Evaluation Of Deglutition

Dra. Myrian Adriana Pérez García

• Venezuelan Otorhinolaringologist• Former coordinator of the laryngology, fonation and swallowing unit of

Children´s Hospital “J.M de los Ríos”• Former Specialist of Instituto de Otorrinolaringología de Caracas• Chair of the UNILAR Unidad Laringológica del Este (Estern

Laryngological Unit). Caracas - Venezuela• Autor of the Book:

– MANUAL DE DISFAGIA PEDIÁTRICA• Professor of the Diplomado Teórico-Práctico de Laringología Básica

Dr. Myrian Adriana Pérez Dr. Myrian Adriana Pérez GarcíaGarcía

BARCELONA, SPAIN. JULY: 2nd-6th

Evaluation of Deglutition in in ChildrenChildren

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ContentsContentsContentsContents

• Suction-swallowing and breathing process maturation (Anatomy/physiology).

• Otorhinolaryngologist evaluation of deglutition (functional endoscopic evaluation of swallowing).

• Pediatric Laryngopharyngeal reflux (It´s relationship with dysphagia).

• Swallowing disorders: Diagnose and Management.

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DysphagiaDysphagiaDysphagiaDysphagia

• Difficulty:

• Sucking-Swallowing-feeding

• Motor-Sensitive

• Safety-Efficiency

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BackgroundBackgroundBackgroundBackground

• Poor Epidemiological data: incidence/prevalence.

• Relatively common in early infancy

• 35% infants presents food selectivity

• 80% Neurological diseases presents dysphagia (Cerebral palsy).

• 90% Associated with malnutrition.

• 80% Oral and pharyngeal phase altered.

• 78% Pediatric Laryngopharyngeal reflux it´s related to dysphagia.

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Anatomy and PhysiologyAnatomy and Physiology

Suction-swallowing and breathing process maturation

Suction-swallowing and breathing process maturation

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Suction-swallowing and breathing process maturationSuction-swallowing and breathing process maturationSuction-swallowing and breathing process maturationSuction-swallowing and breathing process maturation

• Critical and Sensitive Periods

• Prenatal

• Postnatal:

• Preterm

• Full-term

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PrenatalPrenatalPrenatalPrenatal

• Swallowing 10th-12nd w

• Sucking 18th- 24th w

• Sucking reflex 28th w

• Rooting reflex 32nd w

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PrenatalPrenatalPrenatalPrenatal

• Patterns: Reticular formation and brain cortex area

• Respiratory pause-swallowing-respiratory pause(32nd)

• Inspiration-swallowing-expiration(36th)

• Nutrition totally orally(34th-37th)

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PostnatalPostnatalPostnatalPostnatal

• Anatomically/Functionally

• Preterm

• Full-term

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PRETERM

1. Cannot coordinate suction-swallowing and breathing

2. Immature sucking3. Poor negative pressure4. Pharyngeal phase not well

coordinated.

FULL-TERM

1. Coordinate suction-swallowing and breathing

2. Food-seeking behavior: rooting3. Effective sucking4. Normal pharyngeal phase

coordination

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PostnatalPostnatal

PostnatalPostnatalPostnatalPostnatal

• FULL-TERM

• 1st-3rd mo

• 4th-6th mo (transitional)

• 6th-7th mo (developmental)

• 10th-12nd mo

• -36th mo

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11stst - 3 - 3rdrd mo mo11stst - 3 - 3rdrd mo mo

• Excitatory reflex

• Rooting reflex

• Sucking reflex (pump-like reflex)

• Normal rate:

• Suck/Swallow 1:1 - 3:1

• Liquids and solids equal

• Gag reflex

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44thth / 6 / 6thth mo - 9 mo - 9thth (Transitional) (Transitional)44thth / 6 / 6thth mo - 9 mo - 9thth (Transitional) (Transitional)

• Preparatory and oral phase

• No excitatory lower lip reflex

• No rooting reflex

• Posterior gag reflex

• Preparatory and oral phase

• Solid food- posterior tongue positioning

• 5th months, small bites

• Spoon feeding initiation: some developmental skills

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44thth / 6 / 6thth mo - 9 mo - 9thth (Transitional) (Transitional)44thth / 6 / 6thth mo - 9 mo - 9thth (Transitional) (Transitional)

