2 Pharyngeal Phase of Swallowing

Question 1

PHARYNGEAL PHASE IS ______

Answer 1

INVOLUNTARY

Question 2

Pharyngeal Phase:

During swallowing, valves close off to

Answer 2

prevent food from entering the nose (velum contacts posterior pharyngeal constrictors) and airway (vocal cords close and larynx moves anteriorly)

Question 3

1. Swallow Reflex Initiation (3)

Answer 3

1 Infants and older children: sensory info. sent from upper pharynx and vallecular areas to brain (medulla) to initiate swallow.

2 Children 5+: sensory info. sent from back of mouth (primarily anterior faucial pillars) and opening to pharynx.

3 Once reflex is triggered, remaining swallow is involuntary.

Question 4

2. Base of Tongue (or Pharyngeal Tongue) (2)

Answer 4

1 Retracts towards posterior pharynx to make contact with pharyngeal constrictors to “squeeze” bolus down.

2 With muscles of adequate strength, there is firm and tight contact.

*lots of pressures pushing the bolus down

Question 5

3. Pharyngeal Constrictors (4)

Answer 5

1 Lateral and posterior pharyngeal constrictors: Made up of the superior, medial, and inferior pharyngeal constrictor muscles.

2 Muscles contract in a peristaltic wave to propel bolus downward.

3 Posterior pharyngeal wall contracts to meet the base of tongue to squeeze bolus downward.

4 The top-down squeeze of the pharyngeal constrictors and the base of tongue is also called “pharyngeal stripping.”

Question 6

4. Hyoid Bone (3)

Answer 6

1 Moves anteriorly and elevates (elevation increases after 6 mos) during activation of the swallow. Also called hyolaryngeal excursion (hyoid and larynx move).

2 This causes the larynx to move anteriorly and elevate as well.

3 This movement contributes to epiglottis retroflexion/inversion (flips down backwards).

*the main thing that helps the VF close. WATCH hyolaryngeal excursion

Question 7

5. Larynx (3)

Answer 7

1 Vocal cords adduct (close)

2 Moves anteriorly (and elevates in older babies and children).

3 Remains closed until after swallow, then a reflexive exhalation

(take a small drink you will reflexively exhale).

Question 8

6. Vocal Folds (True Vocal Cords) (2)

Answer 8

1 Adduct (close) immediately once swallow initiated.

2 Open once bolus passes through UES, and there is an immediate reflexive exhalation.

Question 9

7. Epiglottis (3)

Answer 9

1 Infants: Remains in contact with velum during oral phase and at rest.

2 As larynx is pulled anteriorly, epiglottis inverts and partially covers airway (epiglottic retroflexion or inversion).

3 Anatomical position aides in directing bolus laterally to pyriform sinuses (vs. medially towards vocal folds) for swallow

Question 10

8. Vallecular Space [Vallecula (one) or Valleculae (plural)]

Answer 10

1 Small reservoir formed at base of tongue and epiglottis.

2 Pooling of food/liquid is NOT normal. (Trace liquids may pool in the valleculae during chewing of something juicy—-ex: apple).

3 Infants: trigger swallow at the level of the valleculae

Question 11

9. Pyriform Sinuses (3)

Answer 11

1 Reservoir immediately lateral to the opening of the airway and immediately above the cricopharyngeal sphincter.

2 “Pocket” formed by fibers running from the thyroid cartilage to cricopharyngeal sphincter.

3 Pooling of food/liquid is NOT normal and puts child at great risk for aspiration

Question 12

10. Cricopharyngeal Sphincter (or Upper Esophageal Sphincter–UES)

Answer 12

1 Made up partially by the inferior pharyngeal constrictor.

2 Partially opened by the movement of the larynx pulling on the CP muscle (hyolaryngeal excursion) and causing it to stretch and open and therefore relax

Question 13

11. Esophagus and Stomach (4)

Answer 13

1 Begins below CP sphincter.

2 Bolus travels down esophagus via peristalsis.

3 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.

