Swallowing Flashcards
swallowing phases
- anticipatory phase
- oral prep phase
- oral phase
- pharyngeal phase
- esophageal phase
anticipatory phase
- food is checked (smell, look, temperature, consistency)
- saliva production
- adapts to optimize feeding and swallowing
oral prep phase
purpose
- optimal bolus positioning
- mastication
duration
- depends on food volume, consistency, and individual’s reaction
requirements
- saliva, clear nasal airway, dentition, cognition
- coordinate lip closure, buccal tone, jaw elevation/depression and rotary/lateral movement, tongue rotary and lateral movement, anterior bulging of soft palate
oral phase
purpose
- clear bolus from oral cavity
- stimulate initiation of the pharyngeal swallow
duration
- 0.3 - 1.0 seconds
requirement
- tongue movement
- velopharyngeal closure
pharyngeal phase
purpose
- transport bolus through pharynx
- nasal and laryngeal airway protection
duration
- 0.5 - 1.5 seconds
requirement
- coordinate velopharyngeal closure, epiglottic tilting, hyolaryngeal excursion, laryngeal closure, pharyngeal peristalsis, relax and open UOS, return to resting position
esophageal phase
purpose
- transport bolus to stomach
duration
- depends on age, bolus volume and consistency
requirements
- active peristalsis
saliva major functions (8)
- protect teeth and gums
- protect oral hygiene
- lubricate food for swallow
- lubricate tongue and lips for speech
- taste
- destroy micro-organisms
- assist in carbohydrate digestion
- regulate acidity in esophagus
saliva production
- salivary glands
- parotid gland
- minor salivary gland
salivary glands
- submandibular
- sublingual
salivary glands innervation
CN 7 (facial nerve)
parotid gland innervation
CN 9 (glossopharyngeal nerve)
minor salivary gland innervation
CN 7 and 9
saliva production percentages
- submandibular (70%, serous and mucoid)
- parotid (25%, serous)
- sublingual (5%, serous and mucoid)
tipper swallow
begins with the tongue tip pressed against the upper incisors and alveolar ridge
dipper swallow
bolus is beneath anterior tongue at onset, tongue scoops the bolus to the supralingual position
airway protection during swallow
- epiglottal descent or inversion
- laryngeal ascent
- vertical approximation of the arytenoids to the base of epiglottis
- adduction of the vocal cords
swallow apnea definition and duration
- respiration ceases during the swallow
- 0.5 - 3.5 seconds
common respiratory patterns
- exhale/swallow, apnea/exhale
- inhale/swallow, apnea/exhale
age-related swallow changes
- presbyphagia
- increased disease prevalence
presbyphagia
- disruption to swallow function without an underlying disease
- minimal to no effect on oral intake, health, and life quality but reduced swallow function reserve
- can progress to dysphagia
acquired factors that affect age-related changes in swallow
- medication use, polypharmacy (impact salivary status, cognitive function, GI tract, and neurological function)
- structural changes (bone density, muscle bulk, dentition, cervical spine)
- decreased appetite
- frailty
- accessory conditions (dementia, stroke)
frailty
- a state of increased vulnerability to poor resolution of homeostasis after a stressor event (infection) which increases the risk of adverse outcomes (fall, delirium, disability)
sarcopenia
progressive loss of skeletal muscle mass, strength, power
phase changes (age-related change in swallowing)
oral prep phase
- decreased tase, smell, oral sensation
- loss of dentition, hyposalivation, and xerostomia
oral phase
- decreased tongue and masticatory muscle strength
- straw drinking and sequential drinking
pharyngeal phase
- initiation of swallow slower with age
- reduced anterior hyoid excursion, pharyngeal stripping, UOS opening, tongue base retraction, hyolaryngeal excursion, and atrophy of pharyngeal musculature leading to reduced pharyngeal pressure
- pharynx volume increases with age
- increased residue in vallecular and pyriform sinuses
- difficulty swallowing large boluses
- longer swallow apnea
esophageal phase
- longer esophageal transit time
- decreased esophageal peristalsis and distal esophageal motility
- intraesophageal stasis and reflux
- esophagitis
natural swallow compensatory mechanisms with age
- longer duration of UOS opening and laryngeal closure
- longer swallow apnea
learned coping mechanisms for age-related changes in swallow
- good dental care and oral hygiene
- cut food into smaller bites, prolonged chewing
- drink fluids with food
are men or women more likely to develop dysphagia later in life
men
feeding
anticipatory reactions to food (prep for intake, place into mouth, bolus management)
eating and drinking
- prep food for swallowing
- focus on anatomy and physiology
swallowing
the act of moving the food from the oral cavity and pharynx into the esophagus
8 week scan
rooting reflex
12 week scan
- taste buds develop
- swallow
- tongue thrusting/cupping
20 week scan
- sucking/suckling
- lungs capable of breathing air
- cough, gag reflex
- sustain nutrition orally
- integrated suck, swallow, breathe
rooting reflex
- birth - 3 to 5 months
- head, mouth, tongue turn in direction and response to stimulus in the peri-oral area and mouth opens
suckle-swallow reflex
- birth to 6 months
- elicited by stroking the anterior third of the tongue or center of the lips
- tongue thrusts forward and backwards resulting in a swallow
- coordination of the tongue, hyoid, mandibular muscles, lower lip, and respiration
gag reflex
- diminishes at 6 months
- protective reflex
- elicited by stimulus to posterior 3/4 of the tongue or pharyngeal wall
- pharynx constricts and elevates in response
- diminishes to posterior 1/4 of the tongue and posterior pharyngeal wall once solid intake increases but remains for the rest of life
tongue protrusion reflex
- birth to 4 months
- protective reflex
- baby pushes food out of mouth when food is placed on the anterior tongue
bite reflex
- present until 6 months
- protective reflex
- stimulus to gum elicits rythmic vertical biting movement of the jaw
- diminishes with solid intake and increased jaw movements
