Assessment of Adults - GSHA · PDF file• speech or voice change • mouth or throat pain ... • Wet/gurgly quality. ... Communicating Positive Results from the MBSS When Is the

Dysphagia:How to Perform an MBSS That

Communicates Positive ResultsAdult and Pediatric Patients

Jennifer Jones, PhD, CCC-SLP, BCS-SBoard Certified Specialist in Swallowing and Swallowing Disorders

Communicating Positive Results from the MBSS

DisclosuresMy name is Jennifer Jones and I am here to discuss Interpreting the MBSS. I have authored a book As They Grow: Birth To Six, which is in it’s 2nd edition and sold by Talk Tools. I receive royalty when my books are sold by Talk Tools. However, I will be discussing only a minimal amount of information that is presented in that book.

I lecture nationally for Talk Tools on the topic of Interpreting the MBSS for Adults and Pediatrics. I do receive financial compensation for those lectures.

I am being compensated for my travel expenses by Talk Tools to lecture here today.

I have no other financial disclosures.


“Normal swallowing includes an integrated interdependent group of complex feeding behaviors emerging from interacting cranial nerves of the brainstem and governed by neural regulatory mechanisms in the medulla, as well as in sensorimotor and limbic cortical systems.”

(Groher, 1997)


Rationale for Performing MBSS• Identify normal & abnormal anatomy & physiology of

swallow• Evaluate integrity of airway protection before, during, and

after swallowing• Evaluate effectiveness of postures, maneuvers, bolus

modifications, and sensory enhancements at improving swallowing safety and efficiency

• Provide recommendations re: the best delivery of nutrition and hydration

• Determine appropriate therapeutic techniques for oral, pharyngeal, and/or laryngeal disorders

• Obtain info in order to collaborate with & educate other team members


How many patients “FAIL” an MBSS?

• You / Your Child will NEVER be able to eat by mouth!

• You / Your Child will ALWAYS need to drink with pudding/honey thickened liquids.

• You / Your Child can NEVER drink water!

• This is the worst swallow I have ever seen.


What is the Goal?

• TO GET THE PATIENT EATING AS QUICKLY AS POSSIBLE HOWEVER POSSIBLE

• Do not leave the exam without the answers for your patient eating!


What defines a “good clinician”?• good clinicians don’t allow their patients to “fail

the exam”

• even if the exam, history and risk factors for pulmonary illness make eating impossible, the exam should point the direction to rehabilitation

• the goal of rehabilitation should be to reestablish at least some oral intake

• The terms “pass” & “fail” should NEVER be used in the MBSS report - verbally or written


Instrumental Assessment

• First – you must be able to determine what is truly a “normal” swallow across the age span – as viewed on the instrumental assessment


Normal and “Elderly”• Presbyphagia – changes with normal aging and

swallowing• Prevalence of swallowing impairment increases with age• Delay in laryngeal vestibule closure• Longer oral and pharyngeal transit times

• Reduced isometric lingual pressures

• Longer duration of pharyngeal pressures• Higher incidences of pharyngeal residue after the swallow

due to decrease opening size of PES• Changes in the activity patterns of the suprahyoid muscles

(Robbins, Hamilton, Lof, & Kempster, 1992; Nilsson, Ekberg, Olsson, & Hindfeldt, 1996;

Miyaoka et al., 2007; Shaw, Cook & Gabb, 1995)


Normal and “Elderly”• Eat less

• Sense of smell & taste• Aguesia / Anosmia– absence of taste /smell• Hypoguesia / Hyposmia – diminished taste /

smell• Dysguesia / Dysosmia – distorted taste / smell

(1/3 of elderly report dissatisfaction with taste / smell)

• Large decrease (~1200 cal.) between 70 – 76 years old

• Eat slower


What Does the Patient Say?Subjective Complaints

• How the patient words the complaint.• Most patients are very accurate about their

problem• Duration• Frequency• Exacerbating factors• Bolus consistency issues• Solids vs. liquids

• Intermittent vs. constantCommunicating Positive Results from the MBSS

What Other Symptoms Exist?

• speech or voice change• mouth or throat pain• nasal regurgitation• mouth odor• coughing or choking • reflux• aspiration• Dysphonia• Breathy vocal quality

• weight loss• change in eating habits• sleep disturbance• pneumonia• dry mouth / saliva

changes• poor nutrition• Harsh vocal quality• Wet/gurgly quality


Positive History to Report?

