Dysphagia

Components of All Swallows - All swallows must have these physiological components in order to clear food from the oral cavity & pharynx with no residue & with good airway protection:

-Oral propulsion of the bolus into the pharynx; -Airway closure; -Upper esophageal sphincter opening; &, -Tongue base-pharyngeal wall propulsion to carry the bolus through the pharynx & into the esophagus. The variations on normal swallowing generally involve changing the relative timing of these elements, but all must be present & normal for the bolus to be cleared safely & efficiently.

The lateral (side view) radiographic view on a Videofluoroscopy is used initially to assess?

-The transit times or speech & efficiency of bolus movement & also for better observation of aspiration. -Can slow it down, see where aspiration happens -Lateral view it's hard to see.... Can't see the pyriform sinuses, VFs, & asymmetric pharyngeal transit (goes down one side)

VFSS/MBS assessment generally uses a variety of food types & consistencies, in measured amounts, mixed with barium to make them radiopaque (visible under vluoro):

-Thick liquids, small amount progressing to larger amount; -Thin liquids, again initially conservative amount; -Soft pureed food, such as pudding &/or applesauce; -Masticated solid, such as a piece of cookie, cracker, or chopped meat; -Cup drinking, single sip, then consecutive swallows; -Straw drinking; -Any particular food type or substance that the patient may report to be problematic.

Oral Structures - Floor of Mouth:

-musculature includes the mylohyoid, geniohyoid, & anterior belly of digastric, all of which attach the body of the mandible anteriorly & the body of the hyoid posteriorly -the hyoid bone forms the foundation of the tongue, embedded in its base. The larynx is suspended from the hyoid, & it elevates & moves forward with movement of the hyoid

Swallowing Physiology - The Four Phases of Swallowing:

-oral preparatory phase -oral phase -pharyngeal phase -esophageal phase

The anatomic areas involved in deglutition include:

-the oral cavity -the pharynx -the esophagus

Edentulous

no teeth

Dysphagia =

swallowing impairment

Lateral sulci

the cheek cavity

Oral preparatory phase overview:

when food is manipulated in the mouth & masticated if necessary, reducing it to a consistency ready for swallow

Esophageal phase:

when peristalsis carries the bolus through the esophagus & into the stomach

Structures - Salivary Glands:

-3 large salivary glands are on each side: the parotid glands, the submandibular glands, & the sublingual glands. Many small glands are also in the mucous membrane of the tongue, lips, cheeks, & roof of the mouth -saliva not only serves to maintain oral moisture & reduce tooth decay, but assists in digestion & is a natural neutralizer of stomach acid that may reflux into the esophagus

The pharyngeal swallow in the infant is similar to that of the adult with two exceptions:

-Laryngeal elevation is much reduced, since the larynx is anatomically elevated under the tongue base & does not need to move upward; & -The posterior pharyngeal wall is often seen to move much further anteriorly during the swallow than is observed in adults

Videoendoscopy (FEES) - Advantages:

-No radiation exposure; -Can be used to test sensory awareness; -Effective means of assessing the patient's oropharyngeal anatomy, providing excellent, valleculae, aryepiglottic folds, & pyriform sinuses; -Can spot landmarks when looking above -Can be used to assess & provide biofeedback for the learning of airway closure maneuvers. Tell what you want to see & how to make it happen

Videofluoroscopy enables visualization of:

-Oral activity during chewing & the oral stage of swallowing. -The triggering of the pharyngeal swallow in relation to position of the bolus; &, -The motor aspects of the pharyngeal swallow, including movements of the larynx, hyoid, tongue base, pharyngeal walls, & cricopharyngeal region.

Oral Preparatory Phase - Semi-Solids/Purees/Pastes:

-Oral manipulation of thicker consistency materials again depends somewhat upon the preference of the individual. -As with liquids, the material is introduced as a cohesive bolus & may be maintained as such & held in either the tipper or dipper hold position, or the material may be manipulated, lateralized, or masticated somewhat before being reformed into a cohesive bolus & initiating the swallow.

