A + P of Swallowing Flashcards
Oral Structures (12):
1) Lips
2) Teeth - 24 deciduous, 32 permanent
3) Maxilla (hard palate)
4) Velum (soft palate) – shared with oropharynx
5) Uvula
6) Mandible
7) Floor of mouth
8) Tongue (all but base (base = pharyngeal structure))
9) Faucial arches - anterior & posterior
10) Palatine tonsils
11) Sulci - anterior & lateral
12) Salivary glands – parotid (near the ear), submandibular (behind back teeth), sublingual (by tongue)
Oral Muscles:
1) Tongue Muscles (intrinsic and Extrinsic)
2) Roof of mouth (palatoglossus + palatopharyngeus)
Intrinsic Tongue Muscles (4):
1) Superior longitudinal
2) Inferior longitudinal
3) Transverse
4) Vertical
Purpose: alter shape
Extrinsic Tongue Muscles (4):
1) Genioglossus
2) Hyoglossus
3) Styloglossus
4) Palatoglossus
Purpose: protrude/retract, elevate/depress
Roof of Mouth Muscles (2):
- Palatoglossus
- Palatopharyngeus
Palatoglossus (location and fnc):
– in anterior faucial arch; pulls velum down & forward against back of tongue
Palatopharyngeus (location and fnc):
– in posterior faucial arch; helps elevate & retract velum (VP closure)
Pharyngeal Structures (11):
1) Pterygoid plates on sphenoid bone (nasopharynx)
2) Velum (oropharynx)
3) Tongue base
4) Mandible
5) Hyoid bone
6) Pharynx! (pharyngeal walls)
7) Epiglottis
8) Thyroid cartilage
9) Cricoid cartilage
10) Vallecula (plural is valleculae)
11) Pyriform sinuses
Valleculae (location and fnc):
– 2 pockets around the epiglottis that help with premature spillage. If premature spillage happens, there “swimming pools” will fill up with the bolus and protect
Pharyngeal/laryngeal Muscles (3):
1) Suprahyoids/submentals
2) Infrahyoid – Thyrohyoid
3) Constrictors
Suprahyoids/submentals (3):
1) Mylohyoids
2) Geniohyoids
3) Digastrics (anterior belly)
Infrahyoid -
Thyrohyoid
Contrictors:
Superior, Middle, Inferior > posterior & lateral walls
Cricopharyngeus (CP)*
Cricopharyngeus (CP) (Location and fnc):
– inferior constrictor fibers attached to cricoid lamina; prevents air from entering esophagus, reduces backflow
* Tonic at rest (when awake); divides pharynx and esophagus)
How are sphincter muscles different from regular muscles?
Sphincter Muscles are opposite of regular muscles in that they expand when they contract. Regular muscles shorten when they contract.
Sphincter Muscles are round muscles that are closed and small until they contract and then they open and expand.
Ant of digastric and suprahyoids func:
- Pulls hyoid Up and forward for swallow
- aids in opening CP
- Triggered during pharyngeal stage
Fnc of thyrohyoid:
- Pulls larynx up and forwards so that the hyoid can go up and out.
- triggered during pharyngeal stage
Why is it helpful for the ant belly of the digastric, suprahyoids, and thyrohyoids to pull the larynx up and forward?
When larynx is pulled up and forward during swallowing, the vfs close and the CP opens so the bolus can travel where it is supposed to
The epiglottis is the ____ line of defense.
1st
The vf are the ___ line of defense.
