Pediatric Dysphagia—Medical Terminology and Abbreviations PDF

Pediatric Dysphagia—Medical Terminology and Abbreviations  Ankyloglossia = tight or shortened lingual frenum (“tongue tied”)  Anoxia = lack of oxygen  Anterior = in front of a part; further forward in position; more ventral  Apnea = temporary cessation of breathing  Asp...

Pediatric Dysphagia—Medical Terminology and Abbreviations  Ankyloglossia = tight or shortened lingual frenum (“tongue tied”)  Anoxia = lack of oxygen  Anterior = in front of a part; further forward in position; more ventral  Apnea = temporary cessation of breathing  Aspiration = foreign substances entering the respiratory tract  Aversion = intense dislike, avoidance, and refusal of something  Bradycardia = low heart rate  Bolus = food bolus — round mass of food formed in the mouth in preparation for swallowing  Bolus = enteral bolus — a set amount of formula given at one time (typically meaning via tube feedings)  Buccal = referring to cheeks  Bruxism = teeth grinding or jaw clenching  D/C = discharge; also commonly meaning “stop using”  Deglutition = act of swallowing  Distal = further away from the point of reference or origin; away from midline  Dysphagia = disordered swallowing, difficulty in swallowing  Dx = diagnosis  Enteral = intake via digestive tract, specifically intestine (generally referred to when nutrition is given other than via mouth)  Extrinsic = outside the body part or organ  GA = gestational age  Glossoptosis = posterior or inferior displacement of tongue  Gustatory = relating to the sense of taste  Hx = history  Hypoplasia = incomplete development of a structure  Intrinsic = within the body part  Intubation = insertion of a breathing tube into trachea; tube is connected to a respirator  Labial = referring to lips  Lateral = to the side, away from midline  Lingual = referring to tongue  Mandibular = referring to jaw  Medial = towards midline on the body  NPO = nothing by mouth, (Latin meaning “nil per os”)  PO = by mouth, (Latin meaning “per os”)  Paralysis = inability to move a structure; complete loss of function  Paresis = slight or incomplete paralysis; partial paralysis  Parenteral = intake other than via digestive tract (i.e. intravenous or intramuscular)  Posterior = behind a part; further back in position; more dorsal  Proximal = nearest to the point of reference; towards midline  S/S = signs and symptoms  Tachycardia = rapid heart rate  Tx = therapy or treatment or treat  WFL = within functional limits  WNL = within normal limits Possible Pediatric Dysphagia Settings  Hospital ♦ Neonatal ICU (NICU) = treating premature or ill newborn babies ♦ Pediatric ICU (PICU) = treating critically ill children from babies to teens with acute trauma, chronic illnesses, status post surgery, etc. ♦ Acute-care floors = treating stable but ill children from babies to teens, typically seen 1-2x/day, goal is to get them stable enough to leave hospital, typically continue Tx in outpatient setting ♦ Outpatient = treating acute or chronic feeding disorders in children from babies to teens on a more long-term basis (6+ months), typically 1-3x/week ♦ Specialty Clinics = evaluating and providing feeding recommendations and dysphagia Tx guidelines for their treating SLP’s for children with chronic feeding problems, patients typically clustered in groups based on Dx type (ex: Craniofacial Team, Neurodevelopmental Team, Congenital Anomalies Team, Feeding Disorders Team, etc.), followed by a team of professionals (ex: specialty physician, SLP, OT, PT, nutritionist, nursing, etc.), follow-up with patient every 4-6 months or every year depending on needs, collaborative approach with entire medical team as a way to consistently follow patient and make sure their needs are being met and they are not “falling” through the cracks  Private Outpatient Clinic = similar to outpatient hospital setting, though typically less medically fragile or medically complicated children  Home Health Agency = treating children in their homes (you travel) versus them going to an outpatient clinic, often children are medically fragile and it is not feasible for them to travel to outpatient clinics, many times it is more convenient for the families, typically see child 1-2x/week  Early Childhood Intervention (ECI) = federally-supported program throughout the nation for children birth-3 years who show signs of developmental delay (including feeding difficulties), children must qualify based on level of delay/disorder, therapist travels to child (home, daycare, etc.), is based on a family-friendly model (communication is always written and delivered in non-medical terms and with full family goals in mind), depending on the agency (broken apart by areas of the city) you would see the child 1-4x/month  Pediatric Dysphagia—Functional Anatomy and Physiology of the Oral Phase of the Swallow * ORAL PHASE IS VOLUNTARY * A. Basic Oral Anatomy and Physiology 1. Lips---obicularis oris * Closure prevents anterior loss of bolus. * Closure aids in creating positive oral pressure during swallowing. * Infant suckling: lips flare out on nipple but are not a vital part of sucking (they do not make the anterior seal during suckling). * Older children and adult sucking: lips contract on straw/spout to form anterior seal (for negative pressure buildup). 