Accuracy of Self-Reporting:

-Patients who do report OROPHARYNGEAL swallowing difficulty are able to describe them are typically highly accurate in their localization & definition of the problem -in contrast, patients with ESOPHAGEAL disorders may be highly inaccurate in describing & localizing their dysfunction

Variations in Normal Anatomy & Physiology - Taste:

-Taste is a chemical sense in the oropharyngeal region & is activated during eating & drinking -With age, rating of the intensity of taste & smell are reduced, smell perhaps more than taste. As a result, loss of interest in nutritious food may develop in the elderly. -Some medications can result in an unpleasant metallic taste in the mouth.

Oral Preparatory Phase - Liquids "Tippers" vs "Dippers":

-The liquid may be held between the midline of the tongue & hard palate with the tongue tip elevated & contacting the anterior alveolar ridge ("tipper"). -Or, it may be held on the floor of the mouth in front of the tongue ("dipper"). About 20% of normal swallowers are dippers

Pharyngeal phase:

when the pharyngeal swallow is triggered & the bolus is moved through the pharynx

Oral phase:

when the tongue propels food posteriorly until the pharyngeal swallow is triggered

Instrumental Techniques for the Study of Swallowing:

-A number of imaging & nonimaging instrumentation procedures have been used to study various aspects of normal &/or abnormal swallow physiology. -It is important that clinicians be familiar with the types of information each procedure provides about swallowing & the basic methodology for each procedure.

Variations in Normal Swallowing - Increasing Viscosity:

-As bolus viscosity increases, the pressure generated by the oral tongue, tongue base, & pharyngeal walls increases & muscular activity increases. -Valve functions, such as velopharyngeal closure, upper esophageal opening, & laryngeal closure, all increase slightly in duration as viscosity increases.

Tongue Base & Pharyngeal Wall Action:

-As the pharyngeal swallow triggers, the tongue base assumes a ramp shape, directing food into the pharynx. -Tongue base retraction and pharyngeal wall contraction occur when the bolus tail reaches the tongue base level. As the two structures move toward each other, pharyngeal pressure builds. -When the tongue base & pharyngeal walls make contact, the pharyngeal wall contraction continues progressively down the pharynx to the upper esophageal sphincter, where esophageal peristalsis takes over bolus propulsion. -Pressure generated by tongue base retraction & pharyngeal wall contraction increases as bolus viscosity increases.

Triggering the Pharyngeal Phase:

-As the tongue movement propels the bolus posteriorly, sensory receptors in the oropharynx & tongue are stimulated sending sensory information to the cortex & brainstem. -When the leading edge of the bolus (or "bolus head") passes any point between the anterior faucial arches & the point where the tongue base crosses the lower rim of the mandible, the oral stage is terminated & the pharyngeal swallow should be triggered. If it does not trigger by this time, the pharyngeal swallow is said to be delayed.

Once the patient's swallowing abnormalities have been identified after the Videofluoroscopy, the clinician should introduce treatment strategies during the study to obtain evidence of the respective strategy's effectiveness. Such strategies may include:

-Changes in head or body posture; -Heightening sensory input prior to the swallow; -Maneuvers designed to change specific aspects of the patient's swallow physiology; -Effects of changing bolus viscosity. -Should only take around 15 mins (on average) - may spend more time getting the patient into position

Oral Preparatory Phase - Liquids:

-During liquid swallows, the extent of oral manipulation of the bolus varies greatly from individual to individual. -When placed into the mouth, a liquid bolus has some degree of cohesiveness that may be maintained as the bolus is held between the tongue & the anterior hard palate in preparation for the pharyngeal swallow. -Some individuals may desire to move the liquid around in the mouth prior to swallowing it, & may in the process spread the bolus evenly or unevenly throughout the oral cavity. However, prior to initiating the swallow, the material is generally pulled together into a cohesive bolus by the tongue & held in either the tipper or dipper position -Holding the bolus more anteriorly between the tongue & the anterior teeth is an abnormal pre swallow position in adults, & often indicates that a tongue thrust swallowing pattern will be used

Coordination of Respiration & Swallowing:

-During swallowing, the airway closes for a fraction of a second-the apneic period, which usually cooresponds to laryngeal closure during the pharyngeal phase. -Duration of the airway closure tends to increase as bolus volume increases. -The predominant pattern of swallow-respiratory coordination involves respiratory interruption during exhalation, with the individual then returning to exhalation post-swallow. This may aid in clearing any mild residue from the airway entrance. -There are indications that dysphagic patients may more often interrupt inhalation to swallow, which may increase their risk of aspiration. -It takes infants approximately 2 to 3 months to stabilize their swallow-respiratory coordination to be more like the adult pattern.

