OF NORMAL SWALLOWING

17

The most important images of the swallowing study are those taken of the lateral view.

1. The base of the tongue and the soft palate close the oral cavity posteriorly (arrow) to prevent spill of food into the open larynx.

2. Hyoid bone and base of the tongue move in a cranial direction and lift the larynx (arrow).

3. Soft palate elevates to prevent spill into the nasopharynx (thin arrow) and the larynx closes by contraction of the aryepiglottic folds (broad arrow)

4. Contraction of the upper pharyngeal constrictor (arrow)5. Contraction of the middle pharyngeal constrictor (arrow)6. Contraction of the lower pharyngeal constrictor and relaxation

of the cricopharyngeal muscle (arrow)7. Epiglottis elevates to regain its resting position and the larynx

opens.8. Epiglottis in resting position and larynx is open (arrow).

www.radiologyassistant.nl/en/440bca82f1b77

Fluoroscopic imaging cont…

18

The swallowing process requires the following elements:◦ Sensory input from the peripheral and central

nervous system Through V, VII, IX & X cranial nerves

◦ A coordinating center or centers Exact role of cerebral cortex is unknown The brain stem swallowing centers receive the input,

organize it in to programmed response and transmit the response.

◦ A subsequent motor response sent back through these systems. Through V, VII, IX, X & XII cranial nerves

Neurological control of swallowing

19

20

There are three types of swallowing disorder, divided on the basis of where the problem is occurring: ◦ Oral Dysphagia◦ Pharyngeal Dysphagia◦ Esophageal Dysphagia

Dysphagia Types

Oral or pharyngeal dysphagia Esophageal dysphagia

• Coughing or choking with swallowing

• Difficulty initiating swallowing• Food sticking in the throat• Drooling• Unexplained weight loss• Change in dietary habits• Recurrent pneumonia• Change in voice or speech• Nasal regurgitation

• Sensation of food sticking in the chest

• Oral or pharyngeal regurgitation

• Food sticking in the throat• Drooling• Unexplained weight loss• Change in dietary habits• Recurrent pneumonia

21

Based up on the cause there are 2 types;1. Mechanical Dysphagia

Dysphagia caused by a large bolus or luminal narrowing is called mechanical Dysphagia

2. Motor (Neuro muscular) Dysphagia Dysphagia due to weakness of peristaltic

contractions or to impaired deglutitive inhibition** causing nonperistaltic contractions and impaired sphincter relaxation is called motor dysphagia.

◦ ** Deglutitive inhibition: The inhibition that precedes the peristaltic contractions.

Causes of Dysphagia

22

MECHANICAL DYSPHAGIA◦ Luminal (Large bolus, foreign body etc...)◦ Intrinsic narrowing (Malignant/ Benign tumors, Webs

and rings etc…)◦ Extrinsic compression (Cervical spondylitis, Enlarged

thyroid gland etc…)

MOTOR (NEUROMUSCULAR) DYSPHAGIA◦ Difficulty in initiating swallowing reflex (Paralysis of the

tongue, Lack of saliva)◦ Disorders of pharyngeal and esophageal striated

muscle◦ Upper motor neuron lesions (pseudobulbar paralysis)◦ Disorders of esophageal smooth muscle

Causes of Dysphagia cont…

23

History◦ h/o dental disorders, recurrent pneumonia, cardio

pulmonary disease or cervicle ankylosis or spondylosis.

Examination◦ Cranial nerve testing (V, VII, IX, X & XII) & direct

observation of lip closure, jaw closure, tongue mobility and strength, palatal elevation & oral sensitivity.

◦ Level of alertness & cognitive status◦ Gag reflex [but an absent gag doesn’t implay the

inability to swallow safely (Logemann JA 1989)]◦ Chest Auscultation.

