Dysphagia Test 1

Prominent cricopharyngeus (reduced upper esophageal sphincter opening) - this results in... Reduced UES opening is due to...

(reduced upper esophageal sphincter opening) - this results in residue in the pyriform sinuses and backflow of material into laryngeal vestibule from UES. Again the residual from the pyriform sinuses can cause aspiration afterthe swallow. Reduced UES opening is due to reduced cricopharyngeal muscle relaxation as well as laryngeal elevation and excursion.

Swallowing is a three-phase process:

1. Oral (Buccal) phase - voluntary •Oral preparatory phase- mastication, mixing food with saliva, create a bolus •Oral transit phase (**trigger of pharyngeal phase/pharyngeal swallow**)- pushing bolus from from to back of mouth (lingual palpations) 2. Pharyngeal phase - involuntary (starts when when the bolus hits the back base of tongue, between the epiglottis and base of tongue (vallecula), or the posterior pharyngeal wall) 3. Esophageal phase - involuntary

Clinical Bedside Swallowing Evaluation steps

1. Review of medical records 2. Comprehensive interview with patient 3. Oral mechanism examination 4. Trial feedings observation 5. Feeding recommendations 6. Referrals for either: •Further instrumental assessment (need physician's prescription to be covered by insurance) •Specialized testing by other professionals

5 Other Impacts of Dysphagia

Dehydration Malnutrition •From problems absorbing food in the stomach Weight loss Psychological well-being •Social isolation Financial Well-being

Oral Mechanism Exam - Supplemental Observations when breathing...

Inhalatory stridor - noisy breathing- narrow trachea Respiratory Retractions (subcostal- under the diaphragm, intercostal-between the ribs , and suprasternal- sternal notch between the clavical)

What supplies blood to the cortical areas involved in speech, language and swallowing. - often damaged during stroke? structures it supplies: when is it often most occluded?

MCA Structures supplied: •Broca's area •Wernicke's area •Motor cortex •Sensory cortex •Basal ganglia •Internal capsule **The middle cerebral artery (MCA) is the artery most often occluded in cortical stroke**

Laryngeal function (CN X) Cont'd

Palpation of the larynx (wear gloves): - Fifth finger: sternal notch - Fourth finger: top of thyroid cartilage - Middle finger: hyoid bone - Second finger: posterior tongue Assess structures at rest and during laryngeal elevation (dry swallow) -The thyroid cartilage is gently mobilized to either side and up and down.

MBSS chair

Patient positioning in dysphagia chair •Usually upright, seated position •Patients with physical limitations from weakness, fatigue, or disease may require special positioning (positioning chairs - e.g. Vess chair) •Transfer patient to radiology suite in positioning chair •Rotating seat allows for AP and Lateral imaging

Oral Mechanism Exam - Supplemental Observations presence of... mental status:

Presence of feeding tube Mental Status •Level of alertness and ability to cooperate in exam •Don't do an exam if they are fatigued

The major disadvantages of MBSS cont:

Size of patient prevents adequate imaging or exceeds limit of positioning devices. Allergy to barium (though this is quite rare). Time constraints due to radiation exposure. As the procedure only samples swallow function, it does not fully represent mealtime function. Limited ability to evaluate a fatigue effect on swallowing. Barium is an unnatural food bolus with potential for refusal.

Variations in Normal Swallowing - Volume Effects Typical liquid bolus: ect how much water do you start with?

Typical liquid bolus 10-25 ml. Smaller volume swallows, such as saliva (1-3 ml) yields all distinct sequential phases. Larger volume swallows (10-20 ml) (as in cup drinking) is characterized by simultaneous oral and pharyngeal phase activity. This is necessary to safely clear the bolus. Increased bolus size associated with longer UES opening. start with a teaspoon

Unilateral pharyngeal wall weakness what happens with the food? how can this be seen? Reduced pharyngeal contraction bilaterally what happens? what is normal/not normal?

Unilateral pharyngeal wall weakness- The food tends to collect in the pyriform sinus on the weak side of the pharynx. This is seen in the AP view on an MBSS. Reduced pharyngeal contraction bilaterally- Typically, an individual would dry swallow to clear residue after the food swallow if they sense residue is present. If there is material that remains on the pharyngeal wall it is due to reduced pharyngeal wall constriction. A slightly coated pharyngeal wall after swallowing is considered normal. However, a large amount of residue increases the risk of aspiration. Patients are at greater risk of penetration or aspiration after the swallow due to the residue.