Elevation and Anterior Movement of the Hyoid & Larynx:

-During the swallow, the larynx & hyoid bone elevate & move anteriorly by the pull of the floor of the mouth muscles. -The elevation contributes to closure of the airway entrance, & the forward movement contributes to opening of the UES. -In young men, the hyoid elevates approximately 2 cm.

Closure of the Larynx:

-During the swallow, the larynx closes at all three sphincters- the true vocal folds, the laryngeal entrance (i.e., the false vocal folds, the anteriorly tilting arytenoids, & the thickening of the epiglottic base as the larynx elevates), & the epiglottis. -Closure of the larynx begins at the level of the true vocal folds & progresses upward to the laryngeal vestibule, clearing any potential penetration. -In normal adults, the airway entrance is closed for approximately one-third to two-thirds of a second during single swallows. During sequential cup-drinking, the airway may be closed 5 seconds or more. -Vocal fold closure occurs when the larynx has elevated to approximately 50% of its maximum elevation.

Pharyngeal Phase: a number of physiological activities occurs as a result of pharyngeal triggering, including:

-Elevation & retraction of the soft palate; -Elevation & anterior movement of the hyoid & larynx; -Closure of the larynx; -Opening of the cricopharyngeal sphincter; -Tongue base retraction; & -Contraction of the pharyngeal constrictors

Esophageal Phase:

-Esophageal transit times can be measured from the point where the bolus enters the esophagus at the UES until it passes into the stomach at the LES. Normal transit time varies from 8 to 20 seconds. -The peristaltic wave pushes the bolus ahead of it & continues in sequential fashion through the esophagus until the LES opens to allow the bolus to enter the stomach. -Motility disorders in the esophagus can be defined during a videofluoroscopic study or Modified Barium Swallow (MBS); however, because the esophageal phase of swallow is generally not amenable to any kind of therapeutic exercise regimen, MBS studies usually do not involve examination of the esophagus. -Patients with esophageal disorders should be referred to a gastroenterologist or for a standard barium swallow or upper gastrointestinal series. Unfortunately, the barium swallow does not always define gastroesophageal reflux, thus a referral to a gastroenterologist may be more productive in identifying the etiology & optimal treatment for the patient's esophageal disorder.

Videoendoscopy (FEES):

-FEES has been used increasingly in recent years to examine the anatomy of the oral cavity & pharynx from above & to examine the pharynx & larynx before & after swallowing. It is performed with a flexible scope inserted into the nose, down to the level of the soft palate or below. -This transnasal position requires light topical anesthetic in the nose to permit comfortable placement. FEES does not visualize the oral stage of swallowing. -Good high quality image; can give a lot of info -Problem = white out -With the tip positioned above the level of the soft palate the dynamics of velopharyngeal closure can be observed. -With the scope placed behind the tip of the uvula, the pharynx is imaged before the pharyngeal relaxes after the swallow. The moment when the pharyngeal swallow triggers causes the pharynx to close around the tube, blocking the image during the swallow. Many important events occur during this closed period. -Can tell a lot more from a fluoroscopy than FEES -Can see aspiration before swallow or see residue after swallow BUT if it happens during a swallow you can't see it (white out period) -Silent aspiration signs = tearing, nose running, gurgling, facial grimaces, can also happen without signs -After swallow happens & you see residue - you have to infer instead of actually seeing it

Variations in Normal Anatomy & Physiology - Older Adults:

-High masticatory performance is maintained regardless of age in normal individuals with complete, or almost complete, dentition. -With age, ossification in the thyroid & cricoid cartilages & the hyoid bone increases. -At age 70 & beyond, the larynx may begin to lower in the neck. -With age, the incidence of cervical arthritis increases, with may cause impingement on the pharyngeal wall, decreasing its flexibility & the strength of pharyngeal contraction, causing increased residue. -Older individuals tend to more frequently hold the bolus in the dipper position prior to initiation of the oral transit phase. -The oral phase of swallowing is slightly longer in older adults, as is the "normal" delay in triggering the pharyngeal swallow. -A small increase in oral/pharyngeal residue & laryngeal vestibule penetration is seen in individuals over 60m but not an increase in aspiration. -Esophageal function deteriorates more significantly with age so that esophageal transit & clearance are slower & less efficient. -A decrease in neuromuscular "reserve" is seen in older individuals, as is a decrease in flexibility in the cricopharyngeal opening. Both of these features have been found to characterize normal aging of the motor system, but it puts affected individuals at increased risk for developing swallowing problems if they become physically weak as a result of any illness, even if it is not in the region of the head & neck.

