NYU Dysphagia

What are the four stages of swallowing?

1. Oral prep

2. Oral stage

3. Pharyngeal stage

4. Esophageal stage

Is the oral phase voluntary or involuntary?

Voluntary

What happens in the oral phase?

The bolus is prepared

Why is saliva important in the oral phase?

It helps to break down the food and forms a bolus. It also coats the bolus to aid in the transition to each phase

In what direction is the bolus pushed?

Posteriorly

When is the pharyngeal stage triggered?

At the location of the anterior faucial pillars

Do the phases of swallowing need to work efficiently in order for a swallow to be successful?

Yes

In which phase can an impairment occur?

In any of the phases

What would happen if the velum "valve" didn't close when it's supposed to?

Food or liquid would come out of the patients nose (nasal regurgitation)

What would happen if the larynx "valve" didn't close when it's supposed to?

The patient would aspirate

What are the two goals of a swallow?

1. Protect the airway

2. Move the food/liquid through the esophagus

What are the major events that happen in the oral prep phase?

1. Labial seal

2. Mastication

3. Mixing the food with saliva

4. Piecemeal deglutition (breaking up the bolus into pieces for us to swallow

What muscles are involved in the oral prep phase?

1. Orbicularis oris

2. Buccinator

3. Tongue muscles

4. Muscles of mastication

5. Muscles of salivation

What nerve innervates the Orbicularis oris muscle?

CN VII (Facial - 7)

What nerve innervates the Buccinator muscle?

CN VII (Facial - 7)

Is dysphagia a disease?

No, it is a symptom

What is the goal of swallowing?

Safety and efficiency

What is considered a safe swallow?

No aspiration (food or liquid out of the lungs)

What is considered an efficient swallow?

Keeping food and liquid moving down the esophagus to the stomach

What can aspiration cause?

Pneumonia or infection

What are the implications of not being able to swallow?

Malnutrition, weight loss, dehydration, quality of life

Who is part of the dysphagia team?

SLP, nursing, dietician, physician, OT, PT, lactation consultant, social worker, dentist, radiologist, ENT, neurologist, radiation technician, gastroenterologist, oncologist, family members

How is dysphagia classified?

Aspiration and penetration

What is aspiration?

Material falls below the VF

Either the patient will cough or silent aspiration will occur

What is penetration?

Material above the VF in the laryngeal vestibule

Either the patient will swallow or is likely to aspirate

Residue

A part of the bolus that remains in the pharynx after a complete swallow (either in the vallecula or pyriform sinuses)

- Patient is at high risk for aspiration

Physiological events for swallowing

1. prepare the bolus - keep it in the mouth

2. push the bolus back

3. initiate the pharyngeal swallow

4. open the UES to let the bolus move through the esophagus

If there is unilateral damage from a stroke, will the buccinator muscle contract?

No

What nerves innervate tongue sensation?

CN V (Trigeminal), CN VII (Facial), CN IX (Glossopharyngeal)

What happens to the tongue during the oral prep phase?

It alters its shape, tone, and position, to position the bolus and seal off the nasal cavity

If the bolus collects in the vallecula during oral prep, should you grade this as a poor swallow?

No, it is normal

Which muscles of mastication are involved in the oral prep phase?

1. Masseter (CN V)

2. Temporalis (CN V)

3. Medial and lateral pterygoids (CN V)

Which nerves innervate the muscles that help produce saliva in the oral prep phase?

CN VII (Facial) and CN IX (Glossopharyngeal)

Why is saliva important?

Helps maintain healthy oral tissue, helps prevent tooth decay by maintaining bacteriostatic nature

How much saliva is produced per day?

1-1.5 liters per day

What happens during the oral phase of swallowing?

1. Bolus is prepared

2. Velum elevates

3. Back of the tongue depresses

4. Pharynx open

5. Hyoid starts to elevate

Which muscles are used during the oral phase?

1. Superior longitudinal muscle

2. Levator veli palatini

3. Hyoglossus

4. Styloglossus

5. Anterior tongue

6. Obicularis oris

7. Buccinator

8. Superior pharyngeal constrictor

9. Mylohyoid

What nerve innervates the Superior longitudinal muscle?

CN XII (Hypoglossus)

What does the Superior longitudinal muscle do during the oral phase?

Helps push the bolus back by raising the tip of the tongue to the alveolar ridge

What nerve innervates the Levator veli palatini muscle?

CN X (Vagus)

What does the Levator veli palatini muscle do during the oral phase?

Elevates the velum to close the nasopharynx

What nerve innervates the hyoglossus and styloglossus?

CN XII (Hypoglossal)

What do the hyoglossus and styloglossus muscles do in the oral phase?

Depresses the back of the tongue so the velum can elevate

Which nerve innervates the anterior tongue?

CN XII (Hypoglossal)

What does the anterior tongue do in the oral phase?

Compresses against the hard palate and moves like a wave (anterior to posterior) to help push the bolus back along the back of the tongue

What do the obicularis oris and buccinator do in the oral phase?

They contract to prevent pressure from escaping the oral cavity

What nerve innervates the superior pharyngeal constrictor?

CN X (Vagus)

What does the superior pharyngeal constrictor do in the oral phase?

Contracts to help with closure of the velum to help protect against nasal regurgitation

What nerve innervates the mylohyoid?

CN V (Trigeminal)

What does the mylohyoid do in the oral phase?

Slightly elevates the hyoid to prepare for the pharyngeal phase

During the pharyngeal phase, breathing and swallowing both occur. Which one takes the primary role?

Breathing

What is the normal amount of air we inhale and exhale during swallowing?

20% for inhaling and 80% for exhaling

Why is it important to exhale after swallowing?

Helps protect the airway

When does swallowing occur?

During Apnea (cessation of breathing)

Once the pharyngal phase is initiated, can it be reversed?

No, it is involuntary and cannot be reversed

Does the pharyngeal phase include the activation and inhibition of muscles in a timely and coordinated fashion?

Yes

How long is considered a fast and efficient swallow?

1 second or less for a healthy swallow

What makes the pharyngeal phase complex?

It completely reorganizes the pharynx from a breathing configuration to a swallowing configuration (remember: breathing is the primary role)

Is a swallow always initiated at the faucial pillars?

Mostly for healthy individuals but research shows that in some healthy adults the swallow can be triggered in the pharynx

Can verbal cueing improve the swallow trigger?

Yes, it makes it higher in the oropharynx

What are the 6 things that happen during the pharyngeal phase?

1. Jaw stabilizes

2. Bolus gets pushed into the pharynx

3. Hyolaryngeal elevation

4. Laryngeal vestibule closes (including t/f VF and epiglottis)

5. Pharynx shortens and constricts

6. UES opens

Why is the cricopharyngeus muscles most of the time contracted?

To avoid stomach contents coming into the esophagus and up into the pharynx

Does the cricopharyngeus muscle contract when the bolus is in the UES?

No

Which muscles are involved in the pharyngeal phase?

Muscles of mastication, tongue muscles, superior/middle/inferior pharyngeal constrictors, palatopharyngeas, salpinopharyngeaus, stylopharyngeas, suprahyoid muscle, laryngeal muscles, and cricopharyngeus