Books to Read-Clinical Anatomy and Physiology of the Swallow Mechanism

swallowing mechanism

This book is a great read to help understand the anatomy and physiology of the swallowing system.  It breaks the information down into an easy-to-read format.  This is a book that I used extensively when studying for for BCS-S exam and still have the book to reference when I question anatomy or physiology.  Definitely worth the money (although you may want to look for it used).

Clinical Anatomy and Physiology of the Swallow Mechanism by Kim Corbin-Lewis, Julie M. Liss and Kellie L. Sciortino

Upcoming Articles!!

One thing I love about the Dysphagia journal, is not only the great research it provides me 4 times a year.  I love the abstracts for the upcoming (now past) Dysphagia Research Society (DRS) conference.  

This year was no exception for exciting new research to come!

Some titles that I am very excited to look into:

  • The Effects of Taste Concentration on SEMG in Swallowing-(Spoiler:  High concentraion sour stimuli elicit higher amplitudes and longer durations on SEMG).  
  • Esophageal Screening as an Adjunct to the Videofluoroscopic Study of Swallowing.  
  • Sour Bolus Facilitates Spontaneous Swallow in Parkinson’s Disease
  • Effects of Age and Sensation on the Anticipatory Stage of Swallowing
  • Physiological Factors Related to Aspiration Risk:  A Systematic Review
  • Pharyngeal Tactile Stimulation Using A Nylon Thread for Enhancing Pharyngeal Sensory Perception

These are just a few of the exciting titles that have caught my attention.  

If you are interested in the Dysphagia journal or the Dysphagia Research Society conference at a discount, make sure to join the Dysphagia Research Society!

books

Course Alert-Head and Neck Cancer

head and neck cancder

Northern Speech Services is offering a new course on head and neck cancer entitled:  Head and Neck Cancer Across the Continuum of Care: Addressing Swallowing Challenges.  The course is taught by Paula Sullivan who is an expert in dysphagia in the cancer population.

Per the NSS website:

This comprehensive online course will provide the participant an in-depth examination of head and neck cancer, its presentation, functional sequelae, evaluation approaches, treatment options, and provide an evidence-based approach of optimal patterns of care for head and neck patients with swallowing dysfunction.  Types of treatment for head and neck cancer and their impact on swallowing and communication function will be described, including both surgical and organ preservation. 

Assessment and evidence-based practice relevant to the head and neck cancer population will provide support for the practitioner in developing a holistic approach to rehabilitation which will optimize functional outcomes and, most importantly, quality-of-life.  Video presentation will be an integral part of this course.  By the completion of this course, the participant will possess a comprehensive understanding of dysphagia management in this challenging and rewarding population. Offered for 0.9 ASHA CEUs – 9 contact hours. 

This is definitely a course on my to-take list!

Has anyone taken this course yet?  If so, let us know what you thought!

The Patient Exercising Their Right to Choose (Formerly The Non Compliant Patient)

patient

EDIT 1/4/17.  Due to a recent Facebook post, I wanted to change some wording on this post.  As with all areas of dysphagia, I continue to grow, learn and change my beliefs, mainly because of the patients I serve.

Although my belief stands that those patients who do not follow my recommendation continue to require SLP services, maybe we should look at these patients not as “non-compliant” but as “exercising their right to choose.”  

There was post recently on the Special Interest Group (SIG) 13 email blast.  An SLP was asking what to do with a noncompliant patient.

When I was first beginning of the ever-changing world of speech pathology, I first learned that if a patient is noncompliant then they are discharged.  The rationale was, a doctor would release a patient for noncompliance and our license is always at stake.

My belief system is not the same, fortunately for my patients!

First, think about this.  Aren’t the noncompliant patients who choose to not follow the SLP’s recommends the ones we should be the most concerned about?  The patients that are compliant are on a modified diet that has been determined to be the safest diet consistency for them, although there is always some risk with every recommendation we make.  They may be regulated by caregivers or a facility, but if they are following all instructions and diet recommendations, they should be safe.  The noncompliant patient who aspirates thin liquids, but continues to drink them is the one you should be the most concerned for their safety.  That is the patient that may be most at risk for aspiration pneumonia.

In my experience, patients are not compliant unless they are forced to be. I have worked with patients that will sneak a drink, sneak a bite whenever they have the opportunity.  I have had patients that were supposed to be on thickened liquids, went home, told me they were continuing the thickened liquids but were actually drinking all thin liquids.

The best thing we can do for our noncompliant patients is to educate and rehabilitate.  Why not make them safer with the consistency they choose?

The first thing I do with every patient that is cognitively able is teach them and/or their caregivers about oral care.  If you read anything about oral care and aspiration pneumonia, the take-home message should be that pneumonia is a result of the bacteria from the oral cavity traveling to the lungs through saliva or a liquid/food swallow.  I recently wrote a post about oral care which you can find here.

It’s important to remember that we want the patient to succeed with the diet they choose to consume.  We can recommend a safe diet and we can advise but we have to focus on the rehabilitation.  Just remember, not everybody that aspirates develops aspiration pneumonia.  There are functional aspirators.