The Patient:

• Can eat/swallow some consistency/texture

• Feels where the pain/discomfort is

• Is motivated to eat


What are the Game Changers?RISK FACTORS FOR ASPIRATION• GERD history, how well controlled• Hx of vomiting / pulmonary complications• Oral care – dependent? Caries? Saliva?• # of medications• Tube feeding• Weight loss• Ambulatory? Bedbound?• Dependent for feeding?


Clinical Observations• General state of health• Hydration and nutrition status

• Feeding tube (NG, Gastrostomy, Jejunostomy, or Intravenous)

• Respiratory status• Tracheostomy, ventilator, and rate

• Mental status• Attention, orientation, cooperation and

sustained attention


Instrumental Assessment• MBSS is the most frequently performed

instrumental assessment because it permits the determination of:• Underlying physiologic or anatomic

reasons for the dysphagia• Analysis of bolus flow

• Direction, duration and clearance• Bolus response to treatment trials


MBSS Procedures• Assess oral & pharyngeal/laryngeal structures &

function.• Identify oral-pharyngeal disorders and plan

intervention.• Utilize varied consistencies, utensils, and

intervention techniques. (Varibar Barium Products)• Thin, nectar, syrup, honey, pudding, cookie, pill

• The patient is initially viewed laterally then A-P • The lateral view is maintained on oral & pharyngeal

structures • May view esophagus or asymmetry in A-P view


Modified Barium Swallow Study


1 →.

2 →

← 3

← 4

5 ↓← 6

← 7

← 8

9 →

10 ↑


Phases of the Swallow Oral Preparatory Phase• Bolus preparation

Oral Phase• Transfer from mouth to

oropharynx

Pharyngeal Phase• oropharynx into upper

esophagus

Esophageal Phase• along esophagus into the

gastric cardia


Oral Phase - The SwallowNotice:

• central groove of tongue• buccal tension• overall containment of

the bolus• Glosso-palatal seal

• Important cognitive indicator


Oral Phase - The Swallow• The tongue tip is elevated to the alveolar ridge• The bolus is compressed against the hard palate


Pharyngeal Phase - The Swallow

• Elevation & retraction of the velum

• Almost always normal even with severe patients


Pharyngeal Phase• Elevation and closure of

the larynx at all three sphincters• aryepiglottic folds• false vocal folds• true vocal folds

• prevent material from entering the airway


Pharyngeal PhaseThe Pharyngeal stripping wave –

superior, middle and inferior pharyngeal constrictors


The Swallow• Relaxation of the cricopharyngeal sphincter to

allow material to pass from the pharynx through the PES into the esophagus


How do we watch an MBSS?

• Watch the bolus?

• Watch the structures?

• What are we looking for?

• How do we know to stop the study?


Before the Swallow is Initiated• Examine the anatomy for any abnormalities

• Cervical vertebrae & esophagus – are there any bulges

• Valleculae – is the epiglottis there?• Tongue base – is there a tongue?• Airway entrance, larynx, trachea• Dentition• Velum, tongue, mandible, lips, VP port, hyoid,

pharynx, PES, pyriform sinuses, PPW

• Watch for any movement disorders


As the swallow is initiatedWatch the bolus movement

• Does the bolus move consistently or hesitate?

• If so, where? How long? Count the delay.

• Where is the bolus head when the pharyngeal swallow is triggered? Count the delay.

• Does any bolus enter the airway before, during or after the swallow?


Before the Swallow• Labial closure

• Mandibular motion & mastication efficiency

• Onset of lingual bolus propulsion

• Lingual Range of motion & control during:• Elevation of bolus to palate

• Bolus seal against palate

• A-P (anterior-posterior) propulsion of the bolus

• Oral Phase Timing


During the Swallow• Tongue base retraction

• Velopharyngeal closure – soft palate

• Epiglottic Inversion

• Initiation of the Pharyngeal Swallow & bolus location relative to timing

• Pharyngeal constriction – stripping wave

• Laryngeal protection: supraglottic & glottic

• Hyolaryngeal motion – anterior excursion & elevation


During and After the Swallow• Pharyngeal Phase Timing

• Pharyngo-esophageal opening

• Coordination of pharyngeal structural movement during swallow

• Presence or absence of upper airway and/or aerodigestive tract obstruction

• Movement of bolus through upper 1/3 of esophagus and esophageal clearance


After the Swallow• Residue in the Oral Cavity

• poor oral tongue movement

• Residue in Valleculae • Reduced tongue base retraction• Unilateral pharyngeal paralysis