Clinical assessment

24

Examination◦ Diagnostic feeding assessment with various food texture.◦ “3-ounce Water Swallow Test”

This test has compared favorably with the video swallow in identifying aspiration

The 3-oz water swallow test is a sensitive screening tool for

identifying patients at risk for clinically significant aspiration

who need referral for more definitive modified barium swallow evaluation. (DePippo KL et al)

it has been shown that if the 3-ounce water swallow test is passed, diet recommendations can be made without further objective dysphagia testing. (Debra M. Suiter &

Steven B. Leder, 2008) CRITIQUE : The 3-oz water screen utilizing the cough reflex

as the sole indica tor of aspiration is not a replacement for

the precision and accuracy of a videofluoro scopic evaluation. (Bernard R. Garon)

Clinical assessment cont..

25

Laboratory Data◦ Routine lab tests◦ Pulse oximetry

Technical Assessment of Dysphagia◦ Videofluroscopy

Easy to use Less expensive Risk of Radiation-present

◦ Ultrasonography◦ CT and MRI◦ Endoscopy

Clinical assessment cont..

26

Videofluroscopy of Aspiration before swallowing

27

1. Notice that contrast enters the pharynx, but does not trigger a swallowing reflex.

2. No swallowing reflex3. Contrast reaches the hypopharynx, but still no swallowing

reflex.4. Contrast enters the larynx, which is still open and not yet

elevated 5. At this moment the swallowing reflex starts and the larynx

elevates6. Contrast is transported to the esophagus and the larynx

closes, but there is already contrast in the trachea.7. Proper relaxation of the cricopharyngeus and finally there is

good closure of the larynx.8. Notice that there is no stasis at the end of the swallow .

www.radiologyassistant.nl/en/440bca82f1b77

Videofluroscopy of Aspiration before swallowing

28

CLINICAL EVALUATION

29

Treatment of Dysphagia Dysphagia treatment rests on 5 principles

1. Amelioration of the underlying disease process2. Prevention of complications3. Improvement of swallowing via therapy4. Compensations to improve swallowing safety and

efficiency &5. Environmental modification

(Braddom 3ird edn)

Occupational Therapist: Evaluates and treats sensory and motor impairments and assesses prosthetic needs related to self-feeding and swallowing. (ASHA)

30

This uses dietary modifications & Compensatory strategies to improve safety and efficiency while allowing for oral nutrition.

Oral feeding with consistency modifications - Thickened liquids increase oropharyngeal control, while a diet of chopped or pureed foods decreases difficulties with mastication.

Dysphagia diet◦ 1 - Thin liquids (eg, fruit juice, coffee, tea) ◦ 2 - Nectar-thick liquids (eg, cream soup, tomato juice) ◦ 3 - Honey-thick liquids (ie, liquids are thickened to a honey

consistency) ◦ 4 - Pudding-thick liquids/foods (eg, mashed bananas, cooked

cereals, purees) ◦ 5 - Mechanical soft foods (eg, meat loaf, baked beans,

casseroles) ◦ 6 - Chewy foods (eg, pizza, cheese, bagels) ◦ 7 - Foods that fall apart (eg, bread, rice, muffins) ◦ 8 - Mixed textures

Direct swallow therapy

31

Compensatory strategies to reduce the risk of aspiration include the following: ◦ Chin tuck - The patient holds his/her chin down, increasing the

epiglottic angles, and pushes the anterior laryngeal wall backward, thereby decreasing the airway diameter.

◦ Head rotation - The ipsilateral pharynx is closed, forcing the food bolus to the contralateral pharynx while cricopharyngeal pressure is decreased.

◦ Head tilt - This technique uses gravity to guide the bolus to the ipsilateral pharynx.

◦ Supraglottic swallow - This technique involves simultaneous swallowing and breath-holding, closing the vocal cords and protecting the airway. The patient thereafter can cough to expel any residue in the laryngeal vestibule. The Valsalva maneuver may be used to maximize vocal cord closing.

