Midterm I Flashcards by Kent Melendez

Name the four stages of swallowing:

Oral Prepatory

Oral Transit

Pharyngeal

Esophageal

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What events take place in the oral prepatory phase?

Mastication

Bolus formation

Bolus maintenance

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Cranial Nerve V innervates which muscles during the oral prep stage?

masseters, temporalis, pterygoid muscle

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Aside from the salivary glands, CN VII innervates which muscles of mastication?

orbicularis oris, zygomatic major/minor, superior levator labii, mentalis, risorius, caninus, depressor anguli

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The salivary glands are innverated by which two Cranial Nerves?

CN VII and CN IX

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When does the oral “voluntary” phase officially begin?

When tongue begins to propel the bolus posteriorly

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Explain in detail what happens during the Oral “voluntary” phase:

After the bolus has been formed through the help of the muscles of mastication and dentition, the tongue will propel the bolus to the back (oropharynx). In doing so, the tongue tip and sides will pan on alveolar ridge. Next the soft palate elevates and the tongue base drops. Pressure is exerted by the tongue, once the bolus reaches the ramus of the mandible, bolus enters the pharyngeal stage

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How long does the oral phase take?

1 - 1.5 sec

*.3 sec longer for persons over 60

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The pharyngeal phase of swallowig involves the complex interaction of:

tongue, velopharynx, and larynx

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Once the tonuge elevates, velopharyngeal closure begins, which triggers:

forward motion of the hypolaryngeal to increase opening of UES (upper esophageal sphincter); larynx elevates, and relaxation of cricopharyngeus musculature

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What mechanisms occur during the Pharyngeal Phase?

Velar elevation

Base of Tongue Retraction

Vocal fold adduction

sequential contraction of pharyngeal constrictors

epiglottis retraction/inversion

laryngeal/hyoid elevation and hyoid movment

constriction of the laryngeal vestibule

opening/relaxation of the cricopharyngeus

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Explain Pharyngeal Transit

base of the tongue retracts and contacts with the posterior pharyngeal wall

followed by a sequential contraction of upper, middle, and inferior constrictors

bolus moves downward via a combination of gravity, base of tongue retraction, and pharyngeal contraction

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What are the four mechanisms of airway protection?

Hyoid/laryngeal elevation

Epiglottic retroflexion

Adduction of the true vocal folds

Closure of the laryngeal vestibule or additus
****************************************************
Epiglottis retroflexion
false vocal cord adduction
true vocal cord adductioni
anterior movement of arytenoid cartillages

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Explain in detail how epiglottic retroflexion works:

suprahyoid, mylohyoid, and geniohyoid muscles are responsible for the anterior movement of the hyoid and tipping of epiglotts to a horizontal position

-base of tongue contributes to horizontal movement

elevation of larynx to approximate hyoid results in moving of epiglottic in vertical position

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What happens during closure of the laryngeal vestibule?

anterior tilting of the arytenoids

false vocal fold adduction

laryngeal elevation

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True or False:

The upper esophageal sphincter (UES) is a tonically contracted group of skeletal muscles separating the pharynx from the esophagus

True

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True or False

The UES at rest is in state of tonic contraction

True

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True or False:

Elevation of the larynx pulls the UES open: fibers of the cricopharyngeus are attached anteriorly to the laminae of the cricoid cartilage

True

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What happens during the Esophageal Stage?

Peristalsis: sequential contraction of the esophagus and relaxation of the LES

*bolus is propelled through the by contraction above and relaxation below the bolus (descending inhibition)

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Name some of the age-related changes in swallowing:

sense of taste is diminished (reduced sensory input due to dysphagia)

percentage of dippers increase

increase in amount of oral/pharyngeal residue

increase in transient penetration, but not incidental aspiration

greater delay during swallow

decrease in laryngeal elevation = decreased UES opening

True or False:

The changes seen in the elderly in regards to swallowing means that they have “less reserve” and may be more prone to aspiration when severely ill

True

Name some of the populations that are higher risk for having Dysphagia:

Cerebral Vascular Accident (patients)

Dementia & other neurodegenerative diseases

Head & Neck cancer

Hospitalized patients

Cardiac conditions: coronary artery bypass graft

Trauma

What is the purpose of a bedside clinical swallow?

screening for possible dysphagia
determine the physiologic factors contributing to dysphagia
determine for need of other tests
make recommendations for safest means of food intake