2nd
Laryngeal Structures (10):
1) Hyoid bone
2) Epiglottis
3) Valleculae
4) Laryngeal vestibule
5) Aryepiglottic folds > lateral vestibule walls
6) Thyroid cartilage
7) Arytenoid cartilages
8) False vocal folds
9) True vocal folds
10) Ventricles – lateral
Laryngeal Muscles (8):
1) PCA (posterior cricoarytenoid)
2) LCA (lateral cricoarytenoid)
3) Interarytenoid
4) TA (thyroarytenoid)
5) Laryngeal strap muscles (Thyrohyoid, Sternothyroid, Sternohoid)
Laryngeal Muscles: PCA (posterior cricoarytenoid) –
attaches cricoid lamina to arytenoid; abducts arytenoids/vocal folds for respiration at end of swallow
Laryngeal Muscles: LCA (lateral cricoarytenoid) –
attaches cricoid cartilage to arytenoid; adducts arytenoids/vocal folds
Laryngeal Muscles: Interarytenoid –
attaches 2 arytenoids; adducts arytenoids/vocal folds
Laryngeal Muscles: TA (thyroarytenoid)* –
attached thyroid cartilage to arytenoid; tilts arytenoids anteriorly during swallow to assist with airway closure
* makes up vocal fold (along with vocalis m.)
Laryngeal strap muscles (3):
1) Thyrohyoid
2) Sternothyroid
3) Sternohyoid
Laryngeal Strap Muscles: Thyrohyoid -
– attaches thyroid cartilage to hyoid bone; elevates & lowers larynx
Laryngeal Strap Muscles: Sternothyroid -
– attaches sternum to thyroid cartilage; suspends larynx & trachea in neck
Laryngeal Strap Muscles: Sternohyoid -
– attaches sternum to hyoid; lowers & stabilizes hyoid
Esophageal Structures:
1) UES (upper esophageal sphincter) (aka CP (cricopharyngeus), Also called: PE segment (pharyngoesophageal sphincter)
2) Esophagus (~25 cm long)
3) LES (lower esophageal sphincter – located right above the stomach, closes off to prevent backflow
What happens to the LES with longterm repeated reflux?
Erosion over time will erode the elasticity of the muscle. It no longer works
Esophageal Muscles:
1) UES
2) LES
3) 2 layers of muscle in esophagus (Striated & smooth muscle)
- Inner circular
- Outer longitudinal
UES (Upper Esophageal Sphincter) (fnc):
– keeps air out of esophagus, keeps contents swallowed from coming back up
LES (Lower Esophageal Sphincter) (fnc):
– keeps contents in stomach
2 Layers of muscle in esophagus
(Striated & smooth muscle)
- Inner circular
- Outer longitudinal
Oral Prep / Oral Phase (time):
time varies with bolus consistency
Oral Prep/ Oral Phrase:
- Labial m., lingual mvmt, sensory receptors, buccal m., nose breathing
- mastication – rotary lateral mvmt of jaw & tongue
- bolus formation – tongue mixes bolus w/ saliva
- “tipper” or “dipper” (where does your tongue go?) (Dodds et al., 1989) – most pts w/dysphagia were “dippers”
- bolus transport (tongue’s posterior mvmt of bolus)
from the oral cavity to the pharynx - ↑ viscosity = ↓ volume = ↑ pressure = ↑ m. activity
- multiple swallows
General Rule about viscosity and volume:
- Increasing the viscosity = decreasing the volume
- e.g. larger sip of water and smaller bite of steak
- Increase the viscosity = increase the pharyngeal pressure = gives you a harder swallow = makes the muscles activate more
Pharyngeal Stage Time
~ 1 second
Pharyngeal Stage: What Happens?
a. Velum elevates & retracts for VP closure, bolus transport with tongue base retraction & pharyngeal wall contraction
b. Epiglottis inverts over the laryngeal vestibule, hyolaryngeal elevation & protraction
c. Closure of larynx (upward and farward movement of the larynxs causes CP opening)
d. CP opening
e. Transport by pharyngeal
constrictors
f. CP closure, larynx rests
Delayed pharyngeal swallow =
if pharyngeal stage not triggered when bolus head passes between faucial arches and tongue base
In MBS: examples of signs of delayed pharyngeal swallow
penetration aspiration premature spillage vallecula pooling etc.
