Swallowing Disorders

Question 1

Anatomy Overview

Answer 1

• Oral Cavity: all structures have sensory receptors that are important in stimulating a swallowing response (not a reflex)
• Location of the larynx in an adult compared to an infant – how high the larynx raises during a swallow
• *Valleculae is a space not a structure *
• Cricopharyngeus (UES – upper esophageal sphincter) – very top of the esophagus, has to open or close for food to go down the esophagus

Question 2

Swallowing Phases

Answer 2

1. Oral Preparatory (not a have-to phase)
2. Oral
3. Pharyngeal
4. Esophageal

Question 3

Oral Preparatory Phase (early)

Answer 3

• Foodstuff (bolus) – likely masticated (vary patterns)
  
  • we don’t normally prepare liquid bolus – so this phase gets skip
• Liquid or pureed – may be manipulated in mouth
• Labial seal maintained
• Mastication

Question 4

Mastication

Answer 4

• Tongue moves food into position
• Adult: rotary mastication
• Food falls medially and is moved laterally (falls in the middle of the tongue, then it’s moved back to the teeth)
• Buccal tension keeps food falling medially (instead of the sulcus)
• Food pulled into a bolus (may be piecemeal – we don’t chew food all at once)

Question 5

Oral Phase

Answer 5

• Begins when the food bolus moves posteriorly (toward the valleculae and epiglottis) – you have to have an oral phase
• Elevated and grooved tongue with bolus (cradles the food bolus in the tongue “bowl” – tongue is elevated on the sides and front covered by the top of the mouth to carry bolus back)
• Buccal tension: negative pressure (lingual movement: higher air pressure in the front, lower in the back – sucking the food backward)
• Phase timing: approx. 1 second
• Sensory Receptors

Question 6

Sensory Receptors

Answer 6

• Swallowing center in the brainstem (high activity is not necessary for swallowing)
• When enough receptor responses are sent to the brainstem, a swallow is initiated (Delayed Swallow – delay in receptors to initiate)
  
  • Mechanoreceptors
    
    • Senses presence of food bolus (tactile)
    • Proprioceptor in the muscles themselves (back of tongue)
  • Chemoreceptors (Sensitive to the change in the chemical
  • Thermoreceptors (Sensitive to changes in temperature – sends message to swallow center to initiate a swallow – swallow patients are more sensitive to cold/sour foods)

Question 7

Pharyngeal Phase (simultaneous action)

Answer 7

• When you have a swallow response is the beginning of this phase
• Elevation and retraction of velum and closure of VP port
• Elevation (hyolaryngeal/excursion: 1. Protection from bolus – pulls larynx up and forward, 2. Epiglottal movement – epiglottis connected, 3. UES opening – muscles have a certain amount of tone at all times, opens by neurological transmission from brainstem causing it to relax, opens by excursion due to a pull) to hyoid bone and closure of pharynx/larynx
• Tongue base retraction and initiation of pharyngeal peristalsis
• Pharyngeal phase timing: approx.. 1 sec
  When the head of the bolus entering the esophagus is the end of the pharyngeal phase

Question 8

Lines of Defense within the Oral Cavity

Answer 8

• Epiglottis/aryepiglottic folds
• False vocal folds
• True vocal folds

Question 9

Tongue base retraction

Answer 9

hard push against the back wall of the pharynx to push food through – primary method)

Question 10

Peristalsis

Answer 10

constrict in a sequence/ “wave”; can have unilateral damage in the tube

Question 11

Esophageal Phase

Answer 11

• When the head of the bolus entering the esophagus is the beginning of the esophageal phase
• Phase timing: varies 8-20 sec.

Question 12

Differences in Pediatric and Adult Swallowing

Answer 12

• Normal reflexes in newborn assist with airway protection and feeling and are inhibited throughout the first year (can resurface after TBI)
  
  • gag (protective; gag is forward during first 6 months)
  • phasic bite (bite reflex that protects the airway)
  • tongue thrust (pushes food out)
  • rooting (survival reflex; move head towards the touch (stimulus)
  • suckle (back and forth instead of up and down movement; physiological flexion – in a ball, can’t pull their neck up yet, hard to move the )

Question 13

Structural Differences in Pediatric and Adult Swallowing

Answer 13

• Physiological flexion predominates early and antigravity extension increases as newborn ages
• Larynx positioned high in pharynx (little laryngeal elevation observed)

Question 14

Changes in Pediatric Swallowing

Answer 14

• Dentition begins to erupt
• Tongue thrust is inhibited
• Gag begins to move backward
• Primitive chewing/munching (up and down not rotary)
• Beyond 6 months (36 months)
  
  • complex state of events the develop through approx. 3 years of age (more adult-like)
• Disorders that effect the normal swallow can create long-tern deficits in the pediatric population
  
  • sensory issues
  • oral-motor development
  • speech development

Question 15

Changes in Older Adults

Answer 15

• Ossification of bone and cartilage
• Laryngeal joint dysfunction due to arthritis
• Slightly longer oral phase with mild delay in triggering pharyngeal response
• Less cleaning of residue
• Penetration increases but not aspiration
• Vocal fold bowing
• Decreases in taste and smell
• Decreases (indiv variation) in amount of liquids and foods

Question 16

Disorders Related to Multiple Phases

Answer 16

• Spillover of bolus
• Penetration (spillover at any time)
• Aspiration (below true vocal folds)
• Stasis (lack of movement – lingual, pharyngeal, epiglottal)
• Inflammations (Laryngitis, Thrush – dosage of antibiotics, very painful; whitish mouth crud that can’t be scraped off easily)
• Carcinoma (cancer, swallowing issues based on location)

Question 17

Disorders in Oral Prep Phase

Answer 17

• Reduced labial closure
• Reduced lingual movements necessary to form, move, and maintain bolus
• Reduced oral sensation
• Cognitive dysfunction
• Pocketing
• Reduced buccal tension

Question 18

Disorders in Oral Phase

Answer 18

• Tongue thrust
• Reduced lingual elevation and A-P movement
• Reduced buccal tension (creates area of high pressure vs low pressure)
• Pocketing in oral sulci
• Premature spillage
• Xerostomia (reduced hydration of the oral cavity – dry mouth)

Question 19

Disorders in Pharyngeal Phase

Answer 19

• Delayed or absent swallow response (without a swallow response, then there is no pharyngeal phase)
• The aspiration that occurs is the secondary problem that’s being caused by something else being damaged
• Reduced or absent:
  
  • VP closure
  • Tongue base retraction (TBR)
  • Pharyngeal peristalsis
  • Hyo-laryngeal excursion (moving up and forward; if there’s not good tongue movement, then the hyoid is not moving well)
  • Laryngeal closure
  • Cricopharyngeal (UES) dysfunction

Question 20

Disorders in Esophageal Phase

Answer 20

• Cricopharyngeal (UES) dysfunction
• Peristalsis dysfunction
• Reflux (LES bottom sphincter dysfunction; causes a number of voice disorders)
• Obstructions (hiatal hernia)