2. Jaw---mandible, and associated muscles for opening/closure * Growth: Infants—jaw proportionally small→ so tongue fills oral cavity leaving very little room for bolus manipulation Children 1+ years—facial growth causes jaw to grow forward→ carries tongue forward (sits in oral floor) and enlarges oral cavity, leaving room for bolus manipulation * Suckling: Jaw elevates and depresses during suckling. * Mastication: Jaw elevates, depresses, and moves diagonally to grind food during chewing (patterns develop and mature as child grows). * Adequate strength and stability allows for jaw grading = ability to move jaw from one height to another smoothly and with control (as in opening a slight amount for spoon vs. full opening, depressing jaw just enough during chewing vs. full opening). Pediatric Dysphagia---Oral Phase 1 3. Cheeks---buccinator muscle * Infants: sucking pads provide structure/stability to prevent buccal pocketing; aide in creating positive pressure on nipple. * Older children: muscle tension/tone provide structure. * Overall: tension of cheeks (when activated) helps increase the pressure in the oral cavity and aids in the pressure system of swallowing (once swallow initiated) * Buccal contraction: results in shortening of buccal muscles (shortening of cheeks) and “drawing in” of cheeks. This decreases the size of the oral cavity and therefore increases the positive pressure for bolus propulsion. 4. Hard Palate * Tongue contacts hard palate to form anterior oral seal. * Slightly elevated contour of palate aides in moving bolus posteriorly. * Shape of hard palate (rounded, concave) is formed during embryological development by the tongue resting against the roof of the mouth…shape of hard palate and tongue contacting that shape aids in bolus propulsion 5. Soft Palate or Velum * Elevates to close off nasal cavity when swallow reflex is triggered. * Thus creating a seal between velum and posterior pharyngeal wall. * Infants only (until ~6-9 mos): Contacts epiglottis to form a posterior oral seal during sucking ( = airway protection) and allows nasal breathing during sucking. Pediatric Dysphagia---Oral Phase 2 6. Tongue (Lingual)--Intrinsic muscles (4) and extrinsic muscles (4) * “Oral tongue” = refers to portion of tongue directly in oral cavity. * “Posterior oral tongue” = refers to posterior 1/3 portion of tongue in oral cavity. * “Base of tongue” = refers to portion of tongue in pharynx (think of the ladder section of the slide). * “Lingual apex” = refers to the tip of the tongue *Anterior oral seal during swallow: tongue tip & lateral borders against hard palate during swallow initiation creates seal and +pressure. * Posterior portion of tongue remains slightly elevated during oral bolus manipulation to prevent bolus from leaving oral cavity before swallow is triggered. *Infants: Tongue fills entire oral cavity b/c oral cavity is small proportionally * Infant suckling: Anterior to posterior movement as well as slight depression creates negative pressure. Elevation causes compression on nipple to create positive pressure. * Older children and adult sucking: Lingual retraction creates negative pressure (as long as lips sealed around straw/spout). * Mastication: - Tongue lateralization transfers bolus to teeth for chewing. - Lateral portion of tongue and buccal tension keep food on teeth during chewing. - Helps mix saliva with food to form a cohesive bolus. * Tongue muscles: Extrinsic—provide stability of base of tongue and posterior oral tongue to allow intrinsic tongue muscles to move freely. Intrinsic—allow oral tongue to be “free” to manipulate bolus, fine motor control of bolus…but ONLY if stabilized by extrinsic tongue muscles. * Preparation for swallowing: - Intrinsic muscles contract to create a concave “trough”---lateral borders of tongue are elevated to contact hard palate. - Anterior portion of tongue elevates and posterior portion depresses and retracts to allow the bolus to be propelled posteriorly. (Think of a playground slide.) - Swallow reflex is triggered by proprioceptive receptors scattered over the oropharynx (anterior faucial pillars, uvula, posterior