Exam 1

Question 1

Triggering the pharyngeal phase of the swallow: triggering occurs between what structures?

Answer 1

The anterior faucial arches to the line of ramus of the mandible.

Question 2

Triggering the pharyngeal phase of the swallow: what cranial nerve is responsible for sensing the bolus at the faucial pillars, and thus “triggering” this phase of the swallow?

Answer 2

Cranial nerve IX - Glossopharyngeal nerve

Question 3

True of false? Triggering the pharyngeal phase is an “involuntary” initiation of a swallow.

Answer 3

False - it is voluntary

Question 4

Triggering the pharyngeal phase of the swallow: There are different trigger points across ages. What are the trigger points for:

1) Infants
2) Young adults
3) Older adults

Answer 4

1) valleculae
2) anterior faucial pillars
3) middle of the tongue base

Question 5

Triggering the pharyngeal phase of the swallow through sensory input: Aside from the glossopharyngeal nerve (CN IX) what else provides sensory input?

Answer 5

1) oral cavity
2) tonsils
3) soft palate
4) post pharyngeal wall

Question 6

It is hypothesized that a sensory recognition center in the _____ _____ decodes sensory information, identifies the swallow stimulus, and sends information to the _____ ______ - which initiates the motor response for the pharyngeal swallow.

Answer 6

lower brainstem; nucleus ambiguous

Question 7

Describe what tongue and velum do during the pharyngeal stage of the swallow.

Answer 7

The velum elevates to seal the nasopharynx, and the tongue base moves forcefully to meet the pharyngeal wall and squeeze the bolus downward

Question 8

What CN are responsible for the oral phase of the swallow?

Answer 8

CN V & CN VII -mastication and jaw opening

Question 9

What CN are responsible for the pharyngeal phase of the swallow?

Answer 9

CN IX and X

Question 10

What CN are responsible for the esophageal phase of the swallow?

Answer 10

CN X

Question 11

What triggers the oral phase of the swallow?

Answer 11

It’s voluntary

Question 12

How is the pharyngeal phase of the swallow triggered?

Answer 12

Sensory input from the oral cavity, tonsils, soft palate, and post pharyngeal wall.

Question 13

What triggers the esophageal phase of the swallow?

Answer 13

.

Question 14

Name the tongue muscles and their functions used during the pharyngeal stage of the swallow.

Answer 14

1) Styloglossus: raises and retracts posterior tongue

2) Hyoglossus: pulls tongue back toward hyoid bone

Question 15

Describe what the velum does during the pharyngeal stage of the swallow.

Answer 15

the velum elevates and contacts the lateral and posterior walls of the pharynx to establish velopharyngeal port closure.

Question 16

This movement closes the nasopharynx at about the same time that the bolus head comes into the pharynx. Name the structure and the movement.

Answer 16

Velum elevation and contraction during the pharyngeal phase of the swallow.

Question 17

What does velum elevation prevent?

Answer 17

bolus regurgitation into the nasal cavity

Question 18

Describe what the tongue does during the pharyngeal stage of the swallow.

Answer 18

the base of the tongue retracts and comes in contact with the pharyngeal wall.

Question 19

Tongue retraction during the pharyngeal phase of the swallow is critical for two reasons - what are they?

Answer 19

1) It closes off the entrance to the oral cavity so that the bolus does not go back into the oral cavity.
2) It creates a tongue-driven force that helps push the bolus down into the pharynx.

Question 20

What are the 4 components of airway protection?

Answer 20

1) Hyoid/laryngeal elevation away from path of bolus
2) Epiglottis retroflection (elevation of the larynx to approximate the hyoid bone results in flipping the epiglottis over to a more vertical position)
3) Closure of laryngeal vestibule
4) Adduction of the false/true vocal folds.

Question 21

Name the function of the palatoglossus

Answer 21

elevates the soft palate and seal the nasopharynx

Question 22

What are the weaknesses with the bedside swallow evaluation?

Answer 22

• person may not cough because they are silently aspirating
• Gross estimates are made, but no real information on the pharyngeal stage of the swallow is collected
• Since the structures cannot be seen, the most appropriate therapy cannot be determined.

Question 23

What are the signs of silent aspiration?

Answer 23

• all the symptoms of aspiration without the cough
• wet, gurgly voice quality
• watery eyes
• painful face
• shortness of breath

Question 24

What are the steps/procedure of the bedside evaluation?