• Residue in Pyriform• Reduced laryngeal elevation• Reduced cricopharygneal opening (PES)• Reduced hyolaryngeal excursion

• Residue on Posterior Pharyngeal Wall (PPW)• Reduced pharyngeal wall contraction – forward and

lateralCommunicating Positive Results from the MBSS

Modify ProtocolModify for:

• Aspiration

• If it is not cleared with prompted / unprompted second swallow or spontaneous / cued cough

• Also use clinician judgment and modify protocol for other disorders that increase the risk of aspiration, such as:

• Delayed / absent triggering of the pharyngeal swallow

• Failure of the PES / UES to open

• Absent or ineffective laryngeal closure


Modification of the protocol involves:

1. Postures2. Therapeutic Strategies / Maneuvers3. Texture adjustment / thickening

(in the order given)

• Purpose: allow patients to eat with the least restrictive diet possible and the most normal posture that contributes to safe swallowing practices.


Modifications

• Patients have worse P-A scores on the first swallow of any new condition, than on other swallows within the same condition.

(Robbins et al. 1999)

• Thus, be sure to always allow the patient another swallow to show that it will or will not be a successful modification.


What You Should Know

To treat Dysphagia it is VERY important to know when the aspiration occurred and whyit occurred.

If you don’t have this information then you can NOT adequately treat the patient.


When Is the Aspiration?

1. Before

2. During

3. After


Decision Making Process

1. The first step in deciding the disorder:

SIGNS AND SYMPTOMS

These are obtained with a good:

a. history

b. clinical examination


Decision Making Process2. Now establish or hypothesize if the signs and

symptoms are related to:

• the swallowing structure (s),

• to other variables such as poor dentition, vision loss, cognitive impairment, lapses in attention, fatigue, etc.

3. If a sign or symptom seems to be related to abnormality within the swallowing anatomy

• then establish or hypothesize what structure (s) are involved.



4. Establish whether the structure itself is involved as in Zenker’s, fibrosis, tumor, surgical wound, etc.

or

• whether movement of the structures are impaired

or

• if both are occurring in combination.

5. Establish why the structure(s) or movement(s) are involved.



5. Establish why the structure(s) or movement(s) are involved.

Two possible variables:

1. movement variables: range, rate, timing

2. control variables: strength, tone, coordination


Treatment Ideas??

• Need to address the specific disorders seen in the MBSS keeping in mind the positive physiology

• Disorder 1 -

• Disorder 2 –

• Disorder 3 -


Treatment Ideas??

• Need to address the specific disorders seen in the MBSS keeping in mind the positive physiology

• Disorder 1 -

• Disorder 2 –

• Disorder 3 -



6. Establish the treatment targets based on:

• interaction of the various signs

(e.g. residual in the pyriform sinuses spills over after the swallow and is aspirated)

• impact on safety & adequacy

• pleasure of nutrition and hydration (QOL)


Decision Making Process7. Next, decide if the target (s) and its variables

(movement or control) are modifiable

• YES:

• then the next step is to pick a method or set of methods (e.g. lingual weakness modifiable with IOPI or other strengthening methodology)

• NO: (or if effects can be expected to take some time)

• then the full range of compensations need to be considered.



8. Finally, decide:

• the intensity and duration of treatment

• the expected outcomes


Identify & Interpret• Penetration: cause, timing, & approx. % / severity

• Aspiration: cause, timing, & approx. % / severity

• Residue: cause, approx. % and location

• Sensory Awareness:• Reaction to residue• Reaction to penetration• Reaction to aspiration (e.g. cough, throat clear)

• Effectiveness of Reaction to:• Residue, penetration, aspiration (e.g. reduction of %

residue, productive cough, & expectoration of material from airway)


VFSS Report Should Explain

• Problems by occurrence

• Sensory vs. motor

• Symptoms: residue, penetration, aspiration

• Physiologic / anatomic causes of symptoms

• Effects of therapy strategies or why therapy not needed / attempted during the study

• Recommended feeding strategies

• Recommended therapy procedures & goalsCommunicating Positive Results from the MBSS

So, what about pediatric patients –

Where do we go with them?