pharyngeal wall, etc.). Pediatric Dysphagia---Oral Phase 3 B. Pediatric Anatomy vs. Adult Pedi/Infant Oral Anatomy Functional Difference Proportionally larger head relative to Infants are unable to hold their heads up body size. independently and require the adult to position the Weak head and neck muscles. head correctly during feeding. Shortened neck 2’to “heavy head” Short neck helps infant maintain head position 2’to heaviness (think of a growing tree and trunk) *Start to see functional changes in swallowing b/c of neck growth 12 mos. Decreased muscle tone in general. Rely somewhat on fat stores to supplement muscle tone to add stability to structures. Sucking pads present in cheeks. Decrease the size of the oral cavity. Provide structure and stability to cheeks. (Adults use muscle tone and contraction.) Disappear by 4-6 months. Soft palate and epiglottis contact each Causes infants to be obligate nose breathers. other at rest. Provides additional airway protection by sealing off oral cavity. *Start to see slow separation ~6-9 mos Tongue is larger in relation to oral Decreases the size of the oral cavity. cavity. Oral cavity is filled by the oral tongue. Jaw is smaller in relation to oral cavity. Tongue moves in anterioposterior Facilitates efficiency of suckle. direction only No ability to move tongue or body across midline (2’to underdeveloped corpus callosum)...not a problem b/c no need to move a liquid bolus laterally) (no extra room in mouth for bolus manipulation anyway!). *Start to see tongue/body movement across midline ~6-9 mos. This is also when infants are introduced to early solid/chewable foods (around 9 mo). Pediatric Dysphagia---Oral Phase 4  Pediatric Dysphagia—Functional Anatomy and Physiology of the Pharyngeal Phase of the Swallow * PHARYNGEAL PHASE IS INVOLUNTARY * * During swallowing, valves close off to prevent food from entering the nose (velum contacts posterior pharyngeal constrictors) and airway (vocal cords close and larynx elevates and moves anteriorly). * Timing and speed of muscle movement during swallow is more important than strength. * Significant anatomical and physiological changes occur from infancy through ~5 yrs of age. A. Basic Pharyngeal Anatomy and Physiology in Pediatrics 1. Swallow Reflex Initiation * Infants (birth to 6-12 mos): swallow triggered at vallecula * Infants and older children: sensory info. sent from upper pharynx and vallecular areas to brain (medulla) to initiate swallow. * Children 5+: sensory info. sent from back of mouth (primarily anterior faucial pillars) and opening to pharynx. * Once reflex is triggered, remaining swallow is involuntary. *CHANGES with age: - Facial growth enlarges oral cavity (very rapidly birth to 6 mo, continues through 12 mos) → Increased oral cavity allows tongue to carry forward → Now room to manipulate bolus AND space to “hold” bolus prior to swallow → At same time, swallow starts to be triggered more anteriorly (in oropharynx) similar to adults SWALLOW TRIGGERED near oropharynx (vs valleculae) around 6-12 mos * Purees: swallow trigger at anterior faucial pillars & oropharynx (like adults) Pediatric Dysphagia---Pharyngeal Phase 1 2. Base of Tongue (or Pharyngeal Tongue) * Retracts towards posterior pharynx to make contact with pharyngeal constrictors to “squeeze” bolus down. * With muscles of adequate strength, there is firm and tight contact. * When muscles are weak or there is poor BOT retraction, contact to pharyngeal wall may be reduced or absent → leads to material left in pharynx b/c it wasn’t “squeezed” down. Pediatric Dysphagia---Pharyngeal Phase 2 3. Pharyngeal Constrictors * Lateral and posterior pharyngeal constrictors: Made up of the superior, medial, and inferior pharyngeal constrictor muscles. * Muscles contract in a peristaltic wave to propel bolus downward. * Posterior pharyngeal wall contracts to meet the base of tongue to squeeze bolus downward. * The top-down squeeze of the pharyngeal constrictors and the base of tongue is also called “pharyngeal stripping.” 