4 Once food enters esophagus, it is no longer “SLP territory.” (our territory if reflux comes up through the UES)

Question 14

B. Coordination of the Pharyngeal Swallow (3)

Answer 14

1 Swallowing is not a step-by-step process. Many aspects happen simultaneously in a synchronized manner.

2 Breathing ceases once swallow reflex is initiated.

3 Upon completion of swallow, there is a reflexive exhalation

Question 15

C. Coordination of the pharyngeal swallow

What occurs during the pharyngeal swallow? (9)

Answer 15

(1) Bolus passes over anterior faucial pillars and other posterior oral receptors and triggers the pharyngeal swallow (triggers near the valleculae 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.

Question 16

Bolus Propulsion (movement) Downward
/ stripping of the bolus

Answer 16

1. Seals create positive pressure
2. Negative pressure (or vacuum)
3. Muscular contraction

Question 17

Bolus Propulsion (movement) Downward

1. Seals create positive pressure

Answer 17

a) Anterior seal (anterior tongue against hard palate) –> +pressure
b) Velopharyngeal –> +pressure
c) Vocal fold closure –> +pressure
d) Cricopharyngeal sphincter –> +pressure

Question 18

Bolus Propulsion (movement) Downward

2. Negative pressure (or vacuum)

Answer 18

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.

Question 19

Bolus Propulsion (movement) Downward

3. Muscular contraction

Answer 19

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).

Question 20

Pedi. Pharyngeal Anatomy

• Larynx is located more anterior and higher in the neck (at C2-3 vs C5-6 in adults). (Close to base of epiglottis.)
• Hyoid bone sits more anterior and higher as well.

Answer 20

Functional Difference

Additional airway protection secondary to position. Relatively little laryngeal elevation during swallow, primarily laryngeal anterior excursion.

Question 21

Pedi. Pharyngeal Anatomy

Birth - ~6 months:

Velum and epiglottis: in contact with each other at rest and during oral phase (secondary to epiglottis’s elevated position).

Answer 21

Functional Difference

**Obligate nose breathers.
Provides an additional “valve” for airway protection.

Question 22

Pedi. Pharyngeal Anatomy

Epiglottis: shorter, narrower, softer, and projects posteriorly at an ~45’ angle (close to horizontal position).

Answer 22

Functional Difference

**Obligate nose breathers.
Provides an additional “valve” for airway protection.

Question 23

Pedi. Pharyngeal Anatomy

Posterior pharyngeal wall: moves further anteriorly in children.

Answer 23

Functional Difference

To contact base of tongue during swallow to push bolus downward.

Question 24

Pedi. Pharyngeal Anatomy

Swallow reflex: triggered near level of the valleculae.

Answer 24

Functional Difference

Requires precise timing and speed of swallow since pharynx is shorter and swallow is triggered in a lower position.

Question 25

_ valves/oral-pharyngeal seals that protect the airway

Answer 25

4

Question 26

Timing and speed of muscle movement during swallow is _____important than strength.

Answer 26

more

Question 27

Significant anatomical and physiological changes occur from

Answer 27

infancy through ~5 yrs of age

Question 28

Swallow reflex for an infant is triggered:

Answer 28

at the valleculae space

Question 29

Child 5+ anatomy vs. INfant

Answer 29

Infant: everything’s almost directly accross from the mandible to C2-C3ish

Child: 90 degree angle and hyoid at C4-5ish

Question 30

Does an infant have hyoid elevation?

Answer 30

no. it only moves anteriorly in infants.

After 6 months you will get superior movement as well

Question 31

Is there innervation to the epiglottis?

Answer 31

No, it is cartilage that has to be pulled to move. This happens during good hyolaryngeal excursion

Question 32

Bolus Propulsion Downward: (3 things)

Answer 32

1. Seals create positive pressure
2. Negative pressure (or vacuum)
3. Muscle contractions

Question 33

Because of how fast babies suck, swallow, breath:

Answer 33

there is no room for in-coordination

any residues will be sucked into the airway very quickly