Dysphagia Intro/Anatomy of a Normal Swallow

What are the four phases of the normal adult swallowing process?

1. Oral Preparatory

2. Oral Transit

3. Pharyngeal

4. Esophageal

“Plate to Lips” is to ____ as “Lips to Gut” is to ___

OT

SLP

What is dysphagia?

A swallowing disorder involving the oral cavity, pharynx, esophagus, or gastroesophageal junction

What are the big three consequences of dysphagia?

malnutrition, dehydration, aspiration pneumonia (aka respiratory compromise)

Name three members on the dysphagia client team

1. dietician

2. OT

3. Respiratory therapist

T/F Dysphagia is not a disease, but a symptom of a disease or condition

True

T/F The treatment of aspiration pneumonia is costly, and it is associated with increased length of stay in the hospital, greater disability at 3 and 6 months, and poorer nutritional status during hospitalization.

true

What is the goal of dysphagia treatment?

1. avoid aspiration

2. have adequate nutrition and hydration

3. least restrictive diet

4. safety and efficiency in swallow

What does safety and efficiency mean re: swallowing?

Safety = risk of aspiration

Efficiency = moving the bolus through the pharynx

Aspiration

entry of food or liquid into the airway BELOW the true vocal folds; silent aspiration – no outward s/s

Penetration

entry of food or liquid into the larynx at some level, can be down to the cords, but not past the cords

Residue

food left behind in the mouth or pharynx after the swallow

Backflow or Retropulsion

food from the esophagus in the pharynx, and/or food from the pharynx into the nasal cavity

Odynophagia

pain when swallowing

Xerostomia

dry mouth

aspiration pneumonia

Pneumonia is inflammation (swelling) and infection of the lungs or large airways. Aspiration pneumonia occurs when food or liquid is breathed into the airways or lungs, instead of being swallowed

any Pt whose aspiration is __% of the bolus of a particular food consistency despite optimal inventions should be restricted.

10

Types of Dysphagia

1. Neurological

2. Structural

3. Psychological/Mental Illness

Phagophobia

the fear of swallowing

What are the normal events of a swallow?

1. Posterior Lingual Propulsion

2. Swallow trigger

3. Velar Elevation

4. Laryngeal Vestibule Closure

5. Pharyngeal Constriction and elevation

6. Upper Esophageal Opening

What is bolus efficiency? (BE)

moving ingested bolus into esophagus in a timely way without significant residue, effort, or repeat swallows

What is airway protection (AP)?

the prevention of ingested materials from enetering the larynx and/or trachea

Posterior Lingual Propulsion

A quick, forceful lingual movement that propels the bolus into the pharynx. Also contributes to epiglottic inversion

Swallow trigger

sensory input from the oropharynx that triggers the reflexive swallow events

Velar elevation

Contributes only to BE, not AP. Velum raises posteriorly to touch the PPW to prevent nasal regurgitation

Laryngeal Vestibule Closure

First line of airway defense during swallowing consisting of epiglottic inversion, arytenoid adduction, and laryngeal elevation

Pharyngeal Constriction and elevation

Clearing force behind the tail of the bolus traveling down the pharynx due to sequential contraction of the superior, middle, and inferior constrictors

UES opening

UES opens to allow bolus to move from the esophagus via relaxation of the sphincter muscles

What are the 4 intrinsic muscles of the tongue and their movements?

Vertical: contraction = flattens tongue

Transverse: contraction= narrows and elongates tongue

Superior longitudinal: contraction= shortens and pulls tip upward

Inferior longitudinal: contraction= shortens and pulls tip downward

What are the four extrinsic muscles of the tongue and their movements?

Hyoglossus: retracts and depresses tongue

Genioglossus: protrudes and retracts, can also depress

Palatoglossus: retracts and elevates tongue

Styloglossus: retracts tongue

What is general sensation?

pressure, touch, vibration, temperature

What is special sensation?

a dedicated organ with special receptors for a particular stimulus type

What cranial nerve is involved in general sensation for the anterior 2/3rds of the tongue?

CN 5 - Trigeminal

What cranial nerve is involved in special sensation for the anterior 2/3rds of the tongue?

CN VII Facial

What cranial nerve is involved in general AND special sensation in the posterior 2/3rds of the tongue?

CN IX Glossopharyngeal

What are the muscles and functions of the soft palate?

Tensor veli palatini= eustacian tube dilation

Levator veli palatini= velum elevation

Musculus uvulae= velum elevation

Palatoglossus = velum depression

Palatopharyngeus = velum depression

What cranial nerves are responsible for motor innervation for the soft palate muscles?

CN V (Mandibular branch) for tensor veli palatini

CN IX and X (pharyngeal plexus) for all others

What nerve is responsible for sensory innervation for both the soft and hard palate?

CN V Maxillary branch

What is referred pain?

Pain that is felt in location that is not the original source. e.g. pain referred from V2 to V1 during brain freeze

What causes brain freeze?

the rapid cooling and then subsequent warming up of nerves and blood vessels in the palate

What does the dynamic function of the soft palate affect?

the elevation and depression of the soft palate affects respiration (directing airflow), resonance, and deglutition (location of bolus flow)

What is the hyoid?

What are the suprahyoid muscles?

Mylohyoid

Stylohyoid

Geniohyoid

Digastric

What are the infrahyoid muscles?

Thyrohyoid

Omohyoid

Sternothyroid

Sternohyoid

What cranial nerve is responsible for sensory innervation of the hyolarynx?

What cranial nerve(s) are responsible for motor innervation within the hyolarynx?

What happens in the oral preparatory phase?

Begins with food in mouth. Bolus is chewed, manipulated and mixed with saliva

Mastication

a rotary lateral movement of the mandible and tongue that occurs during the oral prep phase

What occurs during the oral transit stage?

the tongue begins posterior movement of the bolus

What are two key components for the oral phase of swallowing?

1. Lip closure: need proper seal and pressure

2. Bolus manipulation: need bolus cohesion and bolus propulsion

When does the oral stage end and the pharyngeal stage begin?

when the bolus is propelled to the base of the tongue