Normal Swallow Flashcards
2 Definitions of Dysphagia
- Difficulty moving food from mouth to stomach
- All of the behaviorial, sensory, and preliminary motor acts in preparation for the swallow, including cognitive awareness of the upcoming eating situation, visual recoginition of food, and all of the physiologic responses to the smell and presence of food such as increased salivation.
*** We always need to be aware of what is normal and what constitutes abnormal
Therapy techniques designed to improve feeding attempt to improve: (5)
- positioning of food in the mouth
- manipulating food with the tongue
- chewing a bolus of varies consitencies
- recollecting the bolus into a mass prior to the oral stage of the swallow
- organizing lingual action to propel the bolus
Swallowing therapy
- techniques for reducing any delay in triggering the pharyngeal swallow
- improving pharyngeal transit time and the individual neuromotor actions comprising the pharyngeal stage of the swallow
- techniques used to improve the oral prepatory stage and oral stage of the swallow.
Definition of swallowing
- entire act of deglutition from placement of food in the mouth through the oral, pharyngeala and esophageal stages of the swallow until the material enters the stomach through the gastroesophageal junction.
Symptoms of oralpharyngeal dysphagia (4)
- Aspiration
- Penetration
- Residue
- Backflow
- the entry of food or liquid into the airway below the true vocal folds
- entry of food or liquid into the larynx at some level down to but not below the true vocal folds
- food that is left behind in the mouth or pharynx after the swallow
- food from the esophagus into the pharynx and/or from the pharynx into the nasal cavity
Complications of dysphagia
- pneumonia
- malnutrition
- dehydration
*** multidisciplinary approach to treat (physician, OT, dietician, SLP, nurses, PT, pharmacists, and radiologist)
Indicators that an indepth study is needed (4)
- Rejection of food
- Food selectivity
- Gagging
- Open-mouth posture
Bedside Exam
- Patient chart review (look at respiratory status)
- Take pts. history - Observations upon entering the room (alertness, posture in bed, reaction to entrance, trach tube (cuff, inflated or deflated) and ability to handle secretions
- Check respiratory status
a. Also note timing of saliva swallows relating to respiratory cycle, timing of coughing, duration of comfortable breath, rest breathing pattern - Is there a trach?
Tracheostomy tubes are placed for:
- upper airway obstruction
- potential airway obstruction
- provision of respiratory care
*** Placement is below VF to prevent damage to the larynx (3 and 4th tracheal rings)
- Ventilator dependent patients
2. Intubation
- swallowing and respiration are reciprocal
- No swallowing therapy is appropriate when the pt. is intubated.
What to examine during bedside
- Oral mech exam- lip configuration, hard and soft palate, uvula, dentition, sulci, mandible, oral secretions (mouth wet or dry)
- Oral motor control exam- can pt. open mouth voluntarily? Look at movement and accuracy of movement of lips, tongue, soft palate, pharyngeal walls during speech and swallowing
- identification of oral sensory and bolus types
- Swallowing apraxia?
- Identification of abnormal reflexes (hyperactive gag, tongue thrusting, or tonic bite)
- Labial /i/ and /u// and lingual function (anterior /ta/ and posterior /ka/)
- Assess chewing with gauze
- Soft palate- sustain /a/ for several seconds
- Check gag reflex by touching the base of the tongue or posterior pharyngeal wall w/ tongue blade or laryngeal mirror
- Check palatal reflex by touching the space between the hard and soft palates with laryngeal mirror
- Oral sensitivity (assessed with light touch) Light contact with cotton ball to different regions of the tongue
Laryngeal function exam
-assess voic quality
— is it gurgly (aspiration)
— hoarse (reduced laryngeal closure)
— stength and quality of the pts. cough
— slide up and down a vocal scale
— prolong a phoneme as long as possible after a deep breath
Risk of bedside swallow
- patient is acutely ill
- has pulmonary issues
- weak voluntary cough
- over 80
- cannot follow directions
*** risk is great
If pt. is being fed orally observe feeding for:
- pts. reaction to food
- oral movements in food manipulation and chewing
- coughing or throat clearing
- changes in secretions
- duration of meal
- coordination of breathing and swallowing
Best posture
- tilt head back
2. head downward
Efferent Controls involved in Swallowing
1. Oral
a. Trigeminal V3
b. Facial VII
c. Hypoglossal XII
a. masticatory, buccinator, floor of mouth