4. Hyoid Bone * Moves anteriorly and elevates (elevation increases after 12 mos) during activation of the swallow. Also called hyolaryngeal excursion (hyoid and larynx move). * This causes the larynx to move anteriorly and elevate as well. * This movement contributes to epiglottis retroflexion/inversion (flips down backwards). * Infants: Hyolaryngeal protraction only (hyoid and larynx only move forward, no elevation) * After 12 mos: Start to see hyolaryngeal excursion—hyoid and larynx both move anteriorly and elevate (b/c hyoid and larynx are moving away from each other with pharyngeal growth) 5. Larynx * Vocal cords adduct (close). * See “Hyoid” above for how the larynx moves (moves with the hyoid –called hyolaryngeal excursion). * Remains closed until after swallow, then a reflexive exhalation. Pediatric Dysphagia---Pharyngeal Phase 3 6. Vocal Folds (True Vocal Cords) * Glottis = space between the open vocal folds * Adduct (close) immediately once swallow initiated. * Open once bolus passes through UES, and there is an immediate reflexive exhalation. * Combination of contraction of diaphragm & vocal fold closure = upper airway stabilization for increased pressure during the swallow 7. Epiglottis * Made of elastic cartilage (NOT a muscle). * Infants: Remains in contact with velum during oral phase and at rest. * As larynx is pulled anteriorly, epiglottis inverts and partially covers airway (epiglottic retroflexion or inversion). * Epiglottis movement is passive (moved by being pulled…does NOT move independently). * Anatomical position aides in directing bolus laterally to pyriform sinuses (vs. medially towards vocal folds) for swallow. 8. Vallecula or Vallecular Space * Small reservoir formed at base of tongue and epiglottis. * Pooling of food/liquid is NOT normal. (Trace liquids may pool in the valleculae during chewing of something juicy----ex: apple). * Infants: trigger swallow at the level of the valleculae (until 6-12 mos). Pediatric Dysphagia---Pharyngeal Phase 4 9. Pyriform Sinuses * Reservoir immediately lateral to the opening of the airway and immediately above the cricopharyngeal sphincter. There are two…one on either side * “Pocket” formed by fibers running from the thyroid cartilage to cricopharyngeal sphincter. * Pooling of food/liquid is NOT normal and puts child at great risk for aspiration. 10. Cricopharyngeal Sphincter (or Upper Esophageal Sphincter--UES) * Made up partially by the inferior pharyngeal constrictor. * Partially opened by the movement of the larynx pulling on the CP muscle and causing it to stretch and open and therefore relax. 11. Esophagus and Stomach * Begins below CP sphincter. * Bolus travels down esophagus via peristalsis. * Lower esophageal sphincter (LES) is the porthole from the esophagus and stomach and is what keeps food from refluxing back up into the esophagus and pharynx. * Once food enters esophagus, it is no longer “SLP territory.” Pediatric Dysphagia---Pharyngeal Phase 5 B. Coordination of the Pharyngeal Swallow * Swallowing is not a step-by-step process. Many aspects happen simultaneously in a synchronized manner. * Breathing ceases once swallow reflex is initiated. * Upon completion of swallow, there is a reflexive exhalation (1) Bolus passes over anterior faucial pillars and other posterior oral receptors and triggers the pharyngeal swallow (triggers near the vallecula for infants). (2) Vocal folds adduct (close), closing off opening to the trachea. (3) Soft palate (velum) elevates to meet the posterior pharyngeal wall to close off nasal cavity. (4) Base of tongue retracts to meet the posterior and lateral pharyngeal constrictors to push bolus down via peristaltic wave motion. (pharyngeal stripping) (5) Larynx moves anteriorly (minimal elevation with infants), which causes the epiglottis to invert, partially covering the opening to the airway. (6) Bolus passes through pharynx. (7) Bolus passes through cricopharyngeal sphincter (opening of esophagus) initiating the Esophageal Phase of the swallow. The esophagus uses peristalsis to propel the bolus downward. (8) All structures open and return to resting position and breathing resumes after a reflexive exhalation. (9) There should be nothing coating the pharynx. All bolus materials are gone. Pediatric Dysphagia---Pharyngeal Phase 6 C. Bolus Propulsion (movement) Downward 1. Seals create positive pressure a) Anterior seal (anterior tongue against hard palate) (along with buccal contraction decreasing the size of oral cavity) --- +pressure b) Velopharyngeal --- +pressure c) Vocal fold closure --- +pressure d) Cricopharyngeal sphincter --- +pressure 2. Negative pressure (or vacuum) Hyoid and larynx moving anteriorly and elevating creates a negative space which builds negative pressure and “pulls” the bolus in that downward direction where they were positioned at rest. 3. Muscular contraction Posterior pharyngeal constrictors and base of tongue contract and meet each other in a top-bottom peristaltic wave to “push” bolus down (the pushing pressure of the muscles also creates some positive pressure). Pediatric Dysphagia---Pharyngeal Phase 7  D. Pediatric Anatomy vs. Adult Pedi./Infant Pharyngeal Anatomy Functional Difference Larynx is located more anterior and **Older child (12+ mos) & Adult: Normal pattern is higher in the neck (at C2-3 vs C5-6 in hyolaryngeal protraction & elevation. adults). (Close to base of epiglottis.) In infants