Variations in Normal Swallowing - Straw Drinking:

-In straw drinking, the bolus is brought to the mouth via suction created in the oral cavity. To accomplish this, the soft palate is lowered against the back of the tongue & the muscles of the cheek face contract & create suction intraorally to bring material into the mouth. -When the material has reached the mouth, the suction is discontinued, & the soft palate elevates as the oral stage is initiated by the tongue. -Straw drinking can be dangerous if the patient is using inhalation to create suction, greatly increasing the risk of aspiration into the open airway.

Triggering the Pharyngeal Swallow:

-In younger, normal individuals, the trigger occurs at the anterior faucial arch, & the timing is such that posterior movement of the bolus is such that posterior movement of the bolus is not interrupted. -Older (over age 6o) normal individuals are not seen to trigger the pharyngeal swallow until the bolus head reaches approximately the middle of the tongue base. -Humans cannot swallow unless there is something in their mouth, either food, liquid, or saliva. -If one attempts to swallow four times in rapid succession, it is difficult to continue past the second or third swallow because these dry swallows have depleted saliva in the mouth. -A relationship exists between voluntary attempts to swallow & triggering of the pharyngeal swallow; however, the exact nature of that relationship is not understood. -"Both voluntary & reflex components are involved in the normal swallow. Neither mechanism alone is capable of producing swallowing with the regularity & immediacy which is necessary during the normal process of oral feeding."

Videoendoscopy (FEES) - Disadvantages:

-Inability to visualize the single most crucial moment of swallowing- triggering of the pharyngeal swallow; -Questionable ability to identify silent aspiration; -Transnasal tube placement may interfere with swallowing in some patients & may be uncomfortable & not tolerated well by others; -Children under 6 to 8 years old do not cooperate well with the procedure. Similarly, adults with cognitive disorders or those who are agitated are poor candidates for FEES.

Variations in Normal Swallowing - Volume Effects:

-Large volume swallows (10 to 20ml) are usually characterized by & simultaneous oral pharyngeal phase activity, as opposed to the normally expected sequence, in order to safely clear the large bolus from both the oral cavity & the pharynx. -As bolus volume increases, tongue base retraction & anterior pharyngeal wall bulging occurs later in the swallow in order to assure that the pressure created by this movement is directed at the bolus tail as it reaches the tongue base.

Complications of Dysphagia:

-Pneumonia, Malnutrition, & Dehydration -these may be considered symptoms, but in fact, they are also complications of dysphagia, which result from either unsafe swallowing, resulting in the risk of aspiration pneumonia, or insufficient swallowing, which results in an insufficient amount of food or liquid reaching the stomach

Variations in Normal Swallowing - "Chug-a-Lug":

-Some individuals can chug-a-lug a can of soda or other beverage without swallowing. -To do this, they pull their larynx forwards which opens the UES volitionally, hold their breath to close the airway at the larynx, & then literally dump material through the oral cavity & pharynx by gravity into the esophagus & stomach.

Cricopharyngeal Opening: Cricopharyngeal opening occurs by a complex series of actions:

-Tension in the cricopharyngeal muscle is released, relaxing the sphincter; -The upward, anterior movement of the larynx pulls open the sphincter; -The leading edge of the bolus reaches the sphincter as it opens, & pressure within the bolus widens the opening; -As the bolus passes through the sphincter, the larynx lowers & the cricopharyngeus returns to some level of contraction.

Oral Preparatory Phase:

-The larynx are a trest during the oral preparatory phase of swallowing. -If an individual loses control of a bolus, & part of it trickles into the pharynx, the material may continue to drop down & enter the open airway. -The pharyngeal swallow rarely triggers in response to this material unless the material starts to enter the larynx, possible because the oral stage of swallow has not been initiated. -During this oral preparation, a great deal of sensory information is processed from sensroy receptors throughout the oral cavity, including the tongue. -It is likely that information on bolus volume comes from the shape of the tongue as it surrounds the bolus prior to the swallow.

