Exam #1 Flashcards
Describe the primary functions of swallowing.
- Supportive function- carrying food from the mouth to the stomach
- Protective function- protecting the respiratory system
- *necessary because in the adult human, the upper respiratory and digestive paths are crossed. Crossroads is called the “upper aerodigestive tract”
What are the four phases of the normal swallow?
- Oral preparatory
- Oral transport
- Pharyngeal
- Esophageal
Describe Oral preparatory- Phase 1
Function= Ingested material brought into the oral cavity and contained there
a. Structure= lips involved in grasping, sucking, and forming anterior oral seal; teeth and cheeks are also involved
b. Important to prevent food from spilling out
- Oral preparatory- Phase 2
Function: bolus formation
a. Structure= jaw moves in a “rotary lateral” pattern in mastication
b. tongue positions material between occlusal surfaces of teeth
c. buccal tone prevents spillage of bolus into lateral sulci (cheeks)
d. saliva has several functions: chemical breakdown of ingested material, lubrication of material, promotes oral hygiene
- Oral preparatory- Phase 3
Function= bolus containment
Structure= bolus is contained between tongue and hard palate
b. tongue tip contacts alveolar ridge to contain bolus anteriorly
c. superior tongue surface contains bolus inferiorly
d. lateral tongue margins contact maxillary teeth to contain bolus laterally
e. posterior tongue contacts soft palate to contain bolus posteriorly, forming the retro-oral seal
f. Containment Helps prevent residue in lateral sulci/under the tongue
a. Retro-oral seal prevents food from entering the nose or the lungs
Oral transport- phase 1
Function= bolus is transported posteriorly by the tongue
Structure= bolus is squeezed posteriorly between superior surface of tongue and hard palate by tongue “stripping wave” action
- Oral Transport- phase 2
Function= tongue loading
a. Structure= soft palate elevates and posterior tongue lowers, breaking retro-oral seal
b. superior tongue surface forms a central groove
c. tongue dorsum moves inferiorly and anteriorly, loading the bolus on its surface
i. Bolus sits in central groove to move backwards
Oral Transport- Phase 3
Function= pharyngeal stage of swallow is triggered
Structure= bolus stimulates sensory receptors lining anterior faucial pillars, tongue base, and posterior pharyngeal wall
- Pharyngeal- Phase 1
Function= Formation of the VP seal
Structure= soft palate (velum) contacts posterior pharyngeal wall
- Pharyngeal- Phase 2
Function= Tongue propels bolus into pharynx
Structure= mandible is stabilized
b. posterior tongue makes a piston-like motion that drives the bolus through the pharynx
- Pharyngeal- Phase 3
Function= laryngeal closure
Structure= larynx closes in an inferior to superior direction
b. true vocal fold closure
c. false vocal fold closure
d. arytenoid cartilages to epiglottic base
e. deflection of the epiglottis
f. **important safety parts
Pharyngeal- Phase 4
Function= hyolaryngeal elevation/excursion
Structure= hyoid elevates and moves anteriorly, pulling thyroid cartilage with it
b. once hyoid reaches maximal elevation, thyroid cartilage continues to elevate due to contraction of thyrohyoid muscle
Pharyngeal- Phase 5
Function= epiglottic deflection; (a) allows bolus to empty out of valleculae, (b) directs bolus laterally toward pyriform sinuses, away from laryngeal vestibule
Structure= epiglottis deflects to horizontal
b. mechanical forces of laryngeal elevation
c. epiglottis deflects below horizontal
d. active muscle forces (aryepiglotticus & thyroepiglotticus m.)
e. traction from anterior movement of hyoid (lateral hyoepiglottic ligaments)
- Pharyngeal- Phase 6
Function: opening of Upper Esophageal Sphincter (UES) allows entry of bolus into
esophagus
Structure= UES is comprised principally of the cricopharyngeus muscle
b. during swallowing, UES opens due to:
-relaxation of cricopharyngeus
-traction by anterior/superior movement of hyo-laryngeal complex
-outward pressure exerted by bolus itself (intrabolus pressure)
Pharyngeal- Phase 7
Function= bolus is cleared from the pharynx
Structure= bolus clearance:
i. propagated contraction of pharyngeal constrictors (peristalsis)
ii. shortening of pharynx
Esophageal Phase
Function= bolus transport from pharynx to stomach
Structure= primary peristalsis - progression of a peristaltic contraction along the esophagus in coordination with relaxation of UES and LES
b. secondary peristalsis - peristalsis initiated by intraesophageal distention (e.g., material from a previous swallow, gastric reflux)
Describe the process of coughing
-reflex involving afferent inputs, and forceful expulsion of air from lungs
-rapidly accelerating expiratory airflow sweeps tracheal surface
- List the four main components of the neural control of swallowing.