• Rithmic bites

• Spoon feeding for thin, smooth puree

• Upright position

• Both hands to hold bottle

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99thth - 18 - 18thth mo (Developmental) mo (Developmental) 99thth - 18 - 18thth mo (Developmental) mo (Developmental)

• Precise picking small pieces of food

• Pincer grasp

• Cup drinking

• Finger feeding

• Teeth

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Normal SwallowNormal Swallow Normal SwallowNormal Swallow

• Oral Preparatory Phase

• Oral Phase

• Pharyngeal Phase

• Esophageal Phase

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• Craneal Nerve: IX, X, XI

• Swallow center: pons

• 5 events:

• Velarpharyngeal sphincter

• Pharyngeal muscle

• Hyoid bone

• Vocal fold

• UEE

Functional Endoscopic Evaluation of Functional Endoscopic Evaluation of SwallowingSwallowing

Otorhinolaryngologist Evaluation of deglutition

Otorhinolaryngologist Evaluation of deglutition

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Feeding GoalsFeeding Goals Feeding GoalsFeeding Goals

• Preserve and guarantee Preserve and guarantee

• Good nutrition/ hydration statusGood nutrition/ hydration status

• Safety and efficiencySafety and efficiency

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Clinical Feeding EvaluationClinical Feeding Evaluation Clinical Feeding EvaluationClinical Feeding Evaluation

• History: Prenatal, Postnatal

• Physical Examination

• Non-instrumental/Instrumental

• Feeding Observation

• Non-instrumental/Instrumental

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• History:

• Description of child´s mealtimes:

• Food types

• Frequency

• Duration

• Respiratory system

• Weight

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• History:

• Alert!:

• Feeding time more than 30-40 min

• Respiratory Distress

• Not gaining weight (2-3 m)

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• Physical Examination:

• Baseline health

• Medical status

• Non-instrumental

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• Physical Examination:

• Instrumental:

• Anatomical abnormalities

• Pooling secretions

• Vocal folds

• Safety

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• Non-instrumental:

• Feeding position

• Sucking reflex

• Rooting

• Mouth/lips closure

• Jaw Movements

• Spliting

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• Non-instrumental:

• Feeding position

• Sucking reflex

• Rooting

• Mouth/lips closure

• Jaw Movements

• Spliting

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• Instrumental


• Instrumental

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• Instrumental


• Instrumental

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• Instrumental:

• FEES (FEEST)

• VFES


• Instrumental:

• FEES (FEEST)

• VFES

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• FEES Protocol:

• NB- 4mo: Bottle, water, milk

• 4 - 6mo: Bottle, water, juice, apple sauce, condensed milk, spoon.

• 6mo- 1y: + yoghurt, small cup, jelly, cake.

• 1y - older: + straw, , worst meal

• FEES Protocol:

• NB- 4mo: Bottle, water, milk

• 4 - 6mo: Bottle, water, juice, apple sauce, condensed milk, spoon.

• 6mo- 1y: + yoghurt, small cup, jelly, cake.

• 1y - older: + straw, , worst meal

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And DysphagiaAnd Dysphagia

Pediatric Laryngopharyngeal RefluxPediatric Laryngopharyngeal Reflux

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Pediatric LPRPediatric LPR Pediatric LPRPediatric LPR

Laryngopharyngeal Reflux (LPR)

• UES Dysfunction

• Backflow to the larynx

• Esophagus clearance normal

• Respiratory symptoms

• Cough and hoarseness

• Regurgitation

• Dysphagia

Gastroesophageal Reflux (GERD)

• LES Dysfunction

• Backflow to esophagus

• Esophagus clearance altered

• GI symptoms

• Heartburn

• Regurgitation

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Pediatric LPR and DysphagiaPediatric LPR and Dysphagia Pediatric LPR and DysphagiaPediatric LPR and Dysphagia

Laryngopharyngeal Reflux (LPR) • Endoscopic findings:

• Belafsky Scale:

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Subglottic edema(pseudopsulcus)

Ventricular Obliteration ArytenoidErythema/Hyperemia

Vocal fold edema



• Endoscopic findings:

• Belafsky Scale:

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Laryngeal Edema Posterior comissure hypertrophy

Granuloma /Granulation tissue

Laryngeal mucus

• Results:

• < 7 (no reflux)

• 7-11 (mild reflux)

• > 11 (severe reflux)




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Laryngomalacia Regurgitation




