Unit 1 Flashcards
Prevalence of dysphagia in acute care?
33%
Prevalence of dysphagia in rehab facility?
42%
Prevalence of dysphagia in chronic care setting?
60%
Primary function of the larynx?
Protect the airway
Prevalence of dysphagia based on cause…
Stroke - 49%
TBI - 19.5%
Spinal cord injury/brain tumors - 6.8%
Progressive neurological disorders - 5.2%
Dysphagia
A swallowing disorder
Oral intake
Placement of food in the mouth for nutrition and hydration
Bolus
The food, liquid, or other material placed in the mouth for ingestion
Aspiration
Occurs when food/liquid penetrates the airway below the true VFs
Laryngeal Penetration
Occurs when food/liquid penetrates the portion of the airway above the true VFs
Functional Swallow
A swallow which may be abnormal but does not result in aspiration
Ingestion/Swallow
Refers to all processes associated with bolus introduction, preparation, transfer, and transport
deglutition
Refers only to acts associated with bolus transfer and transport
NPO
not eating by mouth
Anatomic structures of the oral cavity used for swallowing
lips teeth hard palate soft palate (uvula) mandible floor of mouth tongue faucial arches
what are the faucial arches
arch on either side of the uvula when looking into the mouth
Muscles that squeeze the bolus down
pharyngeal constrictors
Three pharyngeal constrictors
superior, medial, and inferior
Cricopharyngeus muscle AKA
upper esophageal sphincter (UES), pharyngoesophageal juncture, P-R segment
Is the cricopharyngeus natrually open or closed? Why?
Closed. It prevents air from entering the esophagus during respiration and prevents material from refluxing into the pharynx
When is the cricopharyngeus open?
When we swallow - it opens and allows the bolus into the esophagus
What/where are the pyriform sinuses?
a spaced formed between the fibers which attach the inferior pharyngeal constrictor to the thyroid cartilage
Space created by the inferior constrictors when they contract
What is at the top of the esophagus?
UES
What is at the bottom of the esophagus?
LES
Layers of the esophagus
2 layers of muscle
- inner is circular
- outer is longitudinal
what are the layers of the muscles of the esophagus made up of?
upper third - striated
middle third - striated and smooth
lower third - smooth
Lower esophageal sphincter (LES) AKA
gastroesophageal juncture
What happens after the LES passes bolus into the stomach?
It closes to prevent reflux
Top most structure of the larynx that rests against the base of the tongue
epiglottis
Web-shaped space by the base of the tongue and the epiglottis
Valleculae**
Opening to the top of the layrnx
Laryngeal cestibule
Laryngeal vestibule AKA
laryngeal aditus
Suspended from the base of the tongue
Hyoid bone
The only free-floating bone in the body
hyoid bone
Pharyngeal recesses
the valleculae and the pyriform sinuses
Why are the pharyngeal recesses important?
In an inefficient swallow, residue is often seen here**
What are the 5 stages of swallowing?**
- Anticipatory stage
- Oral preparatory stage
- Oral stage
- Pharyngeal stage
- Esophageal stage
Anticipatory stage of swallowing
make cognitive judgments about oral intake (e.g., rate, temperature, size of bite)
Oral prep stage of swallowing
Breakdown food and mix it with saliva
In which stage of swallowing is lip seal maintained, mastication occurs, buccal musculature tension is maintained, food collected into a bolus, etc.?
Oral prep stage
what are the 10 components of the oral prep stage
- Lip seal is maintained
- mastication occurs
- buccal musculature tension is maintained
- food is collected into a bolus
- Bolus is held anteriorly and laterally by the tongue against the hard palate
- linguavelar seal
- airway is open
- larynx and pharynx are at rest
- movements vary depending on amount and consistency of food
- this stage is under voluntary control
Where is buccal musculature tension held?
In cheeks
Linguavelar seal
Back of the tongue is elevated and soft palate is pulled anteriorly against tongue to keep material in the oral cavity
How long is the oral prep stage?
Depends what we are eating (e.g., steak vs. water)
Tongue against the soft palate
Linguavelar seal
Soft palate against the wall of the pharynx
Velopharyngeal seal
What are the 4 components of the Oral Stage?
- Tongue propels food posteriorly with a rolling or stripping action.
- Normal transit time is 1 second.