b. lip sphincter
c. tongue
Efferent Controls involved in Swallowing
- Pharyngeal
a. Glossopharyngeal IX
b. Vagus X
c. Hypoglossal XII
a. Constrictors and stylopharyngeus
b. Palate, phaynx, larynx
c. Tongue
Efferent Controls involved in Swallowing
- Esophageal
a. Vagus X
a. Esophagus
Cranial Nerve Functions afferent and efferent
- V
- VII
- VIII
- IX
- afferent- proprioception for mastication, face to cornea, face to mouth (mediates pain, temperature, discriminative touch)
efferent- mastication, tensor tympani, tensor veli palatini, anterior belly of the digastric muscle
ophthalmic branch; maxillary branch; mandibular branch
- afferent- skin of the external ear, taste from the anterior 2/3s of the tongue
efferent- facial expression, salivation, lacrimation, stapedius muscle (inner ear)
- afferent- maintains equilibrium and head orientation in space as well as mediation of audition
- afferent- from the middle ear, palate, pharynx, posterior tongue, taste for the posterior 1/3 of tongue
- gag reflex
efferent- swallowing and parotid gland
Cranial Nerve Functions afferent and efferent
- X
- XI
- XII
- afferent- from pharynx, larynx, thorax, abdomen, and taste from the epiglottis
- gag reflex
efferent- swallowing, phonation, soft
palate (Larynx/pharynx muscles), Major organs
- autonomic: parasympathetic to thorax and associated viscera, regulates nausea, oxygen intake, and lung inflation
- has two components: recurrent & superior laryngeal nerves
a. External Branch of the Superior Laryngeal Nerve
- – Innervation of the cricothyroid
b. Internal Branch of the Superior Laryngeal Nerve
— Sensation above the level of the vocal folds (how you cough)
c. Recurrent Laryngeal Nerve
- – Sensations below the level of the vocal folds
- *** Innervation of most intrinsic laryngeal muscles
- efferent- controls head position by controlling the trapezius and SCM musculature
- Efferent- innervates the ipsilateral intrinsic and most extrinsic muscles of the tongue
Afferent controls involved in swallowing
- General sensation, anterior 2/3 of tongue
- Taste, anterior 2/3 of tongue
- Taste and general sensation, posterior 1/3 of tongue
- lingual nerve, CN V
- chorda tympani, facial (CN VII)
- Glossopharyngeal (CN IX)
Afferent controls involved in swallowing
- Mucosa of vallecula
- Primary afferent
- Second afferent
- Tonsils, pharynx, and soft pallate
- Pharynx, larynx, and vicera
- Internal branch of the superior laryngeal nerve (CN X) (area above the VF)
- Glossopharyngeal
- Pharyngeal branch of the vagus
- Glossopharyngeal
- Vagus (X)
*** Pts. can have taste or sensation differences, especially if they are older
***Pts. with sensory issues are more at risk because they can’t feel if food is stuck or they may silently aspirate and not cough (50% of individuals silently aspirate)
Stage of Swallowing
- Oral Preparation Phase
- Oral Phase (1 sec)
- We directly work with this phase. Diagnosis, alter diet, compensatory treatment and treatment - Pharyngeal Phase (1 sec)
- We directly work with this phase. Diagnosis, alter diet, compensatory treatment and treatment - Esophageal Phase (8-20 sec)
- We now do more with diagnosis and we can do diet modifications, but we do not treat for this phase, GI doctor. Individuals typically have transit issues
The SLP helps patients with oral and pharyngeal stage problems
***Food can get stuck in the vallaculae or pyriform sinuses.
Oral Prepatory Phase (3)
What do you need? (5)
**** Food is prepared for swallowing
- Mouth is sealed to keep food in, forcing breathing to occur through the nose. Velum is pulled down to keep food in oral cavity.
- Food is ground up and mixed with saliva (from the parotid, sublingual and submandibular glands) to form the bolus.
- The risorius and the buccinator contract to keep food from entering lateral sulcus (between gums and cheek wall)
- Lip Closure (must have good lip closure, lip cancer can affect lip closure. If there is lip weakness, individual may not be able to take food off a utencil)
- Facial Tone (can they keep food in the lateral sulcus)
- Rotary Jaw Motion- individuals with jaw cancer may have a problem with this
- Rotary, lateral tongue motion- need this to lateralize food
- Anterior bulging of soft palate- soft palate + anterior pharyngeal wall come together to prevent nasal regurgitation (soft palate must elevate) (also listen for hypernasality)
- Surgical resection or decreased neurological abilities will lead to problems with previous components
*** This phase is not timed because everyone prepares for swallowing differently
-If pt. chews a lot, ask them why or if it is for certain types of foods