Dysphagia and Nasal Regurgitation: Effective Treatment Options

Dysphagia and Nasal Regurgitation Treatments LUCIA DALL’ORSO

What is Dysphagia?  Dysphagia is described as the difficulty in swallowing effectively and safely.  While some individuals with dysphagia struggle to swallow specific foods or drinks, others are completely unable to do so.  Some examples that may cause dysphagia include: stroke, head injuries, down syndrome and certain cancers  Dysphagia may lead to other issues like aspiration, malnutrition and dehydration

Dysphagia is not Dysphasia The Greek prefix dis- signifies that there is difficulty with something The suffix –phagia implies eating The suffix –phasia (from –phatos in Greek) implies speaking

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Normal Swallowing Stages  Oral Preparatory Stage  This stage is where the food is food is chewed then collected to form the bolus  Oral Stage  The next step will be is for the bolus to move the back of the mouth (or the base of the tongue)  Pharyngeal Stage  This step is when the bolus will move down the throat toward to where the esophagus begins  Esophageal Stage  The final stage is where the bolus enters the esophagus  The muscles around the esophagus contracts, which pushes the bolus further down to the stomach

Different types of Dysphagia  Oropharyngeal Dysphagia  Takes place when it becomes challenging to transfer the bolus from the oral cavity to the esophagus  Esophageal Dysphagia  experiences difficulty when food and/or liquids moves through the esophagus.  Esophagogastric Dysphagia  results when a barrier (either physical or motor) prevents food from passing through the lower esophageal sphincter and into the gastric fundus.  Paraoesophageal Dysphagia  happens when the esophageal wall and lumen are physically affected by or when infiltration of the esophageal wall results in obstruction.

How is it evaluated?  Endoscopy  During this examination, the client's digestive system will be viewed using an endoscope, a small, flexible tube connected to a camera and light at one end.  Barium swallow series  The client has to take modest doses of barium to do this assessment. Barium is a metallic substance that coats internal organs easily and has a powdery texture, which allow clinicians take clearer X-rays.  Laryngoscopy  After giving the individual an anesthetic, a small tube is inserted down their throat to check for any laryngeal or throat issues.

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Nasal Regurgitation SOMETIMES WHEN FOOD OR LIQUID IS SWALLOWED, IT MAY TRAVEL BACKWARDS INTO THE NOSE, CAUSING NASAL REGURGITATION. THIS OCCURS WHEN THE NASOPHARYNX DOES NOT CLOSE PROPERLY, AND IT COULD BE AN INDICATION OF AN ISSUE WITH THE NERVES THAT CONTROL THE MUSCLES OF THE SOFT PALATE OR THROAT.

Different treatments/approaches for nasal regurgitation Treatments  Small bites and sips  Thinner consistencies  Masako maneuver  Mendelsohn maneuver  Monkey EEE  Shaker exercise  Chin tuck against resistance Technology  With the help of a wearable machine, clients can perform exercises at home and share their results with a doctor electronically  https://www.youtube.com/watch? v=IPY-ytpkGck

Treatment I want to focus on & evidence  Chosen Treatments:  Mendelsohn maneuver  Monkey EEE

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Candidacy  Individuals 12 years and older with no cognitive impairments  Individuals with dysfunction in the pharyngeal stage  Language ability to follow directions  Individuals with no memory impairments

Pharyngeal Exercises for nasal regurgitation  Mendelsohn maneuver: It consists of performing a prolonged laryngeal elevation voluntarily. To carry out this maneuver, the patient must try to keep the larynx elevated and tongue tip against front teeth when swallowing, causing a contraction of the anterior neck muscles for several seconds. This movement can be assisted manually by placing the fingers on the thyroid cartilage, and keeping the larynx elevated, accompanying the swallowing movement of the patient. Hold it for 1-3 seconds. Repeat 10 times.  Monkey EEE: (effortful pitch glide) the client must say “eee” in normal voice and continue as quickly glide up to the highest pitch possible. Then he must continue saying “eee” applying force to make a strong “eee” sound. Take a breath. Repeat 10 times.

Evidence  Title: Combined Effects of NMES and Mendelsohn Maneuver on the Swallowing Function and Swallowing–Quality of Life of Patients with Stroke-Induced Sub-Acute Swallowing Disorders  “The Mendelsohn maneuver, which focuses on submandibular hyolaryngeal muscles, has been used in clinical practice to effectively improve the function of muscles associated with laryngeal elevation.”  “It has been reported that it is effective in recovering the swallowing of patients with swallowing disorders in the pharyngeal stage. “

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Sample  Santiago is a 12 years-old boy, with no nasal regurgitation and no additional impairments.  His diagnostic is nasal regurgitation  Dysfunction in the pharyngeal stage leads to impaired swallowing initiation, feeling of retention of bolus in pharynx. Impairment in pharyngeal stage may result in nasal regurgitation and aspiration (due to insufficient UES opening).

Objectives & Activity  Objective  Long term: Santiago will strength the pharyngeal phase initiation to improve swallowing.  Short term: He will also swallow without nasal regurgitation in 8/10 of the trials for 5 consecutive therapy sessions.  Activity  Santiago will do the Mendelsohn maneuver during three weekly sessions for 15 minutes.  He will also practice Monkey EEE technique during three weekly sessions for 10 minutes.  NOTE: he must master both techniques to practice them at home

Data Collection

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References  Byeon, Haewon. “Combined Effects of NMES and Mendelsohn Maneuver on the Swallowing Function and Swallowing–Quality of Life of Patients with Stroke-Induced Sub-Acute Swallowing Disorders.” MDPI. Multidisciplinary Digital Publishing Institute, January 12, 2020. https://www.mdpi.com/2227-9059/8/1/12.  Doeltgen, S.H., Ong, E., Scholten, I.M., Cock, C., & Omari, T.I. (2017). Biomechanical Quantification of Mendelsohn Maneuver and Effortful Swallowing on Pharyngoesophageal Function. Otolaryngology–Head and Neck Surgery, 157, 816 - 823.  Dysphagia (ear, nose & throat) . Dysphagia (Ear, Nose & Throat) | Michigan Medicine. (n.d.). Retrieved March 31, 2023, from https://www.uofmhealth.org/conditions-treatments/ear-nose-throat/dysphagia#:~:text=Dysphagia %20is%20the%20medical%20term,your%20mouth%20to%20your%20stomach.  “Dysphagia (Swallowing Problems).” NHS inform. Accessed March 31, 2023. https://www.nhsinform.scot/illnesses-and-conditions/stomach-liver-and-gastrointestinal-tract/dysphagia- swallowing-problems#:~:text=Dysphagia%20is%20the%20medical%20term,up%2C%20sometimes %20through%20the%20nose.  Service, Purdue News. “Millions with Swallowing Problems Could Be Helped through New Wearable Device.” Purdue University News, December 17, 2019. https://www.purdue.edu/newsroom/releases/2019/Q4/millions- with-swallowing-problems-could-be-helped-through-new-wearable-device.html.  Wolf DC. Dysphagia. In: Walker HK, Hall WD, Hurst JW, editors. Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd edition. Boston: Butterworths; 1990. Chapter 82. Available from: https://www.ncbi.nlm.nih.gov/books/NBK408/

Dysphagia

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