Videofluoroscopy:

-The most frequently used technique in the assessment of oropharyngeal swallow is videofluoroscopy. Radiographic procedures (x-ray) have been used to study swallowing since the early 1900s. -Fluoroscopy has been used since the 1930s in the examination of the movement patterns of the oral cavity, pharynx, & esophagus during swallowing. The earliest images were recorded on movie film & called cinefluorography. This allowed examination of movement patterns of the bolus & of particular structures in slow motion & frame by frame however, film development was required, so immediate review of the study was not possible. -FEES & Fluoroscopy are different! -In the early 1980s, fluoroscopic studies began being recorded on videotape, which also permitted slow motion & frame by frame analysis employing a VCR patched into the fluoroscopic equipment. These studies became known as Videofluoroscopic Swallow Studies (VFSS) or, more commonly, Modified Barium Swallows (MBS). -Because it required less radiation exposure and allowed immediate viewing of the study, videofluoroscopy quickly became more popular the cineflurography. -Someone had to do the study, feed the patient, & work the VCR; no developing time -In recent years, digital recording has replaced the use of videotaping, & has allowed advances in computer enhanced graphics. -Videofluoroscopy studies provide information on bolus transit times, motility problems, & amount, most importantly, etiology of aspiration. -Although videofluoroscopy does use radiation, the patient receives a relatively low dose, while the oropharyngeal region is fully viewed in the lateral or anterior-posterior plane.

Oral Phase:

-The oral (or oral transit) stage of the swallow is initiated when the tongue beg posterior movement of the bolus. -If the bolus is held in the dipper position, the tongue tip moves forward & lifts the bolus onto the tongue & into the tipper position. This is done in a smooth action, which moves directly into the oral stage of tongue propulsion. -Tongue movement during the oral phase has often been described as a stripping action, with the midline of the tongue sequentially squeezing the bolus posteriorly against the hard palate. -Another way to describe this tongue movement is as an anterior to posterior rolling action of the midline of the tongue, with tongue elevation progressing sequentially more posteriorly to push the bolus backward. -The sides & tip of the tongue remain firmly anchored against the alveolar ridge. During this time, a central groove is formed in the tongue, acting as a ramp or chute for food to pass through as it moves posteriorly. -Thicker foods require more tongue pressure against the palate to propel them cleanly & efficiently through the oral cavity & into the pharynx. -The oral stage of the swallow typically takes less than 1 to 1.5 seconds to complete. It increases slightly as bolus viscosity increases. -In summary, the normal oral stage of the swallow requires intact labial musculature to ensure an adequate seal to prevent material from leaking out of the oral cavity, intact lingual movement to propel the bolus posteriorly, intact buccal musculature to ensure that material does not fall into the lateral sulci, normal palatal muscles, & the ability to breathe comfortable through the nose.

Oral Preparatory Phase - Solids:

-The oral preparatory phase for materials requiring mastication involves a rotary lateral movement of the mandible & tongue. -The tongue positions material on the teeth. When the upper & lower teeth have met & crushed the material, the food falls medially toward the tongue, which moves the material back onto teeth as the mandible opens. During this phase, the tongue mixes the food with saliva, while moving the material from side to side. This cycle is repeated numerous time before forming a bolus & initiating the oral transit phase. -During active chewing, the soft palate is not pulled down & forward, & premature spillage is common & entirely normal. -Such a premature spillage is not normal during the hold phase before swallows of liquid & paste or pudding materials. -Tension in the cheek closes off the lateral sulci & prevents food particles from being pocketed between the mandible & cheek. -The volume of the bolus swallowed varies with the viscosity of the food, up to 20+ml for liquids, 5 to 7 cc for pudding, 3 to 5 cc for mashed potatoes, & 2 cc for meat. The downsizing with viscosity allows easier passage of the bolus through the pharynx & particularly the upper esophageal sphincter. If larger volumes of thicker foods are placed in the mouth, the tongue subdivided the food after chewing, forming only a part of it into a bolus to be swallowed at one time, & sequestering the rest for subsequent swallows

Variations in Normal Anatomy & Physiology- Infants & Children:

