6. Swallow Flashcards
Swallowing:
! The act of swallowing (deglutition) is an intricate action involving the integration of a complex series of sensory and motor responses.
! The act of swallowing must occur in a ____ and coordinated fashion in order to propel the food bolus into the esophagus and stomach without penetration into the larynx (voice box) and airway (lungs).
sequential
Phases of swallowing
! ____ Preparatory
! ____ Phase
! ____ Phase
! ____ Phase
oral
oral
pharyngeal
esophageal
Oral Preparatory/ Oral Phase:
! Adequate labial seal to prevent ____ leakage
! Mastication as necessary
! ____ movement for bolus formation and control during A-P transfer
! ____ seal to prevent nasal regurgitation
anterior
lingual
velar
Oral phase: labial seal
! Obicularis Oris and Zygomaticus- both lip muscles.
◦ Form seal for ____ oral cavity.
! Buccinator (cheek muscle)
◦ holds ____ in contact with the teeth
! All three innervated by the ____
anterior
food
facial nerve (VII)
Oral Phase:
! Food is moistened by saliva from the salivary glands
◦ 3 large salivary glands on each side: parotid, submandibular, and sublingual
◦ Innervated by ____ nerve
glossopharyngeal
Oral Phase: Mandible
! Muscles involved in chewing are all innervated by the ____.
! Temporalis- elevated, ____, and assists in closing the mandible.
! Masseter- elevated and ____ the mandible
! Lateral Pterygoid- ____, opens and protrudes the mandible (as well as ____ movement)
trigeminal nerve (V)
retracts
closes
depresses
lateral
Oral Phase: Tongue
! ____ to posterior rolling action of the midline tongue
! Tongue elevation progressing sequentially more ____ to push the bolus backward
! Sides and tip of tongue remain anchored against ____
! Central groove is formed in the tongue-acting as a chute or ramp for food to pass through as it moves ____.
anterior
posteriorly
alveolar ridge
posteriorly
Oral phase: Tongue
! Intrinsic muscles of the tongue (superior ____, inferior longitudinal, transverse, and ____) form trough
◦ Innervated by ____
! The tongue then elevated to the roof of the mouth by the extrinsic tongue muscles (____, styloglossus, and ____)
◦ Innervated by ____
! Sensation to tongue innervated by
◦ Anterior 2/3- ____
◦ Posterior 1/3- ____
longitudinal vertical hypoglossal (XII) genioglossues hyoglossus hypoglossal (XII) trigeminal (V) glossopharyngeal (IX)
Oral phase: velar seal
! Palate elevates to make contact with the posterior pharyngeal wall
◦ Tensor Veli Palati and Levator Veli Palati muscles form a “sling,” lifting the soft palate up and backwards, ____ off the entrance to the nasal cavity.
◦ Palatoglossus and Palatopharyngeus muscles ____ off the opening to the oropharnx
So that we don’t have stuff coming out of our nose
◦ All muscles are innervated by the pharyngeal plexus via the ____ nerve, with the exception of the tensor veli palatini (innervated by the ____ nerve,).
closing
closes
vagus
trigeminal
Oral Phase deficits
! Problems of weakness of the lips, tongue and cheeks due to ____, or degenerative neurological conditions can cause problems keeping food in the mouth.
! Such neurologic disorders prevent an individual from organizing the food into a well-formed bolus and moving it ____ in the mouth.
! If there is specific unilateral cheek (buccal) weakness, food can enter a pocket in one cheek making eating unsafe.
! Problems with xerostomia (dry mouth) such as after ____ therapy can result in difficulty breaking down solids and difficulty swallowing them smoothly through the hypopharynx.
! If someone has had oral cancer and has had part of the lips, tongue, cheek or palate removed, similar problems can occur with containing, ____ and transporting food through the mouth.
stroke
posteriorly
radiation
masticating
Pharyngeal Phase:
! Sensory receptors in the ____ trigger pharyngeal swallow
! Elevation and anterior movement of the ____
! ____ of the larynx
! Tongue base retraction
! Progressive contraction of the ____
! Opening of the ____ sphincter
oropharynx hyoid and larynx closure pharyngeal constrictors circopharyngeal
Pharyngeal Phase: hyolaryngeal elevation
! Hyoid bone and larynx elevate and move ____ (anterior belly of the diagastric, mylohyoid, geniohyoid, and thyrohyoid)
! This elevation contributes to ____ of airway and forward movement contributes to opening of the ____
! Innervated by ____
anteriorly
closure
upper esophageal sphincter
vagus (X)
Pharyngeal Phase: closure of the larynx
! Intrinsic muscles (except ____) of the larynx close the vocal folds
◦ ____, lateral cricoarytenoid, ____, and thyroarytenoid
◦ Innervated by ____
PCA
interarytenoid
cricothyroid
vagus (X)
Pharyngeal Phase: tongue base retraction
! Tongue base assumes a ramp shape directing the bolus into the pharynx
! Tongue base ____ and pharyngeal wall ____ to make complete contact
• This is the ____ push to the back of our throat
! Innervated by ____ nerve
retracts
contracts
major
hypoglossal (XII)
Pharyngeal Phase: Pharyngeal Contraction
! Pharyngeal constrictor muscles (superior, middle, and inferior) help move the bolus towards the esophagus via ____ action
! ____ and ____ nerves innervate pharyngeal constrictors
stripping
glossopharyngeal (IX)
vagus (X)
Pharyngeal Phase: Cricopharyngeal opening
! Segment that separates the ____ from the esophagus
! At the end of the pharyngeal stage, it ____ to allow the bolus to enter the esophagus
! Innervated by the ____
! Rare to problems with cricopharyngeal opening- treated with botox or myotomy
phayrnx
relaxes
vagus (X)
Pharyngeal Phase deficits
! Categorized by timing or weakness
! Problems with timing usually occur in patients with neurological deficits. In such persons, the swallow reflex does not trigger effectively enough for the larynx to be protected beneath the epiglottis. This may result in penetration or ____ of food or liquids.