I & P with Pediatric Dysphagia• Infants who had difficulty with feeding in the first few

weeks of life often continue to have problems when they transition to textured foods 6-12 months of age

• NICU grads or term infants who did well during birth –4 months may have difficulty later with increased volume of fluid intake or transition to spoon or finger feeding

• Although parents voice concern about feeding on average around 7.4 months of age, they are not referred to EI until 15.7 months of age

Bailey Jr., et. Al. (2004)Communicating Positive Results from the MBSS

Etiologies of Disorders

• Understanding etiology is essential

• Etiology influences prognosis and management strategies

• We may be the one who identifies the etiology


Common Criteria for Referral • Sucking & swallowing incoordination• Weak suck• Breathing disruptions during feeding• Excessive gagging or recurrent cough w/ feeds• New onset of feeding difficulty• Diagnosis of disorders associated w/ dysphagia• Weight loss/lack of weight gain for 3-4 mos.• Severe irritability or behavior problems during feeds• History of recurrent pneumonia & feeding difficulty• Concern for possible aspiration during feeds


Common Criteria for Referral• Lethargy or decreased arousal during feeds• Feeding periods longer than 30 minutes• Unexplained food refusal & undernutrition• Drooling persisting beyond age 3 years• Nasopharyngeal reflux during feeding• Delay in feeding developmental milestones

• Not spoon fed by 9 months

• Not chewing table food or self-feeding finger food by 15 months

• Not drinking from a cup by 24 months

• Craniofacial anomalies


Pediatric Anatomy on MBSS

12

3

4

5

6

78


Readiness for Initiating Feeding

Initiating feeding before an infant demonstrates readiness can result in development of maladaptive feeding behaviors that will present future challenges.

(DeMauro, Patel, Medoff-Cooper, Posencheg, & Abbasi, 2011)


Factors Influencing Development

1. Rhythmicity –rhythmic movement patterns

2. Stability – ability to hold the body or body parts steady

3. Dissociation/ separation of movement –the ability to move one body part while the others stabilize

4. Grading – slow segmentation (movement) of a muscle through space


Infant Bolus Formation Skills

• Rooting for a nipple

• Latching on to a nipple

• Establishing a rhythmic suck and swallow pattern


Infant Triggering Pharyngeal Swallow

• Swallow initiation begins when the liquid bolus accumulates either:

• In the space between the soft palate and the tongue

• In the space between the soft palate and the epiglottis


Sucking• Sucking patterns are affected by many variables:• General health• Hunger• Nipple characteristics• Flow, shape, size of hole, rigidity

• Level of alertness• Weight• Maturity • TasteConway 1989; Fadavi et al. 1997; Gryboski 1969; Burke 1977; Gryboski 1969


Airway Stability• Prerequisite for successful PO feeding

• If there are airway concerns:

• Bedside oral feeding evaluation

• VFSS

• Monitor status for a few days

• Talk with the pulmonologist


Suck-Swallow-BREATHE• Breathing

• Respiration is first and foremost a survival function

• Timing and grading of respiration is critical to safely swallow a bolus

• Work of Breathing (WOB) = Respiratory effort (aerobic exercise)

• HUGE issue if there is some sort of nasal blockage


Suck-Swallow-BREATHE

• Impact of breathing on sucking:• May use compensatory sucking pattern if

breathing is stressed• May take short sucking bursts

• Impact of breathing on swallowing:• Increased breathing effort disrupts the

swallow• May increase aspiration risks


Infant Positioning with Bottle


Eustachian Tube


Immature vs. Abnormal Patterns• Children with immature oral skills are easier to

manage than those with abnormal patterns

• Common for children to have both types

• Patterns are likely to be distinguishable in:• Suck-swallow sequencing

• Jaw control or stability

• Tongue motility

• Lip closure

• Dissociation of tongue, jaw, & cheek movements while drinking and chewing


Instrumental Exam

• Referral for a Videofluoroscopic Swallow Study (VFSS) is typically made when there are at least:

• 2 indicators of pharyngeal stage disorders including possible aspiration

or

• 1 significant indicator such as recurrent pneumonia, gurgly voice during mealtime, etc.


