A Brief but comprehensive presentation about Dysphagia in pseudobulbar palsy

1. PHINOJ K ABRAHAM
IInd MOTh Student
All India Institute of Physical Medicine & Rehabilitation,
(AIIPM&R) Mumbai

2. 
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
2

3. 
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.
3

4. 
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.
4

5. 
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.
5

6. 
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

Prognosis
◦ Poor nutrition
◦ Psychological dysfunction
◦ Progression of underlying disease
◦ This depends on the underlying cause.
6

7. 


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)
7

8. Tongue
8

9. 9

10. 
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)
10

11. 
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
11

12. 




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
12

13. 
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.
13

14. 
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.
14

15. 


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
15

16. 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

17. FLUROSCOPIC IMAGING OF NORMAL SWALLOWING
17

18. 
1.
2.
3.
4.
5.
6.
7.
8.
The most important images of the swallowing study are those
taken of the lateral view.
The base of the tongue and the soft palate close the oral
cavity posteriorly (arrow) to prevent spill of food into the
open larynx.
Hyoid bone and base of the tongue move in a cranial
direction and lift the larynx (arrow).
Soft palate elevates to prevent spill into the nasopharynx
(thin arrow) and the larynx closes by contraction of the
aryepiglottic folds (broad arrow)
Contraction of the upper pharyngeal constrictor (arrow)
Contraction of the middle pharyngeal constrictor (arrow)
Contraction of the lower pharyngeal constrictor and
relaxation of the cricopharyngeal muscle (arrow)
Epiglottis elevates to regain its resting position and the
larynx opens.
Epiglottis in resting position and larynx is open (arrow).

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19. 
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
19

20. 20

21. 
There are three types of swallowing disorder, divided on
the basis of where the problem is occurring:
◦ Oral Dysphagia
◦ Pharyngeal Dysphagia
◦ Esophageal Dysphagia
Oral or pharyngeal 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
Esophageal dysphagia
•
•
•
•
•
•
•
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

22. 
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.
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23. 

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
23

24. 
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.
24

25. 
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)
25

26. 
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
26

27. 27

28. 1.
2.
3.
4.
5.
6.
7.
8.
Notice that contrast enters the pharynx, but does not
trigger a swallowing reflex.
No swallowing reflex
Contrast reaches the hypopharynx, but still no
swallowing reflex.
Contrast enters the larynx, which is still open and not
yet elevated
At this moment the swallowing reflex starts and the
larynx elevates
Contrast is transported to the esophagus and the larynx
closes, but there is already contrast in the trachea.
Proper relaxation of the cricopharyngeus and finally
there is good closure of the larynx.
Notice that there is no stasis at the end of the swallow .
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29. CLINICAL EVALUATION
29

30. 
Dysphagia treatment rests on 5 principles
1.
2.
3.
4.
Amelioration of the underlying disease process
Prevention of complications
Improvement of swallowing via therapy
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

31. 
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
31

32. 
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.
32

33. 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

34. 
It involve the use of
oral, pharyngeal, laryngeal, and respiratory
exercises to improve flexibility, strength and coordination.
◦ 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
34

35. Common indirect therapy techniques
Therapy technique
Description
ORAL CAVITY
Oral 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
PHARYNX
Laryngeal 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
OPENING
Shaker exs
Active head rising (neck flexion) in the
supine position
Upper esophageal sphincter
dialatation
Expansion of balloon catheter in the upper
35
esophageal sphincter

36. 




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.
36

37. ◦ 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.
37

38. 
Psychological factors

Environmental factors

Hygienic considerations
38

39. 39