◦ Mendelsohn maneuver - This maneuver is a form of supraglottic swallow in which the patient mimics the upward movement of the larynx by voluntarily holding the larynx at its maximum height to increase the duration of the cricopharyngeal opening.

Direct swallow therapy cont..

32

Common postural techniques & some indications for use

Compensatory technique

Indication

Chin tuck Reduced oral bolus control with aspiration before or during the swallow

Neck extension Impaired oral bolus propulsion

Head turn to weak side

Unilat. Pharyngeal weakness with retention after swallowing

Head tilt to weak side

Unilat. Oral & pharyngeal weakness

Reclining position Pharyngeal weakness with retention & overflow after swallowing

Supraglottic swallow In adequate or delayed closure of laryngeal aditus (entrance)

Effortful swallow Poor tongue based retraction

Mendoelsohn maneuver

Inadequate upper esophageal sphincter opening

Syringe feeding Impaired oral bolus propulsion

Alterating solids & liquids

Retention in the pharynx after swallowing

33

It involve the use of oral, pharyngeal, laryngeal, and respiratory exercises to improve flexibility, strength and co-ordination.◦ Biofeedback techniques are used to reeducate

muscles affected in facial palsy and disorders of articulation. Such techniques include EMG feedback, with surface electrodes placed over the anterior neck. Visual feedback is obtained in VFSS while experimentation with head positions and swallowing maneuvers is conducted.

◦ Thermal stimulations in the form of icing of the anterior faucial arches can be performed; this may help to decrease the delay of pharyngeal swallow

Indirect therapy technique

34

Common indirect therapy techniques

Therapy technique Description ORAL CAVITYOral motor control exercises (jaw, tongue, lip)

Jaw opening & closing. Tounge rotation, lateralization, protrusion, retraction. Lip protrusion, lateralization & opening-closing

Relaxation & ROM exs (jaw, tongue, lip)

Stretching & increasing ROM

Resistance exercise (jaw, tongue, lip)

Opening closing jaw against resistance. Pushing the tongue against resistance

PHARYNXLaryngeal elevation exs

Volitional laryngeal elevation by saying a high pitched ‘ee’

Vocal cord adduction exs By uttering ‘ah’ simultaneously

Masako maneuver Swallowing with the tongue tip held anteriorly outside the mouth

Sensory stimulation Tactile stimulation of the faucial arches with cold or sour stimuli

UPPER ESOPHAGEAL SPHINCTER OPENINGShaker exs

Active head rising (neck flexion) in the supine position

Upper esophageal sphincter dialatation

Expansion of balloon catheter in the upper esophageal sphincter

35

Botulinum toxin type A is injected endoscopically into the gastroesophageal sphincter and upper esophagus to decrease tone. This could be very useful in cricopharyngeal spasms causing dysphagia.13,15

Diltiazem can aid in esophageal contractions and motility, especially in the disorder known as the nutcracker esophagus.

Glucagon is used in disimpacting esophageal bodies; diazepam also is sometimes used. No major study has proven their effectiveness.

Cystine-depleting therapy with cysteamine is the treatment of choice for patients with dysphagia due to pretransplantation or posttransplantation cystinosis.16

Nitrates can be recommended, especially isosorbide dinitrate in achalasia.

Medical interventions

36

◦ Esophageal dilatation in achalasia, strictures, and webs

◦ Cervical osteophyte resection ◦ Cricopharyngeal myotomy for upper esophageal

spasm◦ Esophageal resection and reanastomosis ◦ For paralyzed vocal cords, Teflon injection or

reversible vocal cord medialization can be performed.

◦ In recurrent pneumonia, cuffed tracheostomy sometimes is performed to protect the airway.

◦ Laryngectomy or laryngotracheal diversion also may be indicated, as for tracheostomy, and often is performed as a permanent palliative measure when all else has failed.

Endoscopic and surgical interventions

37

Psychological factors

Environmental factors

Hygienic considerations

Other considerations

38

THANK YOU…

39