CSD 6300 Swallowing

Final

Ability of lips to seal the bolus and prevent anterior leakage.

Lip Closure

Cupping/seal of the tongue to contain the bolus.

Tongue Control During Bolus Hold

Chewing and forming a cohesive bolus.

This process involves mastication, where food is mechanically broken down and mixed with saliva, creating a cohesive mass for swallowing.

Posterior propulsion of the bolus by the tongue.

This refers to the movement of the tongue pushing the bolus towards the pharynx during the swallowing process.

Material left in the oral cavity after the swallow.

Oral Residue

Timing of swallow onset, judged at first brisk hyoid movement.

Initiation of Pharyngeal Swallow

Velopharyngeal closure to prevent nasal regurgitation.

Soft Palate Elevation

Vertical lifting of the larynx during the swallow.

Laryngeal Elevation

Forward movement of the hyoid bone.

Anterior Hyoid Excursion

Degree of epiglottic inversion or deflection.

Epiglottic Movement

Airway closure at the height of the swallow.

Laryngeal Vestibular Closure

Contractile wave along the posterior pharyngeal wall.

Pharyngeal Stripping Wave

Overall pharyngeal shortening and constriction.

Pharyngeal Contraction

Diameter and duration of UES opening.

PES and UES opening

Posterior tongue movement and contact against the PPW.

Tongue Base Retraction

Material remaining in the valleculae or pyriform sinuses after the swallow.

Pharyngeal Residue

Swallowing Screening

Rapid pass/fail test identifying aspiration risk (not diagnosis).

Bedside evaluation including history, observation, CN exam, bolus trials.
Cannot visualize pharynx or detect silent aspiration.

Clinical Swallowing Exam

Imaging that shows pharyngeal physiology, airway protection, residue, and silent aspiration.

Intrumental exam (FEES, VFSS)

Validated screen with water challenge; high sensitivity for aspiration.

Yale Swallowing Exam

Nursing-friendly screen assessing voice quality, secretions, water test.

TOR-BSST

Uninterrupted drinking of 3 oz water; identifies risk of aspiration but not physiology.

3 oz Water Swallow Test

• Quick tests of CN V, VII, IX, X, XII (jaw/face strength/sensation, palate elevation, gag/voice, tongue ROM/strength).

• Why: screens for structural/neuromotor impairments affecting bolus control and airway protection.

Cranial Nerve Exam

• Inspect dentition, prostheses, oral mucosa; test lip closure, bolus control, chewing, tongue strength/coordination.

• Why: identifies problems that cause oral residue, inefficient mastication, or aspiration predisposition.

Oral Health Exam

• Quick, bedside—can be done in multiple settings (hospital, clinic, nursing home).

• Gathers broad clinical context (cognition, cooperation, oral health, secretions).

• Can detect overt signs of aspiration (cough, choking, wet voice) and test compensatory strategies in real time.

• Useful for monitoring clinical change and guiding immediate diet/management decisions when imaging not available.

Strenghts of CSE

• Cannot visualize pharynx, larynx, or UES mechanics — you cannot see residue patterns, hyolaryngeal excursion, epiglottic inversion, or UES opening.

• Cannot reliably detect silent aspiration (no cough/voice change).

• Less sensitive/specific than instrumental tests for characterizing physiology, residue, or precise targets for rehabilitation.

• Findings depend on examiner skill and trial standardization; fatigue and environment may alter results.

Limits of the CSE

Why is the CSE insufficient for diagnosing specific swallowing physiology?

It cannot assess hyolaryngeal elevation, epiglottic inversion, residue patterns, or PES opening.

What is needed to rule out silent aspiration?

Instrumental assessment — VFSS or FEES.

When should you refer for instrumental swallowing assessment after CSE?

When pharyngeal-phase impairment is suspected or symptoms are unexplained.

When you need visualization of oral stage, pharyngeal timing, and UES opening.