- Oral stage terminates when the bolus passes the anterior faucial arches and the pharyngeal response is triggered
- This stage is under voluntary control (Cranial nerves V, VII, XII)
3 reasons the pharyngeal stage is considered physiologically most important
- Airway protection (when the larynx elevates, the valves of the larynx close)
- opening of the esophagus
- Downward propulsion of the bolus into the esophagus (due to contraction of the pharyngeal constrictors)
4 components of the pharyngeal stage of swallowing
- Begins with triggering of the pharyngeal response
- When the response triggers, a number of physiological activities occur simultaneously
2a. Tongue base move posteriorly to contact the anteriorly moving posterior pharyngeal wall
2b. velum elevates to achieve VP closure
2c. Pharyngeal contraction begins (squeezing action of the constrictors)
2d. Elevation and anterior displacement of the larynx occurs with laryngeal closure at three levels (aryepliglottic folds, false folds, true folds)
2e. opening of the cricopharyngeus as a result of relaxation of UES, elevation of larynx, and pulsion force of the bolus - Transit time is 1 second
- This stage is involuntary
5 components of the esophageal stage of swallowing
- Transit time is appx 8-20 seconds
- Commences with lowering of the larynx, contraction of the cricopharyngeus to prevent regurgitation , and resumption of respiration
- Esophageal peristalsis begins
3a. Primary peristalsis is initiated by the pharyngeal response (when laryngeal elevation occurs) - which opens the UES
3b. secondary peristalsis is initiated in response to local distention - at the lower end of the esophagus, the LES relaxes prior to arrival of the esophageal peristalic wave to allow passage of the bolus into the stomach. The LES is otherwise closed to prevent gastroesophageal reflux
- This stage is involuntary
Peristalsis
A rhythmic contraction of muscles to move things through a tube
The ability to introduce bolus to the mouth
Feeding
Movement of the bolus from the oral cavity to the esophagus
Deglutition
Swallow vs. Gag reflex*
- No physiologic or protective relationship between swallow response and gag reflex
- Gag is triggered by noxious or foreign stimulus
- Purpose of gag: eliminate foreign stimuli from the mouth or pharynx
- The neuromuscular response that characterizes gagging involves sudden and strong contractions of pharyngeal walls, soft palate, and larynx to squeeze from the pharynx the stimuli that elicited the gag.
- Gag is not protective for swallowing.
- The cough reflex is the protective reflex for the swallow
- Gag cannot predict presence or adequacy of swallow because the force of the gag is the opposite of the swallow and normal subjects exhibit no gag reflex but have a normal and intact swallow.
- Gag is useful for observing pharyngeal and palatal contraction.
What is the purpose of the gag?
To eliminate foreign stimuli from the mouth or pharynx
What is the protective reflex for the swallow?
The cough reflex
How can we tell if someone has unilateral pharyngeal weakness?
By the way they gag
What is the curtain effect?
Everything gets pulled to one side in unilateral weakness
What is it called when bolus comes up through the nasal cavity?
Nasal regurgitation
What is the most important cough? Why?
Reflexive cough - it prevents aspiration
9 anatomical differences between the adult and newborn mouth?
- size of oral space
- size of lower jaw - child is also retracted
- infants have sucking pads
- Tongue takes up most of oral cavity
- child’s tongue is restricted
- newborns - nose breathers
- epiglottis and soft palate approximate
- larynx is higher in newborn
- eustachian tube is horizontal in newborn
Swallow apnea
cessation of respiration during the swallow
Adaptive reflexes
assist in the acquisition of food
Protective reflexes
designed to protect the airway
Rooting reflex
- Used to find food
- Touch corner of mouth, baby turns its face that direction
- birth to three months
- adaptive reflex
Transverse Tongue Reflex
- elicated by touch/taste stimulation applied to the lateral border of tongue
- important for developing the chew
- AKA lateral tongue reflex
Phasic Bite Reflex
Rhythmic closing and opening of jaws in response to stimulation
- Assists with positive pressure sucking
- E.g. put your finger in the infants mouth and they begin sucking
Gag reflex
- Serves a protective function in infants, preventing infant from ingesting food for which its not ready
- Present throughout life (but integrates into our system)
Suckling is a….
reflexive movement
Sucking is a…
voluntary movement
Positive pressure suck
Push tongue against the nipple and liquid squirts into mouth (suckling)
Negative pressure suck
- what we do
- Seal lips around straw and drop back of tongue in order to decrease the pressure
Tonic Bite Reflex
- Abnormal bite
- bite down on object in mouth hard and wont let go
Babkin and Grasp Reflexes
Show the neurological and functional connections between the hand and the mouth
- little relevance for human survival
- building blocks for future development of self-feeding skills
Grasp reflexes
If you press on the baby’s pal,, will grasp
Babkin reflex
occurs when you press both of the baby’s palms - their eyes close, the mouth opens, and the head turns to one side
Reflexes can tell us what about a child?