- Afferent input- sensory
- Medullary swallow centre- brainstem bilateral swallowing control
- Efferent output- motor nuclei, CN innervation to muscles
- Descending cortical and subcortical inputs
Name the primary brainstem nuclei involved in the CPG for swallowing.
- Dorsal swallowing group (programming component)
* * nucleus tractus solitarius (NTS) and adjacent reticular formation (RF) - Ventral swallowing group (motor component)
* * nucleus ambiguous (NA) (important nucleus for motor execution) and adjacent RF
Describe lateralization for swallowing
o Dominant in left hemisphere most prevalent
o Damage to left hemisphere increases chances of dysphagia
o For right hemisphere dominance, the dominance is stronger
Define dysphagia.
- Difficulty moving ingested material from mouth to stomach.
o Cause – malnutrition, dehydrations, AP
o Symptom – COPD, HNC, developmental disability
o Side effect – chemo, pharmacological intervention, psychological condition, breathing tube
Identify the signs of dysphagia.
- difficulty chewing food
- difficulty controlling food in oral cavity
- difficulty initiating a swallow
- coughing when swallowing food
- food sticking in throat
- reflux from esophagus or stomach
Contrast penetration and aspiration.
- Penetration- entry of foreign material into airway to the level of the true vocal folds
- Aspiration- entry of foreign material into airway beyond level of the true vocal folds (tracheal aspiration)
- Identify the main structures of the lower respiratory tract.
o Conducting Zone
o Respiratory Zone
Proximal airway clearance in the LRT.
Pulmonary clearance is mechanical
* 1. Cough
* Mucociliary action – mucus and foreign particles trapped within it are propelled toward major airways and trachea by beating of cilia
* cilia extend from larynx to terminal bronchiole and adjacent cilia beat in coordination
* mucous layer and ciliary action is altered in certain conditions
Identify the signs of massive aspiration pneumonia.
o fever
o leukocytosis – increased WBC count
o cough
o sputum (mucous and saliva combo) production
o inspiratory crackles
o infiltrates in lung on chest x-ray
o Substance that is denser than air (pus, blood, protein)
- List the factors related to aspiration tolerance.
- nature of aspirate (frequency, volume, acidity, depth)
- status of immune system
- level of consciousness
- mobility
- prior history of pneumonia
- age
- pulmonary status
- nutritional status
Name the primary organs and accessory organs relevant for digestion.
- Primary- stomach?
- Accessory- Liver, gallbladder, pancreas
Describe the 2 main etiologies of oropharyngeal dysphagia.
- Neurological Disease
a. Acquired (Stroke/TBI)
b. Progressive/Degenerative (Huntington’s, Parkinson’s, ALS) - Mechanical/Structural Factors
a. Surgical removal/cancers
b. Edema (Swelling/inflammation)
c. Xerostonia- dry mouth (related to medications/radiation)
- Describe the impact of dysphagia.
- Enjoyment of food/drink
- Sustaining our bodies (Malnutrition/dehydration/weight loss)
- Cultural aspects (postures during eating)
- Social connections
- Emotional impact (Isolation/reduced social participation)
- Family connections
- Cost of treatment
- Life-threatening
o C/o food sticking to the roof of their mouth
difficulty with stripping wave h: action, xerostomia/reduced salivary output, tongue not able to move up (gloss. Nerve, tongue muscular damage)
o Patient C/o constantly wiping their chin-
reduced lip closure (anterioral seal), excess salivary output
o C/o slow eater
difficulty forming cohesive bolus, muscles of mastication muscles, delayed initiation of swallow (increased oral transit time)
C/o coughing before swallowing-
premature spillage
C/o food not going down-
absent pharyngeal swallow
C/o food sticking in the throat
PES, not opening to move down, residue in the valleculae, pyriform sinuses, PPW
C/o coughing-
aspiration, inadequate laryngeal closure, penetration
C/o hoarseness
- reflux, may have residue on VFs, inadequate laryngeal closure
o C/o liquid coming out of nose
VP Closure inadequate, nasal penetration
o C/o remnants of food in mouth after meal-
tongue sweeping, reduced sensation, reduced ROM of tongue, strength of tongue, buccal tone, labial tone
- Describe the goals of the swallow screening
o Formal dysphagia screening procedures are associated with increased adherence rates to actually performing dysphagia screens
o Formal screening associated with a decreased pneumonia risk
o Underscores fact that a screening tool should improve health outcomes simply because it was implemented
- Describe the goals of the clinical bedside swallow assessment.