Answer 24

Is the patient showing signs of dysphagia?
1. First, SCREEN to identify high risk patients who require further assessment with a full bedside exam, as well as instrumentation to assess swallow physiology.
- Review their chart to look for factors indicating dysphagia
-observe PT during meatime
- Look for signs suggesting a need for referral or further evaluation.
- you can do a water test, but it’s highly controversial and has a high false positive rate.
-if you decide a bedside swallow evaluation should be done, get physician’s approval/referral.
2. If approved/referred, proceed with bedside swallow exam.
2a) Review PT’s history/chart for med reports and PT complaints
2b) Physical exams
-oral mech
-structures: face, jaw,
tongue, larynx, velum
- Ability to protect airway
- quality of cough
2c) Test swallows
- s/s/ of aspiration, oral, pharyngeal dysphagia
- determine if further
instrumental testing is
needed?

Question 25

What is the difference between penetration and aspiration?

Answer 25

penetration of food/liquid into the larynx that DOES NOT extend beyond the true vocal folds. Whereas aspiration is entry of food/liquid into the airway BELOW the level of the true vocal folds

Question 26

How can we test the function of CN X?

Answer 26

Sensory test: swab velum and look for soft palate elevation. | Motor test:

Question 27

There are 4 stages to a normal swallow - generally speaking, what happens in each stage?

Answer 27

1) Oral prep = food is masticated in preparation for transfer. 2) Oral transport = transfer food from mouth to the oropharynx 3) Pharyngeal = food is transported away from the oropharynx into upper esophagus 4) Esophageal - food is transported from the esophagus to the stomach

Question 28

what specifically are the functions of the oral prep phase?

Answer 28

1) mastication 2) Bolus formation 3) Bolus maintenance

Question 29

Oral prep is under voluntary control. What occurs (as far as the oral cavity structures) during oral prep of food into bolus?

Answer 29

- close lips, good buccal tension - velum lowered for nasal breathing - lingual-velar seal - mastication

Question 30

When does the oral transport phase begin?

Answer 30

when the tongue begins to propel the bolus posteriorly | -

Question 31

What is the sequence of events that take place during the oral transport phase?

Answer 31

- starts when tongue begins to propel the bolus posteriorly - Tongue tip and sides to the alveolar ridge - propels bolus upward and backward - oral phase ends when bolus reaches ramus of mandible

Question 32

What cranial nerves are involved in triggering the pharyngeal phase?

Answer 32

CN IX and X

Question 33

What is the swallowing center?

Answer 33

Medulla; CPG in the nucleus tractus solitarus in the lower brainstem.

Question 34

Is the triggering of the pharyngeal phase of the swallow voluntary or involuntary? What about the pharyngeal phase itself?

Answer 34

Voluntary; involuntary

Question 35

What takes place during the pharyngeal phase of the swallow?

Answer 35

- Airway closure (at 3 levels) - Pharyngeal contractions - The bolus moves inferiorly - Upper esophageal sphincter (UES) opens/relaxes

Question 36

During the pharyngeal phase there is airway closure at 3 levels - what are they?

Answer 36

1) epiglottis 2) Aryepiglottic folds 3) False and true vocal folds

Question 37

During the pharyngeal phase the bolus moves inferiorly via a combination of what 3 things?

Answer 37

1) gravity 2) base of tongue retraction 3) pharyngeal wall contraction

Question 38

Is the esophageal phase voluntary or involuntary?

Answer 38

involuntary

Question 39

Where does the esophageal phase begin?

Answer 39

Where the bolus enters esophagus at UES

Question 40

What takes place during the esophageal phase of the swallow?

Answer 40

- larynx descends to rest position and respiration resumes (exhalation) - velum lowers (VP port open) - UES contracts/closes

Question 41

Opening of the UES allows the _____ to enter the esophagus.

Answer 41

bolus

Question 42

Opening of the UES occurs ____ the bolus arrives and contributes to the pressure differential within the ____

Answer 42

before;pharynx

Question 43

True or false? The UES tenses during the swallow.

Answer 43

False - it relaxes

Question 44

True or false? Elevation of the larynx pulls the UES open.

Answer 44

True

Question 45

True or false? Duration of the opening decreases as bolus volume increases.

Answer 45

False - duration increases

Question 46

More about the esophageal phase

Answer 46

- After entrance of bolus into the esophagus, the food is carried to the stomach via gravity and esophageal peristalsis. - LES closes after food enters the stomach - Esophagus joins the stomach through an opening in the diaphragm

Question 47

what CN is responsible for opening and closing the jaw?