Instrumental Exam

• It is not a stand alone assessment

• It must be taken into account along with:• History - medical

• Clinical findings

• Other health related issues

• Changes to medical status soon to occur

• Family dynamic - involvement


On-line Bolus Modifications• Bolus formation• Bolus manipulation• Texture, temperature, taste

• Bolus transfer• Larger nipple hole• Syringe or tubing to get proper placing on

tongue when weak or inadequate suck/swallow

1998 Arvedson and Lefton-Greif


On-line Bolus Modifications• Bolus Formation• Sensory Deficits – hyporesponsive• Texture (may need heavier or crunchier)• Temperature (cold likely, may respond to warm)• Taste (stronger flavors)

• Sensory Deficits – hyperresponsive• Taste (bland flavors)• Placement (more posterior on tongue,

downward pressure on tongue with spoon)


On-line Bolus Modifications• Pharyngeal Trigger• Delayed onset• Size of bolus – try larger or smaller• Temperature – cold may stimulate swallow• Texture• Side lying position


On-line Bolus Modifications• Pharyngeal• During swallow• Position to use gravity to direct flow to strong side

and/or head turn (unilateral paresis)• Alter method of presentation• Chin tuck (NOT for infants)

• Post-swallow• Voluntary cough (cough/swallow sequences)• Multiple swallow (attempt to clear residue –

stimulate as appropriate w/ pacifier/spoon)


To Thicken or Not To Thicken• Thicken if:

• Delay triggering pharyngeal swallow and no other options worked during MBSS

• Do NOT Thicken if:

• Residue in hypopharynx with poor clearing

• Poor sucking

• Decreased endurance (cardio disease)

• May increase risk of post-swallow aspiration


Aspiration: Before the Swallow

• Limited / Uncoordinated Lingual Movement

• Limited Mandibular Movement

• Delayed or absent swallow

• Poor Pharyngeal Motility


Aspiration: During the Swallow

• Reduced laryngeal elevation

• Inefficient / absent closure of laryngeal vestibule (vocal cords)

• Decreased anterior movement of the hyoid bone

• Decreased closure of true or false cords


Aspiration: After the Swallow• Residue in the Oral Cavity

• poor oral tongue movement

• Residue in Valleculae • Reduced tongue base retraction• Unilateral pharyngeal paralysis

• Residue in Pyriform• Reduced laryngeal elevation• Reduced cricopharygneal opening (PES)• Reduced hyolaryngeal excursion

• Residue on Posterior Pharyngeal Wall (PPW)• Reduced pharyngeal wall contraction – forward and

lateral


Jennifer JonesPhD, CCC-SLP, BCS-S

Board Certified Specialist in Swallowing and Swallowing Disorders

TalkTools1852 Wallace School Road, Suite H

Charleston, SC 29407Tel: 888-529-2879

Email: [email protected]

The Swallowing Process

1. A labial seal is maintained to ensure no food or liquid falls from the mouth.

2. The material is gathered into a cohesive bolus by the tongue and held between

the tongue and the anterior palate.

3. Mastication of material is performed with a rotary-lateral movement of the mandible

and tongue.

• bolus is mixed with saliva & taste is heightened

4. Tension in the buccal musculature closes off the lateral sulcus and prevents food

particles from falling into the sulcus between the mandible and the cheek.

5. The velum is pulled anteriorly and rests against the back of the tongue, serving to

keep material in the oral cavity.

• The tongue tip is elevated to occlude the anterior oral cavity at the alveolar

ridge

• The bolus is compressed against the hard palate

6. Pharyngeal responses occur so close together that they are presented here in one

group – some depend on others, but all work closely together.

• Tongue base retraction

• Epiglottic inversion

• Elevation and anterior movement of the hyoid bone.

• Laryngeal elevation and closure at all three sphincters to prevent material from

entering the airway

• aryepiglottic folds

• false vocal folds

• true vocal folds

• Pharyngeal contraction – stripping wave of the superior, middle and inferior

pharyngeal constrictors

• Relaxation of the PES (cricopharyngeal sphincter) to allow material to pass from

the pharyngeal cavity into the esophagus

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