! When the food passes through the ____(aspiration) the patient may cough in an attempt to expel the dangerous food particles from the airway.
aspiration
vocal folds
Pharyngeal Phase deficits:
! Problems with weakness usually result in residuals and possible ____ aspiration
◦ If one side of pharynx is weak, foods tends of cling to that pharyngeal wall and collect in the ____ sinus on that side.
! Poor airway closure
◦ ____ during the swallow
overflow
pyriform
aspiration
Esophageal Phase:
! ____ wave pushes bolus through the esophagus
! Lower Esophageal sphincter ____ to allow bolus to enter the stomach.
peristaltic
opens
Esophageal Deficits:
! Retrograde flow
! Zenker’s Diverticulum-side pocket forms when
pharyngeal or esophageal muscle ____
! GERD
! ____ Fistula
◦ Usual to see but they do happen, sometimes
after an AEG
herniates
tracheoesophageal
Signs and Symptoms of Dysphagia
! ____ before, during, after swallow
! Frequent coughing at ____ of meal
! ____/wet vocal quality
! Increase of ____
! Pneumonia
! ____
! Dehydration
coughing end gurgly secretions malnutrition
Evaluation of Swallowing: ! \_\_\_\_/ Bedside Evaluation ! \_\_\_\_ Endoscopic Evaluation of Swallowing (FEES) ! Modified \_\_\_\_(MBS)
clinical
fiberoptic
barium swallow
Clinical Evaluation ! Medical history/chart review ! Oral Motor evaluation ! Evaluate the swallow subjectively using varied food and liquid consistencies via ◦ \_\_\_\_ auscultation ◦ Visual exam ◦ \_\_\_\_ of the swallow ◦ Quality of respiration and phonation
cervical
palpation
Blue Dye Evaluation ! Deflate cuff ! Attempt \_\_\_\_ ! PMSV as appropriate ! Attempt various consistencies ! \_\_\_\_ patient after trials to assess for immediate or delayed aspiration of food and liquid trials
cuff
suction
FEES
! Passage of \_\_\_\_ flexible endoscope ! Endoscope placement is below the soft palate, superior to the epiglottis, parallel to posterior pharyngeal wall. ! Direct visualization ◦ \_\_\_\_ port ◦ \_\_\_\_/hypopharynx ◦ \_\_\_\_ structures
transnasal
velopharyngeal
oropharynx
laryngeal
FEES ! Assess secretion management ! Administration of food/liquid ◦ \_\_\_\_ Spillage ◦ Aspiration before/after swallow ◦ Status of pharyngeal constriction ! Utilize \_\_\_\_/strategies/maneuvers during the examination ! Biofeedback
premature
positions
Limitations:
! Does not allow for full analysis of ____ phase
! View of ____ is obliterated during the swallow (“white-out”)
• in a normal swallow, the epiglottis ____ & on the camera you see a “white out”
oral
larynx
inverts
Abnormal FEES
“You can already see pooling of these secretions on the patient’s right side. So you’d infer there’s some sort of weakness here because you usually have pooling towards the patient’s weakness.”
• So you can see their not really initiating the swallow, it’s sort of spilling back there
• They haven’t aspirated yet - it’s just to the point they have penetrated
◦ ____: spilling into the vestibule to the true vocal folds (the V)
◦ ____: spilling past the true vocal folds (V)
‣ She has the mouse cursor on the true vocal cords
penetration
aspiration
MBS
! Defines the abnormalities in anatomy and physiology causing the patient’s symptoms.
! Identify and evaluate treatment strategies that may immediately enable the patient to swallow safely.
! Evaluate ____ stages of the swallow.
! Radiologist and Speech Pathologist ____.
• Modified Barium Swallow allows you to look at:
◦ their anatomy, physiology, anything that is causing their symptoms. ◦ all stages of the swallowing
‣ including their ____ phase.
• Done in conjunction with a radiologist under fluoroscopy.
all
present
esophageal
MBS A-P view
- AP-position view is done to check ____ as the patient swallow the bolus.
