Describing the Typical... (RJ)

Question 1

Describe, integrating relevant head and neck anatomy and physiology, the process of typical swallowing.

Answer 1

There are 4 phases to typical swallowing.
1. Oral Preparatory phase.
In this phase, food is tasted (CN VII and IX), and masticated using teeth, the muscles of the TMJ (innervated by CN V) and manipulated by the tongue (CN XII). Saliva is secreted (CN VII) from the salivary glands which assists in the formation of the bolus and begins the breaking down process of the food (enzymes). Lip seal prevents spillage (CN VII) and nasal breathing due to closed mouth.

2. Oral Transit Phase
   In this phase, the bolus is pushed to the back of the mouth by the muscles of the tongue (CN XII) pushing the bolus to the roof of the mouth, anterior to posterior. When the bolus touches the back of the mouth, sensory receptors at the back of the tongue and oropharynx trigger the pharyngeal/swallowing reflex (CN??).
3. Pharyngeal Phase
   As the bolus enters the pharynx, the soft palate elevates closing off the nasal passageway, the larynx elevates anteriorly, vocal folds close (ceasing respiration and protecting the airways) and the epiglottis is pushed down, covering the opening of the larynx as the bolus is propelled down the pharynx.

4.Esophageal Phase
The bolus is moved by peristalsis and gravity down the esophagus and into the stomach where digestion can occur (about 8 seconds).

Question 2

Describe, integrating relevant head and neck anatomy and physiology, the process of typical speech production.

Answer 2

There are 2 key components for typical speech production:

1. Motor planning
2. Motor execution

Which require the normal functioning of 5 key subsystems:

1. Respiration - provides the subglottic air pressure that is needed to set the vocal folds into vibration
2. Phonation - The production of voice phonemes through the vocal folds vibrations in the larynx
3. Resonance - the proper placement of oral or nasal tonality onto phonemes during speech /mvmt of air in the oral/nasal/pharynx cavity
4. Articulation - the shaping of the vocal airstream into phonemes
5. Prosody - conveys meaning through use of stress and intonation

Motor planning for speech begins in the Association cortex with the intent to move and then the actual planning for the movement.

The message for Motor execution then travels through the control circuits of the basal ganglia day cerebellum to the Thalmus, Primary Motor Cortex and onto the Cranial Nerves which pass the message along to the neuromuscular junction which then innervates the muscles required for articulation. Important muscles include those of the jaw (TMJ), facial muscles such as orbicularis oris and the extrinsic and intrinsic tongue muscles. The muscles move the articulations thus shaping the airflow, producing speech sounds.

Question 3

Describe, integrating knowledge of SP range of practice areas, typical communication in the healthy ageing population.

Answer 3

In the healthy ageing population it is normal for:

1. Language
   - Decline in cognition/processing (perception)
   - difficultly with processing speech in noise
   - difficultly with fast speech rate
   - difficultly with syntactically complex spoken/written language
   - decline in visual/ auditory acuity
   - Decline in written/verbal production
   - decline in word retrieval
   - Decline in spelling
   - Decline in density of ideas
   - increase in off topic speech
   * * semantics is a strength
2. Speech
   - decreased accuracy in articulation due to muscle strength decreasing
3. Fluency
   - longer gaps due to decreased cognitive processing
   - increased duplication of syllables / words to buy time
4. Voice
   - decline in muscle strength which may impact clarity of speech, vocal pitch (decreased mass per unit of length = higher pitched voice), gravelly voice (muscle weakness in vocal folds)

Question 4

Describe, integrating knowledge of SP range of practice areas, typical swallowing in the healthy ageing population.

Answer 4

Anticipatory
- decreased smell, taste, regulation of thirst
Decreased taste sensation => decreased appetite and/or change in food preference => decreased nutrition

Oral Prep Phase
- increased chewing strokes/time (Loss of teeth
+ Decline in muscle elasticity/atrophy (tongue, jaw, throat) + Decline in saliva production => difficultly chewing and increased time for mastication)

Oral Transit Phase

• decreased tongue driving force to propel bolus to back of throat
• delay triggering the swallowing reflex
• more than one swallow to clear bolus

Pharyngeal Phase
- Increased likelihood of laryngeal penetration (reduced laryngeal elevation) => coughing
***
Decline in respiration (decrease chest wall elasticity and compliance, increased functional residue capacity) => Respiration/swallow cycle changes

Question 5

List foods suitable for a healthy ageing swallowing

Answer 5

Aim to be inclusive

Liquids/purées

• Custard
• Soup (blended)
• Yoghurt
• Sauces/gravies
• Jelly (not suitable for dysphagia)
• Ice cream (not suitable for dysphagia)

Soft food

• Well cooked slow cooker casseroles (meats mustn’t be stringy)
• Lasagne/pasta (well cooked but not hard/crispy)
• Salmon
• Dips with soft bread (but not gluggy white bread)
• Boiled vegetables
• omelettes
• Puddings
• Cake

Mixed Texture (need to swallow liquid first then chew)

• Minestrone
• Porridge

NB straws avoid first protection, the lips, and alters I tea oral pressure /safe swallow => increased chance of coughing

Question 6

Describe typical voice production.

Answer 6

To make the voice work, the vocal folds need to be voluntarily adducted by the intrinsic laryngeal muscles which bring the arytenoid cartilages together to which the vocal folds are attached. Expiratory force (caused by respiration) causes air pressure to build up below the vocal folds until there is sufficient pressure to blow them apart momentarily. The ongoing adductors force maintains the medial compression. The speed of the air flowing past creates a suction (Bernoulli effect) which brings them back together until the pressure builds up again. This process is repeated 100-200 x second.