Pharyngeal Phase more cont final part

Upper esophageal sphincter opens to allow passage of bolus from pharynx into esophagus. This occurs through a series of actions. •Tension in the cricopharyngeal muscle relaxes (stimulated by inferior pharyn. constrictor) •Anterior superior movement of larynx begins to open sphincter As bolus passes through UES, the larynx lowers and the cricopharyngeus muscle returns to resting tonic state. Pharyngeal phase ends when the esophageal phase begins as the bolus passes through the UES entirely. Breathing is reinitiated

Recurrent Laryngeal Nerve

You can have damage to the left recurrent laryngeal nerve after cardiac surgery because in innervates the larynx and goes under the heart

what is the pouch in the back called?

Zenker's Diverticulum

cricopharyngeous muscle is part of the

upper esophageal sphincter and is also part of the inferior pharyngeal constrictor -needs to relax and open to let food down When larynx moves anterior and superior (up and forward) it opens up this muscle (but it needs to be relaxed)

The FEES team will consist of: Patient swallows desired consistencies bedside, if necessary

•Physician (nasal decongestant and topical anesthetic administered by physician)- feeds Pt •A Speech-Language Pathologist (holds camera) Patient swallows desired consistencies bedside, if necessary: •Real foods and liquids -- Tint with vegetable dye to maximize contrast •Also used to visualize management of secretions

•Bottom-up sequence from VF to laryngeal vestibule to clear penetration

•True vocal folds approximate •False vocal folds approximate •Aryepigottic folds approximate •Epiglottis inverts to protect the larynx

Within your facility attempt to use standard protocol for consistencies: trial compensatory maneuvers:

•Types, amount and order of consistencies - varies by site •Review protocols for MBSImp and VA Boston Perform lateral view Perform A-P view Trial compensatory maneuvers - Chin tuck, - Mendelsohn maneuver (elevate larynx). Do they improve swallow safety (less penetration or aspiration) or efficiency (better timing, less residue).

•Aspiration during swallowing due to.. what are the main gatekeepers? and what plays only a minor role in preventing aspiration? what happens if both fail?

- due to insufficient closure of the larynx. Closure of the larynx is a result of anterosuperior lifting of the larynx which allows the true cords, false cords and finally, the aryepiglottic folds to contract, followed by a backwards folding of the epiglottis over the closed larynx. The aryepiglottic folds are the main gatekeepers, while the epiglottis plays only a minor role in preventing aspiration. Both failure of these intrinsic muscles of the larynx as well as failure of the extrinsic muscles (i.e. muscles that lift the larynx) may lead to aspiration during swallowing. Weakness of the extrinsic muscles is seen after radiotherapy, in neurologic disorders and in recurrensnerve paralysis (i.e. neuromuscular dysfunction).

Aspiration before swallow trigger what causes it? how can it be helped?

- the result of insufficient closure of the oral cavity during the preparatory phase or delayed swallow reflex. When tongue or soft palate are unable to prevent spillage of food into the pharynx, aspiration may occur since the larynx is still open. Weakness of these muscles in the mouth and the throat is due to paralysis or myopathy. can be helped by flexing their head during chewing and thus holding the food in the anterior part of the oral cavity.

Effective Clinical Practice Requires knowledge of:

•Anatomy(structures) •Physiology(function) of swallowing system •Description of stages of swallow (oral, pharyngeal, esophageal) movements and responses of structures as bolus travels through aerodigestive tract.

Dentition and overall oral hygiene:

•Association between poor oral hygiene and respiratory pathogens •Poor oral hygiene is a risk factor for aspiration pneumonia •Look for evidence of tooth decay, pocketing, residue •Inspect the tongue for milky white patches which could indicate fungal infection/thrush •Observe amount of saliva production as xerostomia (dry mouth) can impair taste and swallowing function (CN IX=parotid gland, CN VII=lingual and submandibular glands)

The major disadvantages of FEES:

•Incomplete examination of pharyngeal stage of swallow •Only visual immediately before and after swallow •Cannot assess oral or esophageal problems

Pharyngeal Phase Dysphagia 6 characteristics: first thing you look for on radiograph:

•Incomplete palatal elevation (nasal reflux) •Delayed initiation of pharyngeal swallow reflex •Weak pharyngeal muscle contraction •Reduced laryngeal elevation (more prone to aspiration) •Inadequate opening of the upper esophageal sphincter (bolus cannot move into the esophagus) •Residue in pharynx first thing you look for: anterior movement of the hyoid pulls the larynx up

Fiberoptic Endoscopic Evaluation of Swallowing (FEES) 2 parts of the assessment

(1) Anatomic and physiologic assessment: examining the structures and function of the swallowing mechanism at rest. The examiner also determines the level of sensation. 2 Video: a) Assessing velopharyngeal function (look for elevation and retraction of the velum and inward movement of the of the lateral and posterior pharyngeal walls) b) Assessing the structure and function of pharynx and larynx c) Assess sensation

Esophageal Phase The opening of the UES (upper 3-4cm of esophagus) is realized by: where is a point of weakness?