-The tongue fills the oral cavity; -The fat pads in the cheeks narrow the oral cavity laterally; -The hyoid bone & larynx are much higher than in adults, affording more natural protection for the airway; -The velum hangs lower, with the uvla often resting inside the epiglottis, forming a picket in the valleculae; -With repeated tongue pumps, the bolus is often collected at the back of the mouth in front of an anteriorly bulging velum or in the vallecular pocket. -Swallowing begins in the fetus, with sucking movements, drinking of amniotic fluid, & occasional presentation of the thumb in the mouth. -When sucking from a nipple, the infant repeatedly pumps with the tongue, expressing milk from the nipple with each pump. Each infant tends to use a pattern of a particular number of pumps predominantly, with some variability. Normal infants may use anywhere from 2-7 tongue pumps, depending on the amount of milk expressed during a single pump. -When a bolus of adequate size has been formed, the pharyngeal swallow triggers. -During the first 21 years of life, the face continues to grow. The jaw grows down & forward, carrying the tongue down & enlarging the space between the tongue & palate, thereby developing an oral cavity space. -The larynx lowers, as does the hyoid bone, thereby elongating & enlarging the pharynx. The greatest elongation of the pharynx & downward displacement of the larynx occur during puberty. -Bite is achieve at approximately 7 months, & chewing begins at approximately 10 to 12 months, although there is great variability in the time when the normal adult chewing pattern is achieved, which can be up to 3 to 4 years. -Once the infant moves to discrete swallows of pureed or soft foods, the oral & pharyngeal swallow physiology is similar to that of an adult, with the exception of reduced laryngeal elevation.

Pharyngeal Phase:

-Typically, in normal swallowers, v-p closure & hyolaryngeal upward & forward movement occurs almost simultaneously. -Opening of the upper esophageal sphincter & closure of the airway usually begin essentially simultaneously. -Pressure on the bolus begins during the oral phase & continues throughout the pharyngeal phase. -It is important to remember that a swallow comprised of velar, pharyngeal, tongue base, & laryngeal activity occurs only as a result of the triggering of the pharyngeal swallow. -Patients can be taught to voluntarily protect their airway ot to open the UES; however, there is no way to voluntarily initiate or modify pharyngeal wall contraction. -Pharyngeal transit time- the time taken for the bolus to move from the point at which the pharyngeal swallow is triggered through the cricopharyngeal juncture into the esophagus- is normally 1 second or less. -During this transit, the bolus does not hesitate for any length of time anywhere in the pharynx, but moves smoothly & quickly over the base of the tongue through the pharynx & into the cervical esophagus. -As the bolus moves through the pharynx, it usually divides as the valleculae, with approximately half flowing down each side of the pharynx through the pyriform sinuses. -The purpose of the epiglottis appears to be to direct the food around the airway rather than over the top of the airway. -The two portions of the bolus join again at about the level of the opening of the esophagus.

Ultrasound:

-Ultrasound studies of the oral cavity have been used to observe tongue function & to measure oral transit times, as well as motion of the hyoid bone. -Ultrasound cannot visualize the pharynx because of the mix of tissue types (cartilage, bone, muscle) in the pharynx. This limits the application to the study of the oral stages of swallow, especially oral tongue function during deglutition & biofeedback for various oral tongue exercises. -Identify gall stones -Don't get good image of what is going on during the pharyngeal stage (most important physiologically)

Palatal Elevation/Retraction to Achieve Velopharyngeal Closure:

-Velopharyngeal closure enables the buildup of pressure in the pharynx to aid in propulsion of the bolus & prevent nasal reflux. -Functional swallowing is possible without the v-p closure if all other physiologic aspects of the pharyngeal swallow are normal, particularly the tongue base & pharyngeal wall contact.

Variations in Normal Swallowing:

-Volume effects -Increasing Viscosity -Cup drinking -Straw drinking -"Chug-a-Lug" -Pharyngeal Swallow with No Oral Swallow

Symptoms often observed during diagnostic assessment procedures:

-aspiration or the entry of food or liquid into the airway below the true vocal folds; -penetration or entry of food or liquor into the larynx at some level down to but not below the true vocal folds; -residue or food that is left behind in the mouth or pharynx after the swallow; -backflow of food from the esophagus into the pharynx &/or from the pharynx into the nasal cavity

In the anterior-posterior (A-P) view on a Videofluoroscopy is most useful in assessing?

-assessing vocal fold symmetry/closure, providing left/right orientation in patients with unilateral pyriform sinus residue, & in visualizing asymmetric pharyngeal transit. -the airway overlies the esophagus & the identification of the presence & etiology for aspiration is difficult.