Answer 47

CN V

Question 48

Suprahyoids assist in jaw opening (depressors). What cranial nerve(s) are responsible for each of the following suprahyoids muscles? 1) Diagastric 2) Stylohyoid 3) Mylohyoid 4) Geniohyoid

Answer 48

1) CN V, VII 2. CN VII 3. CN V 4. CN XII

Question 49

What CN is responsible for muscles of the face?

Answer 49

CN VII

Question 50

Major muscles during chewing - name the associated CN: 1) Temporalis 2) Masseter 3. Buccinator 4. Orbicularis

Answer 50

1) CN V 2) CN V 3) CN VII 4) CN VII

Question 51

Tongue Innervation - name the CN: 1) anterior 2/3 sensation 2) posterior 1/3 sensation 3) anterior 2/3 taste 4) posterior 1/3 taste

Answer 51

1) CN V 2) CN IX 3) CN VII 4) CN IX

Question 52

CN ____ innervates all intrinsic and extrinsic tongue muscles except for palatoglossus.

Answer 52

CN XII

Question 53

Palatoglossus is innervated by CN ___

Answer 53

CN X

Question 54

What CN's innervate muscles of the velum?

Answer 54

CN X, XI, and V

Question 55

What CN raise the velum (vp closure), and raises back of the tongue during stage 1 swallowing (open VP port)?

Answer 55

CN X

Question 56

What CNs shut off nasopharynx during stage 2 swallowing (VP closure), and raises velum?

Answer 56

CN X, XI

Question 57

What CN opens auditory tube?

Answer 57

CN V

Question 58

What are the symptoms of dysphagia?

Answer 58

- Cannot get swallow started - Coughing - Choking - Sticking - Bolus comes back up

Question 59

An absent/delayed reflexive cough indicates a high risk of?

Answer 59

silent aspiration

Question 60

During a screening, you observe a PT during mealtime. What are you looking for?

Answer 60

- reaction to food/self-feeding skills - oral movements in chewing - Coughing, clearing throat or struggle behaviors - changes in breathing, secretion levels through meal - duration of meal and total intake - coordination of breathing and swallowing

Question 61

During a screening, what are the signs suggesting a need for a referral for further evaluation?

Answer 61

- decreased alertness/cognitive dysfunction - inappropriate approach to food - manifestations of impaired oropharyngeal function - PT complaints or observations of: - difficulty initiation swallow - long oral transport time (holding/pocketing food in mouth) - sensation of obstruction of bolus in chest/throat

Question 62

During the pharyngeal phase of the swallow, what CNs are responsible for raising the velum for VP closure and shutting off the nasopharynx?

Answer 62

CN X and XI

Question 63

During the pharyngeal phase of the swallow, what CN is responsible for innervating?

Answer 63

CN X

Question 64

With which stage of the swallow is the cricopharyngeus involved, and what CN innervates it?

Answer 64

Esophageal; CN X

Question 65

What is the Central Pattern Generator (CPG)?

Answer 65

The swallowing center

Question 66

What is the CPG comprised of?

Answer 66

Bilaterally arranged groups of neurons in the brainstem

Question 67

Specifically, where in the brainstem is the CPG located?

Answer 67

medulla oblongata

Question 68

Name the cranial nerve: - sensory/motor innervation to the face - Important for chewing

Answer 68

CN V

Question 69

Name the cranial nerve: - provides motor/sensory innervation to the palate, esophagus, stomach and respiratory tract - recurrent laryngeal nerve

Answer 69

CN X

Question 70

Name the cranial nerve: - sensory/motor fibers - sensation to the oropharynx & taste to the anterior 2/3 of tongue

Answer 70

CN VII

Question 71

Name the cranial nerve: - sensory/motor fibers - taste to the posterior of tongue, sensory.motor innervation the pharynx

Answer 71

CN IX

Question 72

How do you test for motor for CN X?

Answer 72

Have patient say "ah"

Question 73

How do you test sensory for CN X?

Answer 73

Swab velum, both sides should elevate unless there is muscle weakness

Question 74

What CNs are responsible for: 1) Oral prep 2) oral transit 3) trigger oral swallow 4) pharyngeal stage 5) esophageal stage

Answer 74

1) V, VII 2) XII 3) IX, X 4) X is most important 5) X (opens UES)

Question 75

Oral mech exam focuses on what?

Answer 75

- lips/face, jaw, larynx, velum | - exam the sensory/motor functions of CN V, VII, IX, X, XI, and XII

Question 76

Five areas of the oral mech are?

Answer 76

- oral structures/functions/sensation - VP mechanism - Laryngeal function - Respiration - Observation