(i) Contraction of the inferior pharyngeal constrictor starts to relax the UES; •The sudden disappearance of the tonic muscular contraction in the cricopharyngeal muscle creates the possibility for opening of the sphincter by the pull of the larynx; and (ii) Anterior elevation of the larynx which causes it the UES to open. killians's area is a point of weakness Causespouch behind the UES

Contraindications for MBSS- who is not a good candidate

1. Medically unstable, lethargic, unarousable, agitated or uncooperative patients. 2. When the information obtained from the study is unlikely to change the patient's management such as in the situation of advanced care preferences, chronic disease, or end-of-life situations. 3. Patient is unable to be adequately positioned. (ex: recovering from hip surgery) 4. Size of patient prevents adequate imaging or exceeds limit of positioning devices. 5. Allergy to barium (though this is quite rare).

Indications for Instrumental Evaluation 5 indicated 2 not indicated (keep them NPO)

1. Safety or efficiency of swallowing remains a concern 2. Direction for swallowing rehabilitation is needed 3. Nutrition or pulmonary compromise is evident, and unclear whether oropharyngeal dysphagia is contributing 4. Clinical exam fails to address the patient's complaints/problem 5. Patient carries medical diagnosis associated with high risk of dysphagia (stroke, Parkinson's, ALS) Not indicated: 1. Too medically unstable to tolerate procedure 2. Uncooperative/unable to participate in instrumental exam

Indications for MBSS

1. To identify normal and abnormal anatomy and physiology of the swallow. 2. To evaluate integrity of airway protection before, during, and after swallowing. 3. To evaluate the effectiveness of postures, maneuvers, bolus modifications, and sensory enhancements in improving swallowing safety and efficiency. 4. To provide recommendations regarding the optimum delivery of nutrition and hydration (e.g., oral versus nonoral). 5. To determine appropriate therapeutic techniques for oral, pharyngeal, and/or laryngeal disorders. 6. To obtain information in order to collaborate with and educate other team members, referral sources, caregivers, and patients regarding recommendations for optimum swallow safety and efficiency.

SLPs in acute care when did SLPs include swallowing? goal is to provide.. goal is to help..

1980s Goal is to provide short-term management of communication or swallowing disorders. Goal is to help patients recover communications skills or swallowing functions as quickly as possible, and to lay the groundwork for longer-term therapy by other colleagues.

Esophageal web - Achalasia -

3-5 mm extension of normal tissue. Anterior of cervical esophagus. Achalasia - decreased relaxation of LES. Looks like a bird beak on radiograph.

water screen for nurses. how much water do they give? what angle is the patient sitting at?

3oz 90 degree angle

Fiberoptic Endoscopic Evaluation of Swallowing (FEES) how is it used? where can it be done?

A flexible endoscope is passed through the nasal passage, into the pharynx (level of velum or lower) Alighted scope is inserted through the nose, and then the swallow can be viewed on a screen •Video is recorded for later viewing locations: - inpatient bedside - outpatient (ENT office)

Anatomy of the Esophagus

A hollow muscular tube 23 to 25 cm long with a sphincter at each end. •C5/C6 (pharynx) to T12 (stomach) Theupper esophageal sphincter (UES) is a musculoskeletal valve composed of the cricopharyngeus muscle (lower part of the inferior pharyngeal constrictor). The UES relaxes and allows swallowed material to pass into the esophagus and then contracts to prevent the regurgitation of esophageal contents back into the pharynx. The lower esophageal sphincter (LES) relaxes to allow food material to pass from the esophagus into the stomach (gastric cavity) and then contracts to prevent gastroesophageal reflux (GERD).

Clinical Bedside Swallowing Evaluation

A minimally invasive procedure that provides quick determination of the likelihood that dysphagia exists Determine whether it is safe to feed the patient orally (for the purposes of nutrition, hydration, and administration of medication) Identify overt signs of aspiration Determine whether the patient requires referral for further swallowing assessment

Modified Barium Swallow Study (MBSS) what is it? MBSS team:

A moving x-ray is used to evaluate how food/liquid moves from the mouth to the esophagus. A team of specialists performs the MBSS: •A speech-language pathologist specializing in dysphagia coordinates the event and decides the course of actions to take during the process. •A radiologist operates the x-ray equipment and aids in interpreting results. •A radiology technician is also present to help set up the room and aid with equipment.

Information obtained from the FEES examination includes:

Ability to protect the airway Presence/amount of pooling and residue Sensitivity of the pharyngeal/laryngeal structures Effectiveness of compensatory strategies

4 Priorities and Concerns of SLPs who should be NPO? Treatment of aspiration pneumonia/respiratory disease per episode is...