Definition of Dysphagia:

-difficulty moving food from mouth to stomach -recently, some clinicians have expanded the definition to include all of the behavioral, sensory, & preliminary motor acts in preparation for the swallow

Dysphagia may occur:

-in all age groups, from newborns to elderly; -as a result of a variety of congenital abnormalities, structural damage, &/or medical conditions; -as a sudden, acute onset (e.g., CVA), or may worsen slowly over time (e.g., progressive neurological disease)

Signs & Symptoms of Dysphagia:

-inability to recognize food; Ex: person with Dementia -difficulty in placing food in the mouth; Inability to control food or saliva in the mouth; -coughing before, during, or after a swallow; -frequent coughing toward the end or immediately after a meal; significance- build up, reduced peristalsis, reflux -recurring pneumonia; -weight loss when no other reason can be defined -gurgly voice quality or increase in secretions in the pharynx or chest after a swallow or at/near the end of a meal; -patient complaints of swallowing difficulties

Patients with Dysphagia:

-may be acutely aware of their problem & able to describe it to the clinician in great detail, or.... -may be entirely oblivious to any difficulty with deglutition.

Oral Preparatory Phase:

-movement patterns in the oral preparatory phase of swallowing vary, depending on the viscosity of the material to be swallowed & the amount of oral manipulation the individual ues in savoring a particular food -from the time the material is placed in the mouth, labial seal is maintained to ensure that no food or liquid falls from the mouth. This requires an open nasal airway & nasal breathing

Structures - Pharyngeal Constrictors:

-pharyngeal structures involved in deglutition include the three pharyngeal constrictors, superior, medial, & inferior, which form the posterior & lateral pharyngeal walls -inferior fibers of the superior constrictor that attach to the tongue base are known as the glossopharyngeus muscle, & are probably responsible for tongue base retraction & simultaneous anterior bulging of the posterior pharyngeal wall at the tongue base level during the pharyngeal stage of swallowing

Structures - Pyriform Sinuses:

-pyriform sinuses are spaces formed as the fibers of the inferior constrictor attach to the sides of the thyroid cartilage anteriorly, ending inferiorly at the cricopharyngeal muscle. -due to their location bilaterally in the path of pharyngeal bolus transit, patients with pharyngeal muscle weakness are particularly susceptible to residue in the pyriform sinuses

Evaluation & Treatment of Swallowing Disorders:

-requires a thorough knowledge base in anatomy & physiology of the normal swallowing mechanism, as well as the effects of aging & disease processes on the mechanism over time -the clinician must be able to identify the anatomic &/or physiological abnormalities that are causing the problem so that treatment can be directed at these underlying abnormalities

Swallowing Physiology:

-the duration & characteristics of each of the four phases depends on the type & volume of food being swallowed & the voluntary control exerted over it -frequency of swallowing varies with activity-greatest during eating, least during sleep. Mean frequency is 580 swallows per day. Records during sleep have shown periods of 20 minutes or more when no swallow occurs -swallowing & respiration are reciprocal functions; that is, respiration halts during the pharyngeal phase in humans of all ages, including infants

Multidisciplinary Approach:

-the dysphagia team consists of the swallowing therapist (usually, but not always the SLP), the patient's physician(s), nursing staff, dietitian, occupational therapist, physical therapists, pharmacist, & radiologist -in the vast majority of cases, the SLP (in conjunction with the patient's physician) takes the lead role in developing & implementing the individualized feeding program, while the other team members fulfill discipline-specific roles in the care of the patient

Structures - The Esophagus:

-the esophagus is a collapsed muscular tube, approximately 23-25 cm long, with a sphincter or valve at each end: the upper esophageal sphincter (UES) at the top, & the lower esophageal sphincter (LES) at the bottom. The esophagus has two layers of muscle, the inner circular & the outer longitudinal -each layer is made up of striated muscle in the upper third, striated & smooth muscle in the middle third, & smooth muscle in the lower third -the esophagus passes through the neck, then the chest, through the diaphragm to attach to the stomach -in the neck, the esophagus sits behind the trachea, sharing a soft tissue wall so that the posterior wall of the trachea is the anterior wall of the esophagus -the lower esophageal sphincter (LES) marks the boundary between the esophagus and the stomach. Its primary function is to keep food & secretions, including stomach acid, in the stomach

