Swallowing & Dysphagia Flashcards
Normal Swallow Anatomy
Nasal cavity
-Velopharyngeal valve
Oral cavity
- Lips
- Tongue
- Oral tongue
- Tongue base
Epiglottis
-Valleculae (space btwn tongue base & epiglottis)
Larynx
- True vocal folds
- False vocal folds
- Epiglottis & aryepiglottic folds
Pharynx
- Pyriform sinuses (superior, medial, inferior pharyngeal constrictors)
- Pharyngeal recesses (pyriform sinus combined w velleculae - complete surround)
Upper esophageal sphincter (UES) - AKA cricopharyngeal muscle
- tightly closed at rest
- opens to allow food to pass
System of Valves
Lips – keep food in the mouth
Tongue – can close off the oral cavity by touching the roof of the mouth
Velopharyngeal valve
Larynx
Epiglottis & aryepiglottic folds
False vocal folds
True vocal folds
Cricopharyngeus muscle (UES)
Stages of the Normal Swallow
Four phases:
Oral preparation stage
Oral stage
Pharyngeal stage
Esophageal stage
Oral Prep Stage
Beginning of oral prep
- Tongue, teeth, and jaws masticate food
- Soft palate
- Usually down when swallowing liquids
End of oral prep
- Bolus
- Tongue tip holds bolus against the alveolar ridge or
- Tongue tip holds the bolus on the floor of the mouth behind the teeth
Oral Stage
Begins when the bolus is positioned for swallowing
Midline of tongue pushes the bolus posterior to the faucial arches
Movement of the bolus sends sensory information to the brainstem which triggers the swallow
Pharyngeal Stage
Hyoid bone and larynx move up and forward
Velopharyngeal valve closes
Tongue base pushes back
Lateral and posterior pharyngeal walls move inward to meet the tongue base
Airway is closed
UES opens - Opened further by bolus
Peristalsis - wavelike motion that pushed the bolus through the pharynx and esophagus
Apnic pause
Normal process of swallowing
A temporary cessation of breathing while the epiglottis is closed for a swallow
0.3-0.7 seconds long
Swallowing in Infants
Tongue and jaw move together and then independently
Liquid collects in the valleculae
Liquid collects in the esophagus
Frequent backflow
Swallowing in Senior Adults
60 years and older:
- Reflux
- Oral prep - bolus is held behind the teeth
- Delayed pharyngeal swallow
80 years and older:
-Reduced laryngeal movement
Bolus Variations
Larger bolus – oral and pharyngeal stages overlap
Larger bolus – airway closure and UES opening time increase
As viscosity increases – muscle activity and pressure on the bolus increases
Oropharyngeal Swallowing Disorder
Can be:
Unilateral or bilateral
Structural, functional, and/or sensory deficits
-Can affect any one (or more) systems we previously discussed
Oral prep phase
Oral phase
Pharyngeal stage
Esophageal stage
Symptoms of a Swallowing Disorder
Aspiration
- Food enters the airway below the level of the true vocal folds
- Can result in aspiration pneumonia
Penetration
-Food enters the airway, but doesn’t go past the level of the true vocal folds
Residue
-Food sits in or coats the oral cavity or pharynx
Causes of Swallowing Disorders
Neurologic diseases Parkinson's ALS Multiple sclerosis Trauma – head or spine Stroke Children with cerebral palsy
Dysphagia Evaluation
Step 1: Bedside or clinical assessment
- Case history
- Physical exam (oral mechanism evaluation)
- Assess either dry or food/liquid swallows
Step 2: Imaging
Fiberoptic Endoscopic Evaluation of Swallowing (FEES)
Can view the pharynx – before and after the swallow Camera behind soft palate: can see Base of tongue Valleculae Pharyngeal walls Camera lower than sift palate: can see Larynx
Videofluoroscopic swallow study (VFSS)
Moving x-ray; exposes clinician and patient to low level of radiation
- Can view all stages except esophageal
- Give patient variety of food types: thin liquid, thick liquid, pudding, and chewable
- SLP and radiology present and read study results
- Barium is added to the food
- Patient viewed in lateral plane (sagittal)
- Swallow impairment also viewed anterior-posterior (front to back)
- Swallowing strategies are tested
- Goals of VFSS assess swallow and test treatment strategies
Treatment - Compensatory
-Strategies to improve safety of swallow
-Used when individual is expected to spontaneously regain normal function
Example: early recovery period from trauma
- Allows patient to eat orally until full functioning is restored
- Are controlled by the clinician
- Can be used with young children and cognitively impaired adults
- Require little to no effort from patient
- Include changes in posture, head or body position, stimulation (sensory) or changes in bolus volume and/or viscosity
Treatment - Postural Changes
Chin-down – narrows the airway entrance
-Valleculae widens and pushes the tongue base and epiglottis toward the pharyngeal wall
Chin-up – gravity pulls bolus towards the esophagus
Head rotation weak side – squeezes weak side directing food to strong side
Tilt head towards stronger side of the mouth – food flows to side of mouth that can control food better
Lying on back or side – keeps residue from falling into airway
Treatment - Swallowing Maneuvers
Supraglottic swallow – hold breath before and after swallow
-Closes true vocal folds before and after swallow- protects airway
Super-supraglottic swallow – hold breath with effort or while bearing down before and during the swallow
-Closes airway between arytenoid and base of epiglottis and false folds – added airway protection
Effortful swallow – using muscular effort while swallowing
-Increases posterior tongue base movement and increases pressure on the bolus
Mendelson maneuver – longer larynx elevated during the swallow
Treatment - Restorative
Restorative – strategies to improve swallow function
Swallowing exercises
Exercise improve range-of-motion and or coordination
Range-of-motion: lips, tongue, jaw, vocal folds, and laryngeal elevation
Coordination: tongue and jaw while chewing
When possible, start with compensatory and then use restorative