- & they’ll do a whole ____ follow through as well.
symmetry
esophageal
Indications for
FEES or MBS
INDICATIONS FOR FEES:
! Need to assess status of ____
! Pt. unable to be transported to Radiology
! Need exam that ____
! Post-intubation/ post- surgery
! Assess ____ or swallow status over a meal
INDICATIONS FOR MBS: ! Pt will not/does not accept \_\_\_\_ Oral stage needs to be examined \_\_\_\_ complaints Esophageal stage problem or reflux suspected \_\_\_\_ during the swallow (verification)
secretions
day
fatigue
endoscopy
globus
aspiration
Dysphagia Management ! Direct vs. Indirect Therapy ! Compensatory Strategies ◦ \_\_\_\_ Techniques ◦ Swallow Maneuvers ! Food Consistency/ Diet Changes ! \_\_\_\_ Prosthestics
• First we have to decide, can we feed them or not?
• Do we do direct vs. indirect therapy?
◦ ____ therapy: secretion management, swallowing management/ exercises, motor exercises
◦ ____ therapy: puree/food trials
postural
intraoral
indirect
direct
Direct v. Indirect Therapy
! ____ and/or liquid
! ____ Programs
trials following
! ____ Management specified directions
food
exercise
saliva
Postural Techniques ! Chin \_\_\_\_ Posture ! Chin \_\_\_\_ Posture ! Head \_\_\_\_ ! Head \_\_\_\_
down
up
rotation
tilt
Chin Down Posture
! Pushes anterior pharyngeal wall ____
! Tongue base and epiglottis pushed closer to
____
! ____ space between epiglottic base and arytenoid cartilage
! Useful for patients with ____ in triggering pharyngeal swallow, reduced tongue base retraction, and/or reduced airway entrance closure.
posteriorly
PPW
narrows
delays
Chin Up Posture
! Allows ____ to assist in propelling bolus from oral cavity into the pharynx
! Useful for patients with reduced ____ control
gravity
tongue
Head Rotation
! Closes the damaged/weak side of the pharynx so bolus flows through the more ____ (stronger) side
! Pushes damaged/weak side toward ____, improving VF adduction
! Useful for patients with unilateral ____ weakness or unilateral ____ paresis/paralysis
normal
midline
pharyngeal
VF
Head Tilt
! Bolus moves down stronger side with better ____
! Useful for patients with ____ oral impairment
control
unilateral
Swallow Maneuvers ! \_\_\_\_ Swallow ! Super-supraglottic Swallow ! \_\_\_\_ Swallow ! Mendelsohn Maneuver
supraglottic
effortful
Supraglottic Swallow
! Closes the true ____ before and during the swallow
! Useful for patients with reduced or late vocal fold ____ or delayed ____ swallow
vocal folds
closure
pharyngeal
Super-supraglottic Swallow
! Effortful breath hold tilts arytenoid ____, closing airway entrance before and during swallow.
! Useful for patients with reduced closure of ____ entrance
forward
airway
Effortful Swallow
! Effort increases ____ tongue base movement
! Useful for patients with decreased ____ movement of the tongue base
posterior
posterior
Mendelsohn Maneuver
! Increases the extent and duration of ____ elevation and width of ____ opening
! Useful for patients with reduced ____ movement or discoordinated swallow
laryngeal
cricopharyngeal
laryngeal
Diet Changes ! Should be last compensatory strategy ! Food Consistencies: ◦ \_\_\_\_ liquids ◦ \_\_\_\_ liquids (nectar, honey) = pudding-thick liquid ◦ \_\_\_\_ ◦ Soft
thin
thickened
pureed
Intraoral Prosthetics
! Palatal Lift: lifts soft palate into ____ (closed) position.
! Palatal Obturator: used with significant ____ of the soft palate.
! Palatal Reshaping Prosthesis: recontours the ____ to interact with the remaining tongue.
elevated
resection
hard palate
Post-TORS FEES
! Continue primary nutrition via ____ tube with facilitative feeds of puree and nectar with compensatory strategy of head turn to the ____, chin down and ____ swallow
! Prior to initiation of chemoradiation, feeding tube ____ and patient eating a ____ diet
feeding
R
effortful
removed
regular
Post-chemoradiation
• You can see how ____ his secretions are
• His epiglottis is smaller now - you can see it hanging over a little bit. don’t know why they don’t just take out the entire epiglottis because it’s
not really useful after all this.
• His airways still moves ____ - things are a little swollen in there.
• The more the patient swallows, the more they can ____ a lot of that out.
• Radiation can cause ____ and tightening, so once we deem they are
safe to swallow we want them to do as much as possible to get those muscles moving. The more they swallow, the better.
thick
well
clean
fibrosis
Post-chemoradiation FEES
! Pt currently on ____ diet, following FEES recommendations included increasing diet to puree and thin liquids/ nutritional shakes
! ____ swallowing exercises and artificial saliva products
! Secretion management recommendations
! Resumed ____ diet within 6 weeks
liquid
aggressive
regular