Structures of the Larynx:

-the intrinsic structures of the larynx consists of the epiglottis, the false vocal folds, the aryepiglottic folds, the true vocal folds, & the arytrenoid cartilage -together, the epiglottis & aryepiglottic folds; the arytenoids, the base of the epiglottis, & false vocal folds; & the true vocal folds form three levels of sphincter in the larynx, capable of completely closing the larynx from the pharynx & preventing penetration of food or liquid during swallowing

Structures of the Larynx - Laryngeal Vestibule:

-the opening into the larynx is known as the laryngeal vestibule, or laryngeal additus -the laryngeal vestibule is bounded by the epiglottis, aryepiglottic folds, & arytenoid cartilage, & ends at the superior surface of the false vocal folds

Structures - Oral portion of Tongue:

-the oral tongue includes the tip, blade, front, center, & back -anatomically, the oral tongue ends at the circumvallate papillae -the oral tongue is active during speech & during the oral stages of swallowing, & is under cortical or voluntary neural control

Structures of the Larynx - The Epiglottis:

-the primary function of the larynx is to keep food from entering the airway during swallowing -the topmost structure of the larynx is the epiglottis, the top third half of which rests against the base of the tongue, attached into the hyoid bone by the hyoepiglottic ligament. The base of the epiglottis is attached by ligament to the thyroid notch -the epiglottis folds over & down during swallowing to protect the airway & help to direct the bolus into the esophagus

Structures - Roof of Mouth:

-the roof of the mouth is formed by the maxilla (hard palate), the velum (soft palate), & the uvula -the soft palate may be pulled down & forward against the back of the tongue, or may be elevated & retracted to contribute to velopharyngeal closure, by a combination of muscle pulls

Oral Structures - Tongue:

-the tongue is composed almost entirely of muscle fibers going in all directions -functionally, for swallowing, the tongue can be divided into an oral portion & a pharyngeal portion

Structures of the Larynx - The Valleculae:

-the wedge-shaped space formed between the base of the tongue & the epiglottis is the valleculae -together, the valleculae & the two pyriform sinuses are known as the pharyngeal recesses or side pockets, into which food may fall & reside before or after the pharyngeal swallow triggers -on an anterior-posterior radiographic view, the valleculae appears "scallop shaped" being subdivided by the hyoepiglottic ligament

Variations in Normal Swallowing - Cup Drinking:

Cup drinking, utilizing sequential swallows, is characterized by early airway closure & some pre-elevation of the larynx as the cup is approaching the lips with airway closure extending across all of the sequential swallows with duration of anywhere from 5 to 10 seconds, depending upon the number of consecutive swallows produced. V-P closure is maintained, lip seal around the cup in maintained, the tongue repeated propels consecutive boluses from the oral cavity, the tongue base & pharyngeal walls make contact at the tail of each bolus, the larynx elevates fully & the UES opens repeatedly as each bolus approaches.

Variations in Normal Swallowing - Pharyngeal Swallow with No Oral Swallow:

If secretions are collecting in the pharynx or if there is chewing with premature spillage, which is building up in the valleculae & pyriform sinuses, the individual may produce a pharyngeal swallow with little or no oral swallow. If chewing is taking place, the individual will stop chewing, produce a pharyngeal stage swallow, & then return to chewing. This again represents volitional control over the mechanism.

Anterior sulci

is in front of the teeth by/between the lips

Dysphasia =

language impairment (partial loss of language)

The term "feeding" is?

limited to assisting in the placement, manipulation, & mastication (if necessary) of food in the oral cavity, the formation of a cohesive bolus, & the backward propulsion of the bolus by the tongue

Oral Structure-Sulci:

the anterior & lateral sulci (figure 2.3, pg 15) are important because patients with swallowing disorders may retain food or liquid in these natural cavities or space after the swallow

The term "swallowing" refers to:

the entire act of deglutition, from the initial placement of food through the oral, pharyngeal, & esophageal stages of swallowing until material enters the stomach

VFSS/MBS is designed to determine?

why a person aspirates, not whether someone aspirates

Anatomic Structures - Oral Cavity:

-lips -teeth -hard palate -soft palate -uvula -mandible -floor of mouth -tongue -faucial arches -palatine tonsils