When is VFSS preferred over FEES?

When is FEES preferred?

When you need to evaluate laryngeal sensation, secretion management, or use real foods at bedside.

Oral Phase

Lip seal → tongue-palate contact → bolus formation/mastication → posterior tongue propulsion.

Swallow initiation timing, hyolaryngeal movement, epiglottic inversion, LVC, pharyngeal

Pharyngeal Stage

To probe different physiologic demands and reveal consistency-specific impairments.

Why are thin, pudding, cookie, and sequential swallows included?

Why repeat MBSS/FEES with the same protocol?

To reliably measure change over time (pre/post intervention).

Penetration-Aspiration Scale — depth of airway invasion (1–8) and response to it.

PAS Meaning

What does the PAS not tell you?

The underlying physiologic cause of penetration/aspiration.

Quantitative residue measures (normalized residue ratio scale / valleculae residue ratio scale).

What are NRRS/VRRS?

What are examples of PROs/ClinROs?

MDADI (patient-reported), FOIS (function), DIGEST (oncology clinician-rated).

Which maneuvers worked, what didn’t, risk profile, rationale for recommendations, and note that silent aspiration cannot be ruled out without imaging.

What key items must be documented after instrumental exam?

No airway entry (safe).

PAS level 1

What is PAS score 8?

Material enters airway, passes below VF, no cough (silent aspiration).

Why is PAS not sufficient alone?

It quantifies airway invasion but not cause, physiology, residue, or recommendations.

What is IDDSI Level 0? Level 4? Level 7?

Thin, thick, food

ow does viscosity affect swallowing?

Higher viscosity can reduce aspiration risk but may increase residue and transit time; trade-offs exist.

Why is the CSE essential even with instrumental testing?

It provides CNC/medical/contextual info (cognition, cough) needed to interpret imaging and predict pneumonia risk.

Why use standardized protocols and fixed viscosities?

Ensures reproducibility and valid comparisons across time/clinicians.

Laryngeal anatomy, secretions, mucosal lesions, and pre/post-swallow penetration/aspiration (whiteout during swallow).

What does FEES best visualize?

Visualizing oral + pharyngeal + UES function and bolus flow in motion.

What is MBSS (VFSS) best for?

When is FEES preferred?

Bedside eval, repeated trials with real food, patients who cannot be transported or need laryngeal visualization.

Possible causes of Delayed Initiation (C6)?

Sensory deficits, motor timing/CPG dysfunction.

Sensory enhancements (cold/carbonation), postural changes, supraglottic swallow, respiratory–swallow timing training.

Treatments for Delayed Initiation (C6)?

Mechanism of Reduced Tongue Base Retraction (C15)?

Weak TB muscle or poor TB–PPW contact leading to vallecular residue. Treatment includes: Effortful swallow, Masako (caution), IOPI strengthening, and ultrasound biofeedback.

What causes Reduced Laryngeal Elevation / Anterior Hyoid Excursion (C8–9)?

Weakness of the suprahyoid and long pharyngeal muscles. Treatment includes: Mendelsohn, Shaker, CTAR, effortful pitch glide, EMST adjunct.

Why is epiglottic inversion impaired (C10)?

Often insufficient hyolaryngeal excursion/timing. Treatments for impaired epiglottic inversion and LVC (C10–11): Supraglottic/super-supraglottic swallow, Mendelsohn, effortful swallow, consider VF medialization for glottic gap.

Causes and treatment of Reduced Pharyngeal Stripping/Contraction

Pharyngeal weakness or TB–PPW mismatch.Treatments for pharyngeal weakness/residue: Effortful swallow, EPG, targeted strengthening, MDTP/IDR, PES management if obstruction.

Causes and treatment of PES opening

Poor hyolaryngeal traction, CP hypertonicity, or structural obstruction. Mendelsohn, Shaker/CTAR; consider dilation, myotomy, Botox or HRPM when indicated.