You may have a patient that aspirates everything on the Modified Barium Swallow Study (MBSS), goes home and consumes a regular diet without ever having an aspiration event or a pneumonia.  Just because that patient does not choose the diet you recommend does not mean you give up on them.  If they are willing to put in the work and give you some time (they will have to buy-in to your program)  THOSE are absolutely  patients with whom we should work.

Books to Read-Drugs and Dysphagia

drugs and dysphagia

What a great reference for any medical Speech Pathologist.  This book talks about the medications that can affect the swallowing process and how they affect swallowing.  The nice part is that it is also a small, pocket-sized book making it easy to carry around with you as you work with patients.

Drugs and Dysphagia:  How Medications Can Affect Eating and Swallowing by Lynette Carl and Peter Johnson.

Supraglottic and Super-Supraglottic Swallows and Tongue Pressure-Research Review

keep-calm-and-hold-your-breath-67

Fujiwara, S, Ono, T, Minagi, Y, Fujiu-Kurachi, M, Hori, K, Maeda, Y, Boroumand, S, Nitschke, I, Ursula, V, Bohlender, J.  Effect of Supraglottic and Super-supraglottic swallows on Tongue Pressure Production against Hard Palate.  Dysphagia (2014) 29:655-662.  

The Super- and Supraglottic Swallows are maneuvers used to assist in early airway closure to prevent food or drink from being aspirated prior to the swallow.  

Participants:  19 healthy young staff members of the University of Zurich Dental School (13 females, 6 males) with an age range from 17-40.

Equipment:  Tongue pressure measurements were recorded using the Swallow Scan System using a pressure sensor that forms a “T” shape following the curve of the palate.  Participants were seated upright with their heads immobilized by  a head rest.  

Procedure:  This study looked at normal swallow, Supraglottic Swallow (ss) and Super-Supraglottic Swallow (sss).   Each participant swallowed 5 ml of water at room temperature.  For the SS, a syringe was used to inject 5 ml of water into the floor of the oral cavity with the instructions “breathe through your nose, then hold your breath lightly before and during swallowing.  Cough immediately after you finish swallowing.”  For the SSS the same procedure and instructions were given, plus the additional instruction to put the palms of their hands together in front of their chest and press them hard against each other while they held their breath.

Results:  The perimeters measured  were:  duration, maximal magnitude and integrated value of tongue pressure during swallowing.  “The duration of tongue pressure was significantly longer at the anterior-median part of the hard palate during both SS and SSS than with normal wet swallow.  The maximal magnitude increased significantly only at the posterior part of the hard palate during SS, but at all points during SSS.”  Not only do the SS and SSS increase protection of the airway prior to the swallow, they may also function to strengthen the tongue.  

Variations in Tongue-Palate Pressures with Xantham Gum Thickened Liquids-Research Overview

Steele, CM, Molfenter, SM, Peladeau-Pigeon, M, Polacco, RC, Yee, C.  Variations in Tongue-Palate Swallowing Pressures When Swallowing Xantham Gum-Thickened Liquids.  Dysphagia (2014) 29:678-684.

“Thickened liquids are frequently recommended to reduce the risk of aspiration in patients with oropharyngeal dysphagia.”  We know that tongue-palate pressures increase with thicker liquids, however little is known about the differences in swallowing pressures with nectar and honey thick liquids.

“Liquid boluses are initially held in a chamber along the midline groove of the tongue.  The tongue moves upwards and forwards, compressing a bolus against the palate and squeezing it backwards in a conveyer-belt like fashion.  As the bolus reaches the pharynx, the tongue withdraws from the palate, and sweeps downwards and backwards.” 

Participants:  78 healthy adults.  40 (19 men and 21 women) with a mean age of 27 and 38 (22 women and 16 men) with a mean age of 70.  No participants had a history of swallow, motor speech, gastro-esophageal or neurological difficulties.  

Equipment:  Lingual pressures were measured using the lingual manometry module of the KayPentax Swallowing Signals Lab.  Using a soft silicone strip with three pressure bulbs were placed in the palate and measurements were registered at the anterior, mid and posterior hard palate.  Participants took blocks of 4 repeated sips using flavored (lime, raspberry, diet raspberry or cranberry) water, nectar thick and honey thick liquids.  Sip size was not controlled and cups contained 60 ml of liquid.  The cup was instructed to be removed from the lips following each sip.  The xantham thickener was supplied by Flavour Creations, Inc.  

Results:  Healthy adults do recruit higher tongue-palate pressure amplitudes with nectar and honey thick liquids using xantham gum as compared to water.  The authors warn that “although thicker liquids elicit higher amplitudes of tongue-palate pressure compared to water, the observed values should still be easily achieved by most adults, falling below 40% of maximum isometric pressure values.”  It is also important to remember that although thickened liquids require higher tongue pressures to propel, caution is needed when selecting thickened liquids for patients with reduced tongue strength and that viscosity may become too thick to be effective for oral processing.

The authors also warn that there are limitations to the findings including:

  1. That the sweetness of the flavoring may have contributed to the observed pressure differences compared to the water.
  2. Sip volume was not controlled and the influence of the sip size on tongue pressures is unknown.
  3. Participants with dentures had to remove their top plates to avoid damage from glue from the sensors.
  4. Different thickening agents may encourage different results.

Tongue

I think this area will take an interesting turn with the amount of people getting their tongues pierced.  What are your thoughts?