What are some of the clinical findings or signs of a patient with dysphagia?

coughing/choking while eating or drinking

frequent throat clearing

wet vocal quality

drooling

edentulous (missing teeth/no teeth)

SOB (shortness of breath)

spiking a temperature

increased time to complete a meal

oral residue

True or False: If patient is alert you should not do an exam

False

What are you looking for when doing an oral-mech exam?

examining the sensory/motor functions of CN: V, VII, IX, X, and XI checking for structural integrity of lips, jaw, tongue, hard palate, and velum oral hygiene strenght, range of motion, coordination, speed, direction of muscles in lips, tongue, jaw, and velum Palatal reflex (stroke soft palate) Gag reflex

Describe in detail how you would perform an exam testing CN V, VII, X, and XII

CN V: bite down to feel bulk on side (masseter) \*open mouth a bit and place finger on chin and ask them close CN VII: ask person to purse lips (check for lip seal) CN X: look at someone's mouth when they say aaaaa / glottal coup CN XII: movement of tongue, have their tongue push against your finger

As you're conducting the oral mech exam, what are some signs you should be looking out for?

check for the strength/presence of voluntary cough quality/quantity of secretions signs of apraxia/dysarthria/hypophonia rapid/shallow breathing ability to initiate dry swallow palpate for layrngeal elevation

True or False: If you do decide to feed, you can start with a tsp of water or whatever is easiest

True

As you're doing the feeding, what are some things you need to look out for?

lip closure (drooling) delay of initiation of swallow overt coughing or choking (before/during/after) swallow laryngeal elevation during swallow wet-gurgle voice after swallow oral residue after swallow

What does the rule of three stand for?

3 tsps, 3 sips, serial swallow, 3 pieces

What do you call when entrance of food/liquid into the larynx that *does not* extend beyond the true vocal cords

Penetration

What do you call when entry of food/liquid into the airway below the true vocal cords

aspiration

True or False: Brainstem CVAs often result in significant Dysphagia

True

Patients with Parkinson's Disease will show what asymptomatic features in regards to swallowing?

rigidity and bradykinesia (slowness of initiating movement) delayed oral transit (tongue pumping) delayed pharyngeal swallow reduced pharyngeal contraction

What are some asymptomatic features seen in patients with Multiple Sclerosis in regards to swallowing?

spasticity and incoordination of orpharyngeal and respiratory muscles

What are some asympotmatic features you see in patients with ALS in regards to swallowing?

\*swallowing problems in relation to bulbar movement swallowing secondary to weakness from UMN and LMN damage

Patients with Myasthenia Gravis show what asymptomatic features in regards to swallowing?

present with LMN signs oral and pharyngeal stage weakness \*progresses as person continues to eat

Patients with TBI will show these features in regards to swallowing:

poor oral control of bolus delay triggering of swallow weak pharyngeal transit

True or False Cortical dementias like Alzheimer's will typically affect the oral stage of swallowing

True

Patients who have undergone radiation therapy will show what asymptomatic features in regards to swallowing?

tissues tends to become fibrotic and lose their range of motion irritation of mucosa salivary glands are damaged leading to xerostomia

What is Zenker's Diverticulum?

Outpouching or pocket that forms in pharyngeal wall just superior to UES

Name some of the Esophageal Stage Dysphagias:

Zenker's Diverticulum Esophageal Cancer GERD LPRD (laryngopharyngeal reflux disease) Barrett esophagus: cellular changes to mucosa, predispose one to cancer

What does the FEES do?

can observe VP closure, structural integrity of the larynx/pharynx, excess secretions, sensation, and TVC adduction/abduction

This is the typical order of food consistencies given during an MBSS

thin liquids thick liquids puree soft solid regular solid

True or False: A very small amount of liquid is usually started with because it is easiest to clear from the airway and the amount of aspiration will be less

True

Match the following time frames during Pharyngeal of what is considered to be a delay in swallowing: ## Footnote A.) Mild Delay +5 seconds B.) Moderate Delay up to 3 seconds C.) Severe 3-5 seconds

Mild Delay: up to 3 seconds Moderate Delay: 3-5 seconds Severe: +5 seconds

What is the purpose of the Anterior/Posterior View of an MBSS?

allows one to view symmetry of bolus: transit residue and any anatomical variations check entire esophagus for any abnormalities