(Obvious): define presenting problem
o acquire relevant health history
o gain information about possible etiologies/initiate appropriate referral process
o make initial observations of oral/pharyngeal/laryngeal sensorimotor and swallowing function
o estimate probability of aspiration
o determine need for additional tests/readiness for radiographic tests
(Less obvious): postural considerations
o determine need for alternate nutritional support as patient awaits additional tests
o estimate risk of malnutrition, dehydration, aspiration pneumonia
o selection of optimum swallowing instructions (posture, strategies)
Describe the Oral Preparatory Phase
Ingested material is broken down mechanically and chemically to form a bolus
a. Mechanically= chewing
b. Chemically= due to the enzymes in the saliva
Describe the Oral Transport Phase
Bolus is moved posteriorly over the tongue surface
a. Semi-voluntary process
Describe the Pharyngeal Phase
a. Phase is triggered when a moving bolus excites oropharyngeal sensory receptor
b. Bolus transported from mouth to esophagus
Describe the Esophageal Phase
a. Bolus is transported to stomach
b. Involuntary process
Distal airway clearance in the LRT?
Distal- Pulmonary clearance is different in distal segments
- Clearance of particles
* pulmonary clearance of particles is cellular
* alveoli are protected by alveolar macrophages which provide phagocytosis (particle ingestion) and carry particles to lymph nodes
* alveolar macrophages kill pathogens after phagocytosis - Clearance of liquids
* pulmonary clearance of liquids is by lymphatics
* lymphatics normally clear 400-700 ml/day
* persons with chronic heart failure (CHF) have reduced lymphatic clearance
* Risk pneumonia
Describe the Dorsal Swallowing Group
Programming Component
* * nucleus tractus solitarius (NTS) and adjacent reticular formation (RF)
o Involved in arousal/alertness
* afferent information from CN IX and CN X (pharyngeal branch)
* palatal, pharyngeal, laryngeal inputs:
o “trigger neurons” – certain amount of sensory input needed to be triggered
o sensory “threshold” (affected by level of arousal and sensory capacity)
* Most complex ‘reflex’ initiated by CNS
* active early in swallow (1st steps with sensory info)
Describe the Ventral Swallowing Group
Motor Component
* * nucleus ambiguous (NA) (important nucleus for motor execution) and adjacent RF
* active following neuronal firing in the dorsal swallowing group
* active later in swallow
* Damage to the dorsal swallowing group would mean that ventral response does not happen
Describe the Conducting Zone
transporting air to RZ (trachea, mainstem bronchi, secondary bronchi, tertiary bronchi/segmental bronchi)
Describe the Respiratory Zone
site of gas exchange
Includes respiratory bronchioles, alveoli, alveolar ducts and sacs
Respiratory defense mechanisms
Identify the best predictors of compromised airway safety.
- Failure on thins
- Wet voice after swallow
- Failure on thick
- Cough after swallow
- Inability to self-feed
What are the contraindications of trial swallows?
-If there is anything in report of recent and continuous aspiration, we wouldn’t pursue a trial swallow
-Severe dysarthria- inadequate laryngeal closure no trial swallow
-Mental/cog. status severe impairment (not able to follow single-step instructions)
-Severe dysphonia (Perceptual characteristic of breathy voice- worry that the airway is staying open (not safe))
-Trial cough- if inadequate, could mean no closure of VFs and they wouldn’t be able to clear something from the airway
Compare and contrast VFSS and FEES (procedure, purpose, key differences).
VFSS:
* more comprehensive
* uninterrupted
* access limited to Radiology department
* radiation exposure
FEES:
* focused on pharynx
* lost at peak of swallow
* superior for evaluating anatomy, pooled secretions
* portable
* no radiation
* sensory testing capabilities
Go study the anatomy landmarks!
Okay!
What is the purpose of VFSS (videofluoroscopic swallow study)?
To evaluate anatomy/physiology of swallowing mechanism
To identify patterns of impaired swallow physiology
To confirm patient symptoms
To identify consequences of impaired swallowing
To evaluate effect of compensations on safety and efficiency
To make recommendations re: nutrition/hydration intake, oral diet level, need to modifications/intervention
What is the purpose of Fiberoptic Endoscopic Evaluation of Swallowing – FEES?
To evaluate anatomy/physiology of swallowing mechanism
To identify patterns of impaired swallow physiology (pathophysiology)
To confirm patient symptoms
To identify consequences of impaired swallowing
To evaluate effect of compensations on safety and efficiency
To make recommendations re: nutrition/hydration intake, oral diet level, need to modifications/intervention
What is the procedure of FEES?
Scope is passed through nasal cavity
With scope in the nasopharynx, view velopharyngeal port closure
Speech tasks
Dry swallow
Tip of scope is deflected, and passed into oropharynx
Note saliva, appearance of pharynx/larynx, position of epiglottis
Dry swallow, breath hold, cough, phonation
Vocal fold adduction
Symmetry of vocal folds (rest, adduction)
