Swallowing & Dysphagia

Moving a bolus from the lips to the stomach safely and efficiently

What is the goal of swallowing?

To provide nutrition and hydration to sustain life

Why is swallowing necessary?

bolus

Swallowed food - a small rounded mass

nasal cavity, tongue, larynx, trachea, pharynx, soft palate (velum), epiglottis, esophagus

Identify the structures: 1-8

True

True or false: Swallowing involves many of the same structures as speech and respiration

Jaw, lips, teeth, hard palate, soft palate (velum), tongue, pharynx

Shared anatomical structures for swallowing and respiration/speech

larynx (speech/respiration), esophagus (swallowing)

Differences in anatomical structures used for swallowing vs respiration/speech

top of the larynx

While respiration & swallowing share a common pathway through much of the upper airway, they separate at the ______

larynx, moves past the VFs, down the trachea, and into the lungs

Airflow for respiration (and speech) enters the …

larynx

A swallowed bolus is kept out of the _____ by several protective mechanisms and is guided into the esophagus towards the stomach.

oral, pharyngeal, esophageal

3 phases of swallowing

oral preparatory and transport phase

two components of the oral phase

Oral preparatory stage

In this phase, the bolus is prepared: anticipate eating, food is brought to mouth, liquids sipped/sucked, food chewed (masticated) and mixed with saliva, prepare a cohesive bolus to swallow

oral transport stage

In this phase, the bolus is moved to the back of the mouth (oral cavity). The bolus is propelled anteriorly to posteriorly through mouth to pharynx, takes ~1 sec

Pharyngeal phase

In this phase, the bolus is propelled through the pharynx to the esophagus. Where a bolus takes a different pathway from respiration. Takes ~1 sec.

1. Soft palate elevates to seal off the nasal cavity

2. The larynx moves up and forward

3. The epiglottis folds downward to cover the airwary

4. The vocal folds adduct

5. Reflexive cough

List the types of safety mechanisms the pharyngeal phase includes

esophageal phase

In this phase, the bolus is moved through the esophagus into the stomach, takes ~8-20 secs, swallowing is complete and digestion begins

• Oral prep/transit: voluntary, resp continues, ~1 sec (depending on food consistency)

• Pharyngeal: involuntary, resp pausing, ~1 sec

• Esophageal: involuntary, resp continues, ~8-20 secs

Compare swallowing phases

False

True or false: dysphagia is a primary disorder

Developmental disabilities, acquired neurological disabilities, degenerative neurological disabilities, trauma

What disorders is dysphagia secondary to?

• Coughing during or immediately after eating/drinking

• Wet sounding voice during/after eating/drinking

• Extra effort/time needed to chew/swallow

• Food/liquid leaking from mouth/getting stuck in mouth

• Recurring pneumonia/chest congestion after eating

• Weight loss/dehydration from not being able to eat/drink enough

• Discomfort/difficulty w/ eating/swallowing

List the signs and symptoms of dysphagia

symptoms

What the patient or client reports.

signs

What you observe/see.

penetration or aspiration

When the bolus enters larynx instead of esophagus

nasal regurgitation

When the velum does not raise to block off nasal cavity and the bolus enters the nasal cavity

Penetration

Bolus enters the larynx but does not pass beyond the VFs

aspiration

Bolus passes beyond the VFs, below larynx and into trachea and possibly lungs

lung damage, distress, or pneumonia

Consequences of aspiration may include …

• Preventing adequate nourishment/hydration

• Pain or discomfort when swallowing

• Decreased quality of life

• Social isolation

Other consequences of dysphagia may include:

True

True or false: Dysphagia may involve problems accepting, gathering, sucking, chewing, or swallowing food

food acceptance and bolus preparation

Problems with the oral preparatory phase involve …

moving the bolus to the back of the mouth

Problems with the oral transport phase involve difficulty …

moving the bolus through the pharynx to the esophagus

Problems with the pharyngeal phase involve difficulty…

moving the bolus through the esophagus to the stomach

Problems with the esophageal phase involve difficulty …

• Medical conditions that result in low muscle tone, delayed motor development, or physical deformity may cause dysphagia - Down syndrome, Cerebral palsy, Cleft lip and palate

• Inadequate feeding behaviors (i.e. inefficiency, overselectivity, refusal, feeding delay) - low birth weight, prematurity, prenatal drug exposure

Dysphagia or difficult feeding behaviors can occur in children with a variety of conditions such as

premature

_____ babies are often at increased risk for feeding and swallowing difficulty because they do not have fully developed systems and often have low birth weights.

• Unsafe/inefficient swallowing

• Delayed growth

• Food intolerance

• Poor appetite regulation

Difficulties premature babies may have include

Pica

ingestion of nonnutritive substances (e.g., clay, soil, pebbles, etc.) for one month or longer

True.

True or false: medical interventions may limit exposure to feeding development, feeding routines, and food tastes & textures

Tube feeding, tracheostomy, mechanical ventilation

Interventions for swallowing difficulties in pediatric population

neurological damage, laryngeal damage, trauma

Acquired dysphagia can result from

affected phase, underlying cause, and severity

The characteristics of adult dysphagia are related to the…

• Referral

• Screening

• Assessment

  • Case hx

  • Clinical swallowing eval

  • Instrumental swallowing assessment

Evaluation of feeding and swallowing disorders includes

without instrumentation

Clinical swallowing assessment refers to swallowing assessment …

Oral mechanism exam

Assesses structures used in swallowing

Observation

Determine readiness for food

Trials with food and drink

Look for signs or symptoms of dysphagia

instruments

Instrumental swallowing assessments examine the swallow using

Videofluoroscopy (VFSS or MBSS)

An individual eats or drinks food or liquid with barium in it, and swallowing is viewed by X-ray

Endoscopic assessment (FEES)

A lighted scope is inserted through the nose into pharynx, and the swallow is viewed on a screen

Compensatory or rehabilitative

Two main approaches to tx for dysphagia

compensatory

________ approaches ‘compensate’ for the disordered swallow which may include changing the diet, the environment/equipment, the patient/position

Rehabilitative

______ techniques attempt to improve the disordered swallow, which may include exercises for strengthening weak swallowing muscles. Also adjunct techniques like Neuromuscular Electrical Stimulation (NMES)