neurological maturity
Purpose of nutritive sucking
Obtain nourishment
Purpose of non-nutritive sucking
State regulation, satisfy sucking desire, exploration
rhythm of nutritive sucking
Initial continuous sucking burst, moving to intermittent sucking bursts with bursts becoming shorter and pauses longer over the course of the feeding
rhythm of non-nutritive sucking
repetitive patterns of bursts and pauses; stable number of sucks per burst and duration of pauses
Has a rate of one suck/second and is constant over the course of feeding
Nutritive sucking
Have a rate of about 2 sucks/second
Non-nutritive sucking
Ratio is 1:1 to 3:1
Nutritive SSB
Ratio is 6:1 to 8:1
Non-nutritive SSB
When have swallowing and breathing movements been documented in infants (age)
18-19 weeks gestation
Two biochemical methods of nutritive sucking
- Positive pressure (suckling)
2. Negative pressure (suck)
Pressure is put on the nipple that expresses the liquid
Positive pressure method
The lips seal around the nipple and then the back of the tongue is depressed
Negative pressure method
Strength and control of the tongue develops from…
back to front
When does the larynx dissend in infants?
After about 3 months
What do we change while feeding infants once the larynx dissends?
move them to a more vertical feeding position
Swallow apnea
Cessation of respiration during swallow to prevent aspiration
Which takes prescendence, swallowing or respiration?
respiration - if child has trouble with SSB, they tend to choke - they will breathe first, not feed
What is Aspiration
Action of material penetrating thte larynx and entering the airway BELOW the level of the true VFs
Once material is in the airway, it may be expectorated…
patient mush have intact cough reflex and adequate laryngeal and respiratory control
Once material is in the airway, it may be silently aspirated…
if patient does not have a cough reflex, the material remains in the trachea and bronchial tree; may result in aspiration pneumonia
When food enters the airway, but stays above the true VFs
Penetration
How do we describe the timing of ASPIRATION?
Before, during or after (when aspiration occurs in relation to when the pharyngeal response occurs)
For materials to be aspirated, what three valves must it penetrate?
- Aryepiglottic folds
- False Folds
- True Folds
Aspiration when the larynx has not yet elevated to close the airway
Aspiration before
Aspiration when the laryngeal valves are not functioning adequately
Aspiration during
Aspiration when the larynx lowers and opens for inhalation
Aspiration after
How do we know when the pharyngeal response occurs?
Hyoid and larynx elevate
Is aspiration a swallowing problem?
No, it is a symptom
Why does it help to know the timing of aspiration?
Can help to rule in/out certain disorders
How do we treat aspiration?
treat the CAUSE of the problem
Reduced lip closure.
Oral Prep Phase Disorder
-results in food falling from the mouth anteriorally
Reduce range of tongue motion of coordination.
Oral Prep Phase Disorder
-Results in inability to form a bolus
Reduced tongue shaping and coordination.
Oral Prep Phase Disorder
-Results in difficulty holding a bolus and risk of aspiration BEFORE the swallow
Reduced labial tension or tone.
Oral Prep Phase Disorder
-Results in material falling into the anterior sulcus
Reduces buccal tension or tone.
Oral Prep Phase Disorder
-Results in material falling into the lateral sulcus
Tongue thrust; reduced tongue control.
Oral Prep Phase Disorder
-Results in abnormal hold position
Reduced mandibular movement.
Oral Prep Phrase Disorder
-Results in inability to align teeth and difficulty chewing
Where is the anterior/lateral sulcus
Between the gums/teeth and the cheeks
Where is the floor of the mouth?
Under the tongue
reduced tongue lateralization.
Oral Prep Phase Disorder
-Results in inability to lateralize material with tongue to place onto teeth
Reduced tongue elevation.
Oral Prep Phase Disorder
-Results in inability to mash materials
Reduced tongue control.
Oral Prep Phase Disorder
-Results in material falling to the floor of the mouth
Apraxia of swallow.
Oral Phase Disorder
-Results in delayed oral onset of swallow and/or searching motion/inability to organize tongue movements
Reduced oral sensation.
Oral Phase Disorder
-Results in delayed oral onset of swallow. Bolus may be held with no lingual movement due to lack of recognition of the bolus as something to be swallowed
Tongue thrust.
Oral Phase Disorder
-Results in tongue moving forward to start the swallow and possible pushing food from the mouth
Reduced labial tension.
Oral Phase Disorder
-results in residue (stasis) in the anterior sulcus
Reduced buccal tension or tone.
Oral Phase Disorder
-Results in residue (stasis) in the lateral sulcus
Reduces tongue shaping or coordination.
Oral Phase Disorder
-Results in residue (stasis) on the floor of the mouth
Scar tissue in tongue.
Oral Phase Disorder
-Results in residue (stasis) in a midtongue depression
Reduced tongue ROM.
Oral Phase Disorder
-Results in residue (stasis) of food on the tongue
Lingual discoordination.
Oral Phase Disorder
-Results in disturbed lingual contraction (peristalsis)
Reduced tongue elevation.
Oral Phase Disorder
-Results in incomplete tongue-to-palate contact and adherence (residue) of food on the hard palate
Reduced lingual strength.
Oral Phase Disorder
-Results in adherence of food on the hard palate. Distinguished from above because of build-up of food collecting on the palate as more viscous food is presented
Repetitive lingual rolling.
Oral Phase Disorder
- typical in pts. with Parkinsons
- Characterized by a repetitive upward and backward movement of the central portion of the tongue
Reduced tongue control.
Oral Phase Disorder
-Results in uncontrolled bolus or premature loss of liquid or pudding consistent into the pharynx with a risk of aspiration BEFORE the swallow
Reduced linguavelar seal.
Oral Phase Disorder
-Results in same as reduced tongue control
Piecemeal deglutition.
Oral Phase Disorder
-Characterized by two, three, or more repeated swallows to empty the oral cavity
Delayed pharyngeal swallow.
Disorder in Triggering the Pharyngeal Swallow
-occurs when the head of the bolus enters the pharynx and the pharyngeal swallow has not been triggered. Risk of aspiration is BEFORE the pharyngeal swallow response triggers.
Look at slide 55 and 56
Has info about item that will be on test…
How do you time a delayed pharyngeal swallow?
The delay is timed from the point where the bolus head passes the point where the lower edge of the mandible crosses the tongue base until the pharyngeal swallow is initiated (where laryngeal and hyoid elevation begin as part of the pharyngeal swallow)***
When is a pharyngeal swallow response determined to be absent?
a pharyngeal response delay of greater than 10 seconds*** (because it wont work for the purpose of ingesting food orally)
what is the delay of the pharyngeal response measured in?
Seconds
Reduced velopharyngeal closure.
Pharyngeal Stage Disorder
-results in nasal penetration during the swallow
Fold of mucosa at the base of the tongue.
Pharyngeal Stage Disorder
-results in pseudoepiglottis (after total laryngectomy)
Cervical osteophytes.
Pharyngeal Stage Disorder
-bony outgrowth from the cervical vertebrae that can be large enough to interfere with the swallow by narrowing the pharynx
Reduced pharyngeal contraction bilaterally.
Pharyngeal Stage Disorder
-results in coating on the pharyngeal walls after the swallow and presents a risk of aspiration AFTER the pharyngeal response when the pt. inhales
Reduced posterior movement of the tongue base (retraction).
Pharyngeal Stage Disorder
-results in vallecular residue bilaterally and a risk of aspiration AFTER…
Pharyngeal pouch/scar tissue.
Pharyngeal Stage Disorder
-results in coating in a depression on the pharyngeal wall and a risk of aspiration AFTER…
Residue AKA
Stasis
Diverticulum AKA
Pharyngeal Pouch (bad breath is a symptom of this)
Reduced laryngeal elevation.
Pharyngeal Stage Disorder
- results in residue at the top of the airway and a risk of aspiration AFTER…
- If the larynx doesn’t fully elevate, then the epiglottis wont fully invert
Reduced closure of the airway entrance (arytenoid to base of epiglottis).
Pharyngeal Stage Disorder
-results in laryngeal penetration and, depending if the penetrated material remains in the larynx, aspiration AFTER the swallow upon inhalation
Reduced laryngeal closure.
Pharyngeal Stage Disorder
-results in aspiration DURING the pharyngeal swallow response (this is the only one that is during)***
Reduced anterior/superior laryngeal movement.
Pharyngeal Stage Disorder
-results in stasis or a residue in both pyriform sinuses and a risk of aspiration AFTER…
Cricopharyngeal dysfunction.
Pharyngeal Stage Disorder
-results in residue in both pyriform sinuses and a risk of aspiration AFTER…
Generalized reduction in pharyngeal contraction.
Pharyngeal Stage Disorder
-results in residue throughout the pharynx and a risk of aspiration AFTER…
Where are the pyriform sinuses located in relation to the USE?
Just superior
If the pyriform sinuses are just above the UES, why would reduced laryngeal elevation result in residue in the pyriforms?
Because the UES doesn’t open
Unilateral damage to posterior movement of the tongue base.
Pharyngeal Stage Disorder
-results in unilateral vallecular residue and risk of aspiration AFTER…
Unilateral pharyngeal wall damage.
Pharyngeal Stage Disorder
-results in residue in one pyriform sinus and risk of aspiration AFTER…
Unequal height of the vocal folds.
Pharyngeal Stage Disorder
-results in inadequate vocal fold closure and a risk of aspiration DURING…