transverse tongue reflex
- present until 6 months
- tongue moves laterally if touch or taste is applied to the tongue’s lateral edge
types of sucking
- non-nutritive sucking (NNS)
- nutritive sucking (NS)
NNS
- for comfort
- single sucks and long pauses
- seen in premature infants at 27-28 weeks gestation (can assist in transition to oral feeding)
- 30-38 weeks = more organized burst-pause pattern
NS
- for nutrition
- continuous sucking bursts
- 30-70 seconds
measurements of NS
- frequency and periodicity
- timing of swallow events
- respiratory patterns
suckling
characterized by forward and backward movement of tongue (backward phase is more pronounced)
sucking
- strong activity of intrinsic muscles of the tongue
- body of tongue raises and lowers with small vertical excursion of the jaw
- replaces suckling patterns 6 months after
infant head and neck anatomy
- higher hyoid bone
- more epiglottis work
- vertebrae bunched up
- no teeth
3-6 months head and neck anatomy
- upper lip becomes more mobile
- transitional feeding (5-7 months)
- bite, suckle swallow, and gag reflex diminish
- voluntary oral control
- initiate self feeding behavior
6-9 months head and neck anatomy
- upper lip proficiency (role in creating anterior seal)
-incisors emerge - anterior jaw movement more developed
- larynx descends
9-12 months head and neck anatomy
- lateralize food in the mouth
- good sitting posture and head control
- chewing patterns and continual development
- primitive reflexes disappear more fully
12-18 months head and neck anatomy
- lateral and rotary jaw movements in chewing
- lip closure on swallowing
- good lip seal on drinking from a cup
- smoother control of food from hand to mouth
- independent feeding progresses
18-24 months
- lick lips with tongue
- transfer food from one side of the mouth to the other
- suck with a straw
- rotary shewing is more mature
24-36 months
- oro-pharyngeal and laryngeal structures continue to mature
- gag reflex is gone from posterior 1/3 of tongue
optimal period for feeding
6 months - 2 year
development of taste at birth
- detect sweet
- reject sour
- indifferent to salt
development of taste 4 months
- recognize salt water
- differentiate between salt and non-salt fluids
development of taste 18 months
- reject salt water
- accept salt in food
infant subsystems
- physiological support systems
- motor systems
- state system
- attention system
- self-regulatory system
infant physiological support systems
- respiration
- heart rate
- skin color
infant motor systems
- posture
- tone
- physical movement patterns in environment/when stimulated
infant state system
ability to move from one state to another without disrupting physiological status sleep (sleep to wake)
infant attention system
duration and quality of attention
self-regulatory system
ability to maintain quiet sleep state or calm state when alert
clinical symptoms of pediatric dysphagia
- bolus not formed
- no lip seal
- limited/no lip movement
- lack of retraction/asymmetry
- delayed initiation of pharyngeal swallow
- tongue atrophy
- excessove thrusting
primary motor disorder
- inefficient sucking/swallowing at breast/bottle
- taste differentiation noted with liquids in bottle
- incoordination with all textures
- mixed textured food swallowed whole
- difficulty manipulating bolus (food dropped or in cheeks)
- vomiting
- gagging after food moves through oral cavity
- gagging with liquid/solid after swallow initiated/triggered
- toleration of others’ fingers in the mouth
- accepting of teething toys but not able to bite or maintain in the mouth
- no problem with toothbrushing
primary sensory disorder
- nipple confusion from breast to bottle
- lack of taste differentiation of liquids in bottle despite intact sucking
- efficiency with liquids better than with solid foods
- sorts out food of different textures (fruit piece in yogurt)
- food held under tongue or in cheek to avoid swallowing
- votimiting (texture-specific)
- gagging when good approaches or touches lip/tongue
- gagging with solids, normal swallow with liquids
- toleration of one’s own fingers in their mouth but not others
- no mouthing of toys
- refusal of toothbrushing
factors influencing normal swallowing
- bolus consistency and volume
- straw v cup drinking
- taste
- temperature
- carbonation
- verbal cueing
bolus consistency and volume (factors influencing normal swallowing)
as viscosity increases
- oropharyngeal transit time, oral pressure, duration of velar excursion, laryngeal elevation, duration/extent of hyoid movement, UES opening/diameter, and tongue base to posterior pharyngeal wall duration increases
- late onset of swallowing apnea
larger volume
- central tongue groove deepens
- decreased oral transit time and state transition duration
- earlier onset of anterior tongue base movement, palatal/laryngeal elevation, and airway closure
- shorter tongue base to posterior pharyngeal wall contact
- increased airway closure duration and duration/extent of UES opening
straw v. cup drinking (factors influencing normal swallowing)
straw drinking
- influences the onset time and speed of the swallow (longer bolus dwell times)
- reduces oral spillage
taste (factors influencing normal swallowing)
- increased tongue pressure
- earlier onset and greater submental muscle contraction with taste (sweet, sour, salty)
- increased pharyngeal pressure
temperature (factors influencing normal swallowing)
- cold bolus can speed the pharyngeal swallow up, increase pharyngeal pressure, and improve UES opening (reduced airway compromise in pre-term dysphagic patients)
- cold-sour bolus induced shorted pharyngeal transit times
carbonation (factors influencing normal swallowing)
- increase sensory input which speeds motor swallow up
- increase pharyngeal pressure and UES opening
verbal cueing (factors influencing normal swallowing)
- swallowing is altered with verbal cues which affected bolus position at onset of timing measures (increased duration)
- bolus positioned more posterior in the oral cavity at the onset of oral transit with cues
