Swallowing

Explain the **Oral Prep Phase**:

Begins with food being placed in the mouth and is first masticated.

Explain the **Oral Phase**:

Begins with the anterior to posterior tongue action that moves the bolus posteriorly. Ends as the bolus passes through the anterior faucial pillars when the swallowing reflex is initiated.

Explain the **Pharyngeal Phase**:

Consists of reflex actions of the swallow. Reflexes are triggered by the contact the food makes with the anterior faucial pillars. This phase involves velopharyngeal closure, laryngeal closure by an elevated laryngeal to seal the airway, reflexive contractors to move the bolus down and eventually into the esophagus.

Explain the **Esophageal Phase**:

This phase is not under voluntary control. Begins when the food arrives at the orifice of the esophagus. Food is propelled through the esophagus by peristaltic action and gravity and into the stomach. Bolus entry into the esophagus results in restored breathing and a depressed larynx and soft palate.

Rooting Reflex:

Tactile stimulation to the side of the lips or cheek. Baby will turn head toward the stimulus and open mouth. Continues 3-6 months after birth.

Suckling Reflex:

Tactile stimulation on the top of the tongue or middle of hard palate. Baby will move the tongue in a forward-backward motion.

Disorders of the **Oral Prep** phase of swallow:

1. Problems in chewing food: Reduced range of tongue movement, reduced range of mandibular movement, reduced buccal tension, poor alignment of the mandible and maxilla.
2. Difficulty in forming/holding bolus: Weak lip closure, reduced tongue movement, inadequate tongue and buccal tension.
3. Aspiration before swallow

Disorders of the **Oral** phase of swallow:

1. Anterior (Instead of posterior) tongue movement and generally weak tongue movement.
2. Tongue Thrust: A forward, instead of the normal backward, movement of the tongue.
3. Reduced range of tongue movement and elevation.
4. Reduced labial, buccal, and tongue tension and strength.
5. Decreased tongue sensation may cause premature loss of the bolus over the base of the tongue.
6. Food residue suggesting incomplete swallow due to tongue and buccinator weakness.
7. Premature swallow of solid and liquid food and aspiration before swallow.
8. Piecemeal Swallow: Attempts at swallowing abnormally small amounts of the bolus.

Disorders of the **Pharyngeal** phase of swallow:

1. Difficulties in propelling the bolus through the pharynx.
2. Delayed or absent swallowing reflex
3. Nasal and airway penetration of food
4. Food coating on pharyngeal walls: Food residue in valleculae due to reduced base of tongue strength and retraction, on top of airway, in pyriform sinuses, and throughout the pharynx.
5. Delayed pharyngeal transit.
6. Reduced pharyngeal peristalsis.
7. Inadequate closure of the airway: Aspiration before and after swallow.
8. Reduced movement of the base of the tongue.

Disorders of the **Esophageal** phase of swallow:

1. Backflow of food from esophagus to pharynx.
2. Reduced esophageal contractions.
3. Formation of diverticulum: A pouch the collects food.
4. Development of tracheoesophageal fistula: A hole.
5. Esophageal obstruction: By a tumor.
6. Achalasia: A special form of esophageal swallowing disorder due to esophageal motility impairment or a failure of the lower esophageal sphincter to relax. Consequently, the food is not passed into the stomach but retained in the esophagus.

Explain **Supraglottic Swallow**:

Close the vocal cords before, during, and after the swallow to prevent aspiration. Appropriate for individuals with diminished vocal cord closure and delayed pharyngeal swallow onset.

__Instructions__: Inhale and hold breath tightly. Begin swallow process while continuing to hold breath. Volitionally cough immediately after the swallow prior to inhalation.

Explain **Effortful Swallow**:

Appropriate for individuals with reduced back of tongue strength and range of motion. Increased tongue base movement and pharyngeal pressure. Reduces degree of pharyngeal residue.

__Instructions__: Swallow while “squeezing” all your muscles as tightly as you can.

Explain the **Chin Tuck** posture:

Improves airway protection through repositioning the tongue base and epiglottis posteriorly, narrowing the supraglottic region. Opens the valleculae. Important to have patient keep chin tucked until the swallow is completed.

Explain the **Mendelson Maneuver**:

Appropriate for individuals with decreased laryngeal motility and reduced swallow coordination. It extends the duration of the UES opening and helps normalize the timing of the swallow.

__Instructions__: “Catch” the swallow at the apex of laryngeal elevation and hold for several seconds.

Explain the **Head Rotation** posture:

To the *weakened* side. Predisposes the stronger side of the pharynx to control the largest portion of the bolus.

Fiber Optic Endoscopic Evaluation of Swallowing (FEES):

Fiberoptic wand is placed in nose and routed to oral pharynx. Patient is given trials (Dyed green). Shows the status of the hypopharynx, laryngeal vestibule, and vocal cords during pre- and post-swallow periods. Excellent to visualize pharyngeal residue. No visualization of oral/esophageal stages. No visualization of the actual swallow.

Videofluoroscopic Swallow Study (VFSS):

Completed by SLP and radiologist in radiology suite. Real-time imagery of oral, pharyngeal, esophageal swallowing stages. Determination of aspiration. Patient is given various consistencies laced with barium.

Explain the **Shaker Exercise**:

Increase opening of UES by strengthening the geniohyoid, thyrohyoid, and digastric muscles to aid in UES opening.

__Instructions__: Lay flat on your back. Hold your head off the floor looking at your feet for 1 minute. Relax for 1 minute. Repeat x2.

Explain the **Head Tilt** posture:

To the *strong* side. Tilting head to strong side aids in allowing gravity to propel bolus into the neurologically intact side.

Explain the **Head Back** posture:

Enlists gravity to help with oral transport of bolus.