14-Swallowing Flashcards
What are the 3 main phases?
- Oral phase
- Pharyngeal phase
- Esophageal phase
Explain the oral phase
First phase
When you swallow you first:
- Form a bolus in your mouth on the top of your tongue, your lips seal, the tongue holds your food and velopharyngeal port closes
•The food or liquid is closed in your mouth - You chew and chew and your tongue moves it around; it gathers all of the food in a bolus until you feel ready to swallow
What should you not see in the oral phase?
- Any leak into your nose or milk coming out your upper lip
- Any leakage going into the larynx
- No food pocketed in your cheek
- No food under the tongue
T/F the oral phase does not need to be contained
False •Any leak into your nose or milk coming out your upper lip •Any leakage going into the larynx •No food pocketed in your cheek •No food under the tongue
What triggers the pharyngeal phase?
Is triggered as the bolus reaches the back of the tongue
the larynx comes up with all this massive closure
oFood is contained in a bolus in the middle of your mouth until you decide to swallow
What are two important factors for pharyngeal phase?
Negative air pressure and the muscles
Explain negative air pressure
- It helps drive the bolus backwards
* Because you’ve closed the velopharyngeal port and lip seal you have closed off air participating in this swallow
What important muscles acts in the pharyngeal phase ?
First set of muscle?
o Tongue, the bowl flattens out and the food is compressed/pushed back into the pharynx.
o It presses up to the roof of the mouth, it squeezes from the front to the back
- First muscle of peristalsis
- Peristalsis = a snake–muscle are contracting and pushing the food to the back
To drive the bolus into the esophagus
What is the single most important action in the pharynx to the swallow?
- Larynx lifts and closes
- Most critical part of the pharynx
- It must pick up because that’s how it closes most tightly
- It is a sphincter action and it has to lift and close
Why is the lift and close action so important?
Your food will go down the trach = aspiration
How is the larynx quadruple protected?
oThe tongue goes up and the epiglottis closes over the opening of the larynx (15:00)
•Moves backwards and covers the additus laryngeus or vestibule
oThe epiglottis closes backwards and aryepiglottic folds close in to make the seal
oThe false VF close up
oThe true VS close up
What happens in the esophageal phase?
oCharacterized by even more closure
oThe esophagus is supposed to be a one way valve
oOnce food gets into the esophagus we are done
If there’s problems in the esophageal phase what happens?
•If esophageal phase does not work and it comes back out
-if it goes into the trach we care
•If the larynx isn’t closing right we won’t be able to fix is but we need to know that it is happening
Define aspiration
THAT SOMETHING HAS PENETRATED BELOW THE LEVEL OF THE TRUE VF
T/F dysphagia can occur in all ages
true
-from neonatal care to old age
what is swallowing
Swallowing is moving the food from the mouth to the stomach.
Issue at it’s foundation?
-from esophagus to pharynx it needs to be SAFE
What is a safe swallow? what happens when the swallow does not work?
food goes into the esophagus and into the stomach
unsafe? through the esophagus into the trachea
What are extrinsic muscles?
supporting and fixing the larynx into place
One attachment is outside the larynx and on is inside (to hyoid, thyroid, or thyrohyoid)
subgroups: suprahyoids and infrahyoids
What are suprahyoids?
originate or insert above the level of the hyoid bone
**critical swallow muscles
Name the suprahyoids? what do they do?
they are laryngeal elevators and slightly forward and backwards to have a straight up motion
Digastricus
Mylohyoid
Stylohyoid
Geniohyoid
Explain digastricus
•Extends the length of your jaw
•Deep to digastricus
•Elevates hyoid and moves down a little bit in contraction
•When it pulls up on the hyoid bone
oThe whole larynx goes UP
•Origin is the medial aspect of the border of the mandible (mastoid process) and courses inferior/posteriorly and inserts on a midline raphe
Explain mylohyoid
this muscle forms the floor of the mouth.
•Elevates hyoid and moves down a little bit in contraction
•When it pulls up on the hyoid bone
oThe whole larynx goes UP
•Origin is the medial aspect of the inferior border of the mandible (mastoid process)
Explain stylohyoid
a long and slender muscle that is lateral and superficial to the digastricus posterior belly (runs parallel)
- On contraction pulls anteriorly and up
- Long slender muscle
- Right next to posterior belly of digastricus—but slightly superior
- ORIGINATES from the styloid process (of the mastoid bone) runs anterior, inferiorly to insert on hyoid bone
oSticky outy of the styloid process
Explain geniohyoid
- Runs the same course and anterior belly of digastricus
- Make a mylohyoid sandwhich
- Anterior belly is underneath, mylohyoid is in the middle with geniohyoid is ontop
**so - it is located superiorly to the mylohyoid
ORIGINATES from interior border of mandible (chin), courses posteriorly and inferiorly to ATTACH on the body of the hyoid bone
What are the structures in the larynx?
True VF False VF Aryepiglottic folds Epiglottis Arytenoids (you can't see these) Cuneiform
Name the places and spaces
- Valleculae
- Common place for food to be pocketed - Pyriform sinuses
- Aditus laryngeus, aditus, or vestibule
- The triangular space - Anterior commissure
- Posterior commissure
What constrictors are in the VP port
- Superior pharyngeal constrictor
a. Participates with closing the velopharyngeal port - Middle constrictor
a. Squeezes food away from the mouth into the esophagus
3.Inferior
What are the infrahyoid muscles?
they’re laryngeal depressors
- Sternohyoid
- omohyoid
- thyrohyoid
- sternothyroid
Explain sternohyoid and what it does
- ORIGINATES the posterior surface of the manubrium (sternum)—and courses straight up from the inferior body of hyoid bone
- Strap muscle
- Downward pull
Explain omohyoid and what it does
• Starts on the scapula courses anteriorly and superiorly and moves up to the hyoid bone
Explain thyrohyoid and what it does
- A cheating muscle because both attachments are in the larynx
* Looks like a infra but acts like a supra
* It is both intrinsic and extrinsic elevators - When it contracts it pulls larynx up to hyoid bone
- Originates from thyroid lamina courses upward to the inferior portion of hyoid bone
Explain sternothyroid and what it does
- Originates from the medial aspect of the manubrium and first rib first
- A little more centered
What are the risks for dysphagia?
a. Lack of muscle control/function
i. Especially with lack of muscle function goes with lack of sensation
b.Lack of sensation
c. Lack of swallow reflex
i. Cough/clear reflex
What are dysphagia terms?
Aspiration
Penetration
Residue
Blackflow
Explain pentration
i. The food may be sitting at the level of the true VF
ii. Because the food is in the vestibule
iii. Not below the level of the true—its AT the level
explain residue
i.What’s left over in the laryngeal area
ii. Can also be what’s left behind in the mouth
1. If it’s sitting on the tongue
2. But if it’s in the cheek or under the tongue = pocketed
iii.Could Potentially hanging on the posterior pharyngeal wall
Explain backflow
i. Referring to the esophageal phase
ii. Food or liquid has gone into the esophagus and it’s coming back up again—it never got to the stomach
- We care about the fact that it is possibly being aspirated
- Because it is leaking from the esophagus into the pharynx which is why it is an aspiration risk
What does a bedside clinical assessment show?
:Yes/no evaluation for aspiration
i. Typically identifies that the patient is aspirating, but not why.
1. But then you do a study to determine why: what’s happening where?
What does MBS stand for? what does it focus on?
Modified Barium swallow (MBS)
i.Looking at the larynx= Laryngeal function
ii. Most popular eval
iii. an x-ray
What do you specifically look at in a MBS?
Looking at lateral view of how they manipulate the bolus in the oral phase, when the pharyngeal phase triggers, when or does the larynx move up, does the tongue propel the bolus into the pharynx, is does the epiglottis close over?
- Does food penetrate or aspirate?
- Is there residue left in the pharynx or oral cavities ?
What are you looking for in a barium swallow?
i. Once you determine there’s a swallowing eval this is the most typical physiological examination
ii. Looking for Esophageal function
- Looking for upper esophageal function
- Opening of LES into the stomach
iii. Peristaltic function
Anterior, posterior, and lateral view
Need radiologist
What is another type of endoscopic eval ?
FEES
Fibroptic endoscopic eval of swallow
What is FEES
ii. Can be done by a SLP no radiologist necessary
iii. Scope goes through the nose pass/lower to the level of the velopharyngeal port and watch the patient swallow
iv. Anterior, posterior, and lateral view
Both FEES and MBS are designed to show what?
how and where the breakdown
- Where is the abnormality in the anatomy and/or physiology
- And give you an idea for treatment strategies might be
- You can test the structures
a. You can go through a list of treatment strategies and probe to see what works
4.But remember MBS is an x ray
What are the signs and symptoms of aspiration
i. Coughing after swallowing
ii. History of pneumonia
iii. Diagnoses that put the patient at greater risk
iv. Food squirting out the tracheostomy
v. Some sort of neuroligcal disease that lead to paralysis, paresis, lessened sensation
vi. Stroke or TBI
What are some items on the checklist for dysphagia screening?
i. Is there a history of recurrent pneumonia?
ii. Radiation
iii. Prolonged intubation
1. Nerve damage
iv. Gurgle voice
1. Sounds like liqud on the VF
v. Coughing
vi. Poor awareness
vii. Not swallowing
viii. Reduced laryngeal lifting
ix. Significant fatigue
x. Voice changes
xi. Multiple swallows with one spoonful of applesauce
xii. Anything that can lead to tissue not function the way it should
In the physiological evals how many consistencies do you use?
Swallow At least 3 consistencies of food used in the evaluation
i. Thin liquid
1. Hardest to manage, keep in a bolus, keep from leaking
ii. Thick liquid or sort of a pudding
1. Apple Sauce
iii. Nectar
iv. Barium on a cracker
What are some treatments of swallowing or swallowing maneuvers ?
a. Head positioning
i. Chin position
1. Up
a. Let gravity help you pull it down
2. Down
a. Close of velecullae and piriform sinus
ii. Head turn
1. Depending on paralysis
b. Laryngeal manipulation
c. Food alterations
d. Multiple swallows
i. Simple but effective
e. Swallow-cough
i. They don’t feel penetration and aspiration
ii. If the cough clears the aspiration this is great!
f. Food then a sip of liquid to clear, etc.