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Physiopathology

• Sensitive:

• Hyposensivity: Laryngeal Adductor Reflex

• Hypersensivity: Oral

• Motor: LES low pressure

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• Air pulse- Arytenoids

• Normal response: 2-4mmHg

• Reflex:

• Vocal fold closure

• Swallowing

• Cough

Pediatric LPR and DysphagiaPediatric LPR and Dysphagia Pediatric LPR and DysphagiaPediatric LPR and DysphagiaPhysiopathology

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LPR

Regurgitation

Acid/PepsinAnd/or

Oral and Pharyngeal erythema

Laryngeal edema

Altered Sensitivity

Oral

Larynx

Vomiting

Adductor reflexMicroaspiration

DysphagiaDysphagia


Diagnosis

• Esophageal Manometry

• 24 pH double probe

• Esophagoscopy

• Fiberoptic nasopharyngolaryngoscopy

• Videofluoroscopy

• Fibro endoscopic evaluation of swallowing

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Management

• Upright position

• 2 hours after meal

• Avoid citric, lactose products

• Small Frequent meals

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• Pump-bomb Inhibitors

• Prokinetics

• H2 antagonists

Diagnose and ManagementDiagnose and Management

Swallowing DisordersSwallowing Disorders

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DysphagiaDysphagia DysphagiaDysphagia

Interdisciplinary team approach

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•OtorhinolarygologistOtorhinolarygologist•Speech PathologistSpeech Pathologist•NutritionistNutritionist•GastroenterologistGastroenterologist•Pediatric surgeonPediatric surgeon•PediatricianPediatrician•NeumologistNeumologist•NeurologistNeurologist

(1)Padovani AR, Moraes DP, Mangili LD, Andrade CRF. Procolo fonoaudiológico de avaiaciao do risco para disfagia (PARD).Rev Soc Bras Fonoaudiol.2007;12(3):199-205


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•Primary problem areasPrimary problem areas•Severity of swallowing disorder Severity of swallowing disorder •Saliva poolingSaliva pooling•Other diseases (LPR, pulmonary infection)Other diseases (LPR, pulmonary infection)•Nutritional/Hydration statusNutritional/Hydration status•Actual SkillsActual Skills


Diagnosis


Severity Swallowing Disorder

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PhonoaudiologicalPhonoaudiological Protocol for dysphagia risk evaluation (PARD) (1).Severity levels: 7Consistencies, strategies/time/cough→ ManagementLevel I: Normal DeglutitionLevel II: Functional DeglutitionLevel III: Mild Oropharyngeal dysphagiaLevel IV: Mild to moderate Oropharyngeal dysphagia



Diagnosis

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PhonoaudiologicalPhonoaudiological Protocol for dysphagia risk evaluation (PARD) (1).Severity levels: 7Consistencies, strategies/time/cough→ ManagementLevel V: moderate Oropharyngeal dysphagiaLevel VI: moderate to severe Oropharyngeal dysphagiaLevel VII: severe Oropharyngeal dysphagia




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Level I: Normal DeglutitionLevel II: Functional Deglutition

More timeLevel III: Mild Oropharyngeal dysphagia

Diet changes, may need some therapyLevel IV: Mild to moderate Oropharyngeal dysphagia

One (1) consistency restriction. Therapy for avoiding aspiration risk.Need nutritional suplement




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Level V: Moderate Oropharyngeal dysphagiaOral and feeding tube. Therapy. Restriction two (2) consistencies

Level VI and VII: Moderate to severe Oropharyngeal dysphagiaNon-oral feeding



Non-surgical management

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•Posture-positioning changes•Volume, consistency, texture, temperature bolus changes•Non-nutritive program•Nutritive program•Botulinum toxin if needed



Surgical management

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•Nasogastric feeding tube•Gastrostomy tube•Surgical management of salivary glands•Vocal fold medialization•Cricopharyngeal miotomy•Tracheostomy•Laryngopharyngeal Division


ConclusionsConclusions ConclusionsConclusions

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•Emphasis in whole infant status (safety, comfort, pleasure).

•Oral feeding is not always the “GOAL”.

•Real Goals : Pulmonary stability and Nutritional well-being

•If we diagnose LPR we must give treatment for it!

•Close follow up to make changes when needed


Thank youThank youwww.unilar.com.ve

Evaluation Of Deglutition

Health & Medicine

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