Adequate nutrition and hydration •Maintain and maximize health status •Eating by mouth (oral feeding) not always a priority nor is it appropriate for all patients •E.g. nasogastric, G-tube, J-tube •Tube feeding does not preclude some oral feeding Safety of patient during oral feeding •Patients who aspirate 10% or more of bolus despite all possible adjustments should be nil per oris (NPO) •Treatment of aspiration pneumonia/respiratory disease per episode is $15,000

5 oral phase problems

Anterior spillage- Patients may have difficulty containing the liquids in the oral cavity due to poor lip seal. Decreased mastication- due to weakness of the mastication musculature, poor lingual lateralization, reduced buccal tension, improper dentition. Buccal (lateral) pocketing- Weakness or reduced sensation of the buccal muscles may cause patients to pocket food in the buccal cavities. Patients may require cues to sweep their tongue laterally to clear the food. It may occur only on one side or bilaterally Pocketing in the anterior sulcus - Weakness or reduced sensation of the orbicular oris (reduced labial tension) Tongue pumping- Tongue pumping can be due to uncoordinated lingual movements. This is frequently seen in patients with Parkinson's Disease.

The major advantages of the FEES :

Assess effect of fatigue- start at the end of their meal time to do this Assess management of secretions Portability to bedside Cost effective No radiation Test sensory awareness by touching pharyngeal and laryngeal structures No barium which is distasteful to the patient Direct viewing of laryngeal structures for airway protection Functional - it simulates natural every day eating Strong evaluation tool in the establishment of treatment and compensatory strategies

What are you assessing and evaluating on a Fiberoptic Endoscopic Evaluation of Swallowing (FEES) what phases are not visualized? Cant see what happens during moment of...

Assess laryngeal and pharyngeal anatomy Assess secretions Assess swallow function with liquids and solids (use food dye to enhance visualization) Evaluate movement of laryngeal and pharyngeal structures Evaluate impact of compensatory maneuvers **Oral and esophageal phases of swallow are not visualized** Can't see what happens during moment of airway protection

Trial Feeding Observation Begin with..

Begin with water, ice chips, or crushed ice as it is relatively safe if partially aspirated. - Observe oral preparation and transport •Look for lip, buccal tension, mandible alignment, swallow initiation (delayed or timely) Manually feel thyroid cartilage for laryngeal elevation -Tongue base retraction -Height of laryngeal elevation -Number of swallows per bolus (counted by the movement of laryngeal elevation) Observe quality of phonation after swallow (starting with thin consistency then moving up)

define bolus define mastication

Bolus: Food, liquid, or material placed in mouth for ingestion (mixed with saliva). Mastication: chewing or the process by which food is crushed and ground by the teeth. Tongue must be able to move laterally

Red Flags Related to Trial Feeding

Breathing difficulty/open mouth posture Increased secretions Poor control of secretions Poor awareness Multiple swallows per bolus Pocketing/Residue Infrequent swallowing (less than 1 swallow in five minutes Throat clearing/gurglyor wet-sounding voice Significant fatigue/lethargy Longer meal times Pocketing or residue in oral cavity Gagging/Coughing/Choking Food selectivity Rejection of food Labored chewing Labored breathing Reduced laryngeal movement Difficulty/struggle to trigger swallow Sensation of bolus in throat or chest (globus sensation) Nasal regurgitation of food Emesis - vomit Inability to handle secretions Odynophagia (painful swallowing) Leakage of food from mouth

Dysphagia can be caused by a number of different disorders including:

CVA TBI Brain tumors Parkinson's disease Encephalopathy Multiple sclerosis Amyotrophic lateral sclerosis Chronic reflux Myasthenia gravis Bell's palsy Dementia Head and neck cancer (iatrogenic) Natural aging Infection Cardiac-related events

Esophageal Stricture-

Can develop anywhere in the esophagus (Can occur secondary to chemoradiation, GERD, mucocitis)

4 Limitations of Clinical Exam

Cannot visualize pharyngeal or laryngeal structure and function Majority of patients who aspirate do not cough SLPs do not identify aspiration 40% of time when it is present in clinical exam Clinical exam results not strongly predictive of aspiration on videofluoroscopy

Review of Medical Records

Check the patient's chart for the admitting diagnosis and additional diagnoses which may put the patient at risk for dysphagia. (is it chronic, acute, transient, progressive decline?) Check nurses progress notes, look for indications of coughing or choking. Check for notes regarding the patient's level of alertness (Glasgow Coma Scale)- severe is score of less than 8 Check the patient's current diet - note any dietary restrictions. Review the patient's current nutritional status,

SLPs Role in Swallowing Disorders

Clinical swallowing assessment ("bedