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
Oral Phase Description 1
- Begins when bolus is finally ready to swallow
- Tongue drops and pulls posteriorly
Mastication stops - Anterior tongue elevates to the hard palate and squeezes the bolus back toward the faucial pillars (contact at this point triggers the pharyngeal stage)
- Use tongue to move bolus up & back to trigger swallow reflex
- — If the patient can not make a bolus they are at risk of aspirating
- Piece meal deglutition
- — Patients who can’t collect food in a bolus
***Tongue is the most important structure of swallowing
- With a stroke you will see unilateral weakness, you will need to teach them to compensate
Oral Phase Description 2
- The swallowing reflex should trigger the anterior faucial arch predominantly from the 9th cranial nerve.
- There is no direct stimulus in the oral cavity which immediately triggers the swallow other than the movement of the patients tongue.
- Check for gag reflex, but lack of gag reflex does not mean swallowing is impaired or not impaired
***When reflex triggers
When reflex triggers
— Soft palate elevates (so food doesn’t go through nasal cavity)
- – Larynx elevates (protection of airway)
- If there is a delay here, try to increase the speed of the swallow
— Vocal Folds close (protection of airway)
— Epiglottis will close over
- – Cricopharyngeus muscle relaxes (always closes except when swallowing)
- If the cricopharyngeus muscle doesn’t relax, food pools and may be aspirated.
——- Peristalic action
Pharyngeal Phase (5)
- The soft palate is elevated accomplishing velopharyngeal closure
- The bolus passes the base of the tongue
- The larynx has begun to elevate but has not yet closed
- The upper esophageal valve has not yet opened
- Pharyngeal peristalsis begins
Esophageal Phase 1 (4)
- The soft palate is completely relaxed
- The larynx begins to open and lower
- The bolus moves through the pyriform sinuses and enters the esophagus (food collection at the pyriform sinuses means greater risk of aspiration, more so than pooling in the valleculae)
- The cricopharyngeus muscle/upper esophageal valve is open
***Once the bolus enters the esophagus it is out of volitional control
Esophageal Phase 2 (3)
- Once the bolus has entered the esophagus, it is out of volitional control and does not respond to exercise programs
- The esophageal phase begins with the bolus passing the upper esophageal valve and ends as the bolus passes through the lower esophageal valve.
- Normal transit times vary from 8-20 seconds and often lengthen with age.
Oral Phase Swallowing Disorders (8)
- Abnormal Hold Position (Can’t hold it, it will fall out)
- Reduced Lip Closure (Structural or functional)
- Reduced Buccal Tension (can they hold food in)
- Reduced Lateral Tongue Movement
- Reduced Tongue Elevation (can they propel the bolus?)
- Reduced Anterior-Posterior Tongue Movement (Can they lateralize the bolus?)
- Abnormal Patterns of Tongue Movement
- Reduced Oral Sensation
*** PD patients have repetitive thrusting of the tongue
Pharyngeal Stage Swallowing Disorders (6)
- Delayed / Absent Swallowing Reflex- As an individual continues to try swallowing food may collect in the valleculae (need a MBS)
- Have the pt. tell you when they swallow, feel their swallow, does the larynx elevate
- If laryngeal elevation is absent then the swallowing is severe, airway is left wide open and large risk of aspiration (need a MBS to confirm) - Reduced Pharyngeal Peristalsis (squeezing effect)
- Have pt. swallow again to try to move the bolus through the pharynx and esophagus
- If it doesn’t move you can try to suction to prevent aspiration
- Coughing only helps with penetration, if it is above the airway. - Unilateral Pharyngeal Dysfunction
- Reduced Laryngeal Elevation
- Reduced Laryngeal Closure
- Cricopharyngeal Dysfunction- if this muscle doesn’t relax, food just sits there
Respiratory Status
- If patient is in respiratory distress it may be inappropriate to assess or begin swallowing therapy
- When swallowing food it interrupts exhalation (we hold our breath)
- Most adults return to exhalation after the swallow
- Inhalation following the swallow rather than exhalation puts patient at risk for aspiration
- The patient should be able to hold his/her breath comfortably for 1 seconds, 3 seconds, and 5 seconds (assess during oral mech exam)
***pts. in respiratory distress are high risk
- larynx is compromised with trach
Typical Swallowing Disorders in Neurologic Population 1
- Cortical Stroke (language and possibly speech) (4)
- Brainstem Stroke (speech) (4)
- Typically the medulla
- Delayed/absent pharyngeal swallow (aspiration before swallow)
- Swallow apraxia (Left CVA)- more likely to occur with anterior CVA (motor issues, MSD)
- Disrupted lingual peristalsis
- Reduced tongue base retraction (aspiration after swallow)
*** Motorstrip is intact with posterior strokes
- Delayed pharyngeal swallow
- Reduced laryngeal elevation/cricopharyngeal dysfunction
- Unilateral pharyngeal weakness
- Reduced laryngeal closure (unilateral vocal cord paralysis)
UMN/LMN, spastic or flaccid issue
Typical Swallowing Disorders in Neurologic Population 2
- Head Trauma (more diffuse trauma) (5)
- CP (3)
- Delayed/absent pharyngeal swallow (aspiration before swallow)
- Reduced tongue control
- Reduced tongue base retraction (aspiration after swallow)
- Tracheoesophageal fistula (aspiration after swallow)
- Cognitive issues with swallowing - Reduced lingual control (aspiration before swallow)
- Delayed pharyngeal swallow (aspiration before swallow)
- Reduced tongue base retraction (aspiration after swallow)
- Type of CP and type of movement (neuro)
Typical Swallowing Disorders in Neurologic Population 3
- ALS (5)
- MS (exacerbations and remissions) (7)
- Reduced lingual control (aspiration before swallow)
- Reduced tongue base retraction (aspiration after swallow)
- Delayed pharyngeal swallow (aspiration before swallow)
- Reduced laryngeal closure (aspiration during swallow)
- Cricopharyngeal dysfunction (aspiration after swallow) - Reduced lingual control (aspiration before swallow)
- Reduced tongue base retraction (aspiration after swallow)
- Delayed pharyngeal swallow (aspiration before swallow)
- Reduced laryngeal closure (aspiration during swallow)
- Cricopharyngeal dysfunction (aspiration after swallow)
- Reduced pharyngeal contraction
- Possible sensory changes
*** LMN issues
Typical Swallowing Disorders in Neurologic Population 4
- PD (EPS) (5)
- Cerebellar Degeneration (1)
- MG (LMN issue at the myoneural junction) (2)
- LMN is the axon
- Abnormal lingual peristalsis (“pumping” motion)
- Reduced tongue base retraction
- Delayed pharyngeal swallow
- Reduced laryngeal closure
- Cricopharyngeal dysfunction - No consistent disorders
- Involvement of any cranial nerve musculature
- Fatigue (Do fatigue study)
- Tax the system**
- Sustain a vowel, count to 200
- Complain of being tired, immediately, chewing makes them tired, but if they rest, the system goes back to normal
- Structure
2. Function
- Head or Neck cancer, function is intact but structure is missing
- Neurological disorders affect function due to weakness (spasticity or flaccidity)
***Always think about structure and function
Vocal Folds and Swallowing
- behind the adam’s apple
- protect the airway (prevents aspiration), happens when the larynx elevates
Normal vs Impaired
- When doing an evaluation, figure out the patient’s problem and then figure out what was impaired
- Can also say what CN is impaired and then see how it affects the pt.
- If pt. shows signs of something that was not previously noticed, the pt. should be referred to an ENT
- If the pt. has a breathy voice it means the VF are not closing properly