Anything coming over the tongue base and pharyngeal swallow has not triggered =
premature spillage
Also need to say there is a delayed pharyngeal swallow
Also mention where it landed
If the bolus goes into the vallecula or pyriform sinuses =
poolings
If stuff is there AFTER the swallow =
residue
Esophageal Stage (time):
8-20 seconds
Esophageal Stage: What happens?
- transit time is measured from UES through LES
- bolus flow through the esophagus via peristaltic contractions of striated and smooth muscle along the esophageal wall
- relaxation of LES allows bolus to flow into the stomach
Young Normal A+P Variations (4):
1) Higher hyoid & larynx (better protection), less elevation
2) Lower velum, shorter pharynx
3) Uvula in epiglottis, pocketing valleculae
4) Pharyngeal swallow is triggered at anterior faucial arch (bolus flow uninterrupted, no pause)
* Infants = can Suck swallow breath so bolus flow is uninterrupted, no pause
Older normal A+P Variations (8):
1) Ossification of cartilages & hyoid bone
2) Pharyngeal swallow triggered when bolus head reaches middle of tongue base
3) 70+ larynx lower
4) Arthritis in C vertebrae impinge on pharyngeal wall
5) Typically “Dippers”
6) Delay, residue, penetration
7) Reduced hyolaryngeal excursion, plateaus at CP opening
8) Reduced CP opening flexibility
Neurologic A+P Variations (1):
1) Pharyngeal swallow triggered when bolus head reaches middle of tongue base or when falls into pyriforms
Is Aspiration ever normal?
No.
Aspiration is NEVER normal at any age! If they are normal health people, they should not be aspirating! They move into the dysphagia category
Sensory (afferent) nerves for swallowing (5):
Trigeminal (V) Facial (VII) Glosso-pharyngeal (IX) Vagus (X) Hypoglossal (XII)
Sensory: “Try for Good Vibes Honey”
Trigeminal (V) afferent fnc:
Sensation anterior 2/3 of tongue
Facial (VII) afferent fnc:
Taste anterior 2/3 of tongue
Glosso-pharyngeal (IX) afferent fnc:
Taste & sensation post. 1/3 of tongue
Vagus (X) afferent fnc:
Mucous membrane of pharynx, larynx, bronchi, lungs, esophagus, stomach
Hypoglossal (XII) afferent fnc:
Sensation, mucous membranes of pharynx, palate, post. tongue & tonsils
Motor (efferent) nerves for swallowing (6)
Trigeminal (V) Facial (VII) Accessory (XI) Glosso-pharyngeal (IX) Vagus (X) Hypoglossal (XII)
Motor: “Try for a good vibe honey”
Trigeminal (V) motor fnc:
Mastication
Facial (VI) motor fnc:
Lips, face, salivary glands
Accessory (XI) motor fnc:
Uvula, palate, pharyngeal constrictors
Glosso-pharyngeal (IX) motor fnc:
Pharynx, gag reflex
Vagus (X) motor fnc:
Trachea, larynx, pharynx, cough reflex
Hypoglossal (XII) motor fnc:
Tongue
Which nerve is the most important for protection?
Vagus, especially for airway protection!
Which nerve has been damaged with silent aspirators?
Silent aspirators – Vagus has been damaged.
What is the CPG (central pattern generator)=
area for reflexive/automatic swallowing located in the medulla
Cortical input: what is cortical input to swallowing?
Cortical damage –> abnormal swallowing
Undeveloped/absent cortex (infants) –> normal swallowing
Is swallowing volitional or reflexive? Cortical or brain stem?
We don’t know. Maybe it’s both and when one is gone the other takes over? We don’t know for sure.
Explain the Apneic period:
- During pharyngeal stage
- Lasts ~ 1 second
- Increases as volume increases
- Mostly during exhalation (at end or near end)
- Safer than inhalation
- Dysphagia occurs during inhalation
