Artic/Resonance/Swallowing

source filter theory

Voicing is generated by the vocal folds and routed through the vocal tract where it is shaped into sounds of speech by the articulators

Articulators

structures that come together or change shape of the vocal tract

mobile articulators

tongue, mandible, velum/soft palate, lips, cheeks, area behind oral cavity (fauces and pharynx), larynx, hyoid

immobile articulators

alveolar ridge (maxilla), hard palate, teeth

resonance

Selective amplification and filtering of the complex laryngeal tone by the cavities of the vocal tract

what is assessed in an oral motor exam

face, lips, tongue, jaw, hard and soft palate

other names of oral motor exam

cranial nerve exam or oral-peripheral exam

3 areas of OM exam

• observation of the oro-motor anatomy

• Examination of speech characteristics

• Diadochokinetic task

what we test on OM exam

Strength, symmetry, range of motion, sensation

skull

• Bony framework

• 22 bones joined by sutures

• Divided into cranial skeleton and facial skeleton

sutures of the cranium

sagittal, lambdoidal, coronal

bones of the cranium

frontal, occipital, temporal, parietal

mandible

• unpaired, lower jaw

• used for mastocation

• landmarks: ramus, corpus (body of jaw), angle (curvature of jaw), ramus

maxilla

• upper jaw

• roof of mouth

• floor of orbital cavity (nasal cavity)

• paired

• Landmarks: palatine process, intermaxillary suture, premaxilla

palatine bones

Comprises posterior ¼ of hard palate and extend superiorly

nasal bones

bridge of the nose

zygomatic bones

• cheek bones

• paired

• point of attachment for lip muscles

• Zygomatic arch = zygomatic bone + temporal bone

Vomer bone

• Unpaired, midline bone

• Makes up part of nasal septum

• Knife blade/plowshare; pointed anteriorly

Lacrimal bone

almost completely hidden in skull, constitute small part of lateral nasal wall and medial orbit

hyoid bone

connected via musculature to mandible, plays role in articulation

mandibulectomies

removing part of the mandible usually due to cancer, often replaced with titanium plate

maxillectomy

removal of the maxilla, replaced with obdurator (retainer-like), closes off roof of the mouth

cleft palate

opening in hard palate

frontalis

• elevate eyebrows and skin of forehead

• facial nerve CNVII

orbicularis oris

drawstring contraction for pursing lips

Motor: CNVII (facial)

Sensory: CNV (trigeminal)

risorius

retracts corners of mouth

Motor: CNVII (facial)

Sensory: CNV (trigeminal)

Buccinator

Retracts lips for masctication

• Motor: CNVII (facial)

  Sensory: CNV (trigeminal)

Levator Labii Superioris, Levator Labii Alaeque Nasi Superioris, Zygomatic minor

Elevates upper lip

Motor: CNVII (facial)

Sensory: CNV (trigeminal)

Smiling muscles

Levator Anguli Oris, Zygomatic Major

Motor: CNVII (facial)

Sensory: CNV (trigeminal)

Lip depressors

Depressor Labii Inferioris, Depressor Anguli Oris

Motor: CNVII (facial)

Sensory: CNV (trigeminal)

Mentalis

Elevates and wrinkles chin, pulls lower lip out (pout)

Motor: CNVII (facial)

Sensory: CNV (trigeminal)

Platysma

Often considered neck muscle, depresses mandible

Motor: CNVII (facial)

Sensory: CNV (trigeminal)

Assessment for lips

• Strength: smile, purse their lips in 4 quadrants and try and pull them apart, blow their cheeks up with air and try to push it out

• Symmetry: smile

• ROM: Smile to pucker

• Sensation: close their eyes, touch. diff places and ask them what you’re touching

Types of teeth

Incisors- cutting, Cuspids- tearing, Bicuspids-crushing, Molars- grinding

there are ___ deciduous teeth

10

class 1 occlusion

normal, upper arches slightly more advanced than lower arches

class 2 malocclusion

overbite

class 3 malocclusion

underbite

dentulous

having natural teeth present in the mouth

edentulous

toothless, having lost natural teeth

sparse

have some natural teeth but missing

dentures/repair

upper/lower/both

good/poor

Nasal cavity

• separated from oral cavity via hard and soft palate

• highly vascularized respiratory mucous membrane

• filter, warm, humidify air, nasal sounds

Oral cavity

• undergoes most significant changes during speech because tongue is the most mobile articulator

• extends from lips to posterior faucial pillars

buccal cavity

space between dental arches and cheek

Pharyngeal cavity

made of nasopharynx, oropharynx, laryngopharynx/hypopharynx

function of soft palate

move backwards to close off nasal cavity

function of epiglottis

move downward to close off airway

wrong

wrong

Laryngeal cavity

• extends from aryepiglottic folds to lower border of cricoid cartilage

• houses laryngeal vestibule, ventricle, vocal folds, subglottis

Nasopharynx

• Velopharyngeal port, acts as opening into nasal cavity, must be open to create nasal sounds

• closed off during swallow by soft palate

• highest point of pharynx

oropharynx

• middle section of pharynx

• posterior to oral cavity

• lined with mucosa that protects it from friction when swallowing

Laryngopharynx

lowest part of pharynx, posterior to larynx

pyriform sinuses allow food to travel from larynx to esophagus

Jaw role in A/R/S

• articulation: jaws open/close for speech sounds

• resonance: allows for more volume/clarity

• swallowing: allows for mastication

Masseter

• elevates mandible

• Motor/Sensory: CNV trigeminal

Temporalis

elevates/retracts mandible

Motor/Sensory: CNV trigeminal

Medial/internal pterygoid

elevates mandible

Motor/Sensory: CNV trigeminal

External/lateral pterygoid

protrudes the mandible

Motor/Sensory: CNV trigeminal

Assessment for jaw

• strength- keeping mouth open while trying to close it

• symmetry- gliding jaw from side to side

• ROM- opening/closing multiple times, how wide they can open the mouth

• sensation- close the eyes and touch each side

Soft palate role in A/R/S

• articulation- palatal sounds, close off cavities

• resonance- adjust what the voice sounds like according to shape

• swallowing- no nasal regurgitation, closes off every time we swallow

Point of insertion of velum

Palatal aponeurosis

Levator veli palatini

• Elevates and retracts soft palate from the back

• M: CNX vagus

• S: CNV trigeminal

Musculus uvulae

• shortens velum, may move uvula upward

• M: CN X Vagus

• S: CNV trigeminal

Tensor veli palatini

• Tenses velum, dilates eustachian tube

• M/S CNV trigeminal

Palatoglossus

• connects soft palate with tongue

• depresses velum and raises tongue

• AKA Anterior faucial pillars

• M: CNX vagus

• S: CNV trigeminal

Palatopharyngeus

• Elevates larynx and and pharynx, constricts pharynx, depresses velum

• AKA posterior faucial pillars

• M: CNX vagus

• S: CNV trigeminal

velum should be _____ for swallow, _____ for breathing

elevated, depressed

Assessment of velum

• strength/rom/symmetry: say aahhhhhh open wide to see if velum goes up

• sensation: touch the faucial pillars

Tongue role in A/R/S

• Articulation: major articulator, moves the most

• Resonance: height of tongue determines pitch

• swallowing: pushes the food back, gets it out of the buccal cavity

Assessment of tongue

• strength: use tongue depressor, ask client to push it against the cheek

• symmetry: how well they can move it left/right

• ROM: stick tongue out

If there is muscle weakness, the tongue will deviate to the ___ side

weak

Parts of the tongue

• apex

• dorsum

• base

• root

Tongue is divided into

anterior 2/3, posterior 1/3

Intrinsic muscles of tongue

• both attchments within tongue

• provide fine modifications of the tongue

  • Superior longitudinal

  • inferior longitudinal

  • transverse

  • vertical

Superior longitudinal

•Middle of the tongue

•Shortens and turns tip up

Inferior longitudinal

•Underside of tongue

•Draws tip down

Transverse

elongates/protrudes the tongue

Vertical

flattens the tongue

Extrinsic muscles of tongue

• one attachment in tongue, one outside

• move tongue as a unit

  • genioglossus

  • styloglossus

  • hyoglossus

  • palatoglossus

Genioglossus

bulk of tongue, helps lower the tongue

Styloglossus

draws tongue up and back

Hyoglossus

pulls sides of tongue down

Palatoglossus

elevates posterior tongue

Cranial nerves of tongue

Motor: CNXII hypoglossal

Sensation: CNVII facial anterior 2/3, CNIX glossopharyngeal posterior 1/3

Dysphagia

difficulty swallowing

Phases of swallow

• oral preparatory

• oral

• pharyngeal

• esophageal

brainstem

reflex center for swallow

Lowest point of swallow mechanism

lower esophageal sphincter

oral prep phase

voluntary, mastication to compress food against hard palate and form bolus

Swallow is also known as…

Deglutition

Oral phase

voluntary, tongue delivers food to posterior part of oral cavity, lasts 1-1.5 seconds

When should the swallow trigger

Bolus passes posterior faucial pillars/base of tongue

Pharyngeal phase

involuntary, soft palate closes, hyoid elevates, VF close, epiglottis inverts, respiration stops momentarily, UES relaxes, about 1 second

Pharyngeal constrictors

propel bolus and help push food down into esophagus- superior, middle, inferior

Esophageal phase

Bolus moves from UES to LES by peristaltic contractions

GERD

Gastroesophageal Reflux disease- gastric contents from stomach go into esophagus

symptoms of dysphagia

• decreased attention to eating/drinking

• pocketing/holding food in mouth

• coughing or throat clear before, during, after swallow

• loss of food from mouth

• change in vocal quality or breath sounds after eating or drinking- wet/gurgly noise

• patients body language/complaints- strained/painful

What can happen with aspiration

• pneumonia

• respiratory distress

• dehydration

• weight loss

• loss of pleasure with eating or drinking

• death

Clinical bedside evaluation

Completed at the hospital bedside or in a clinic setting

Greater than a swallow screen but not an objective assessment

Mostly subjective; however, contains some objective components

Oral prep and Oral Phase

Requires clinical intuition and critical thinking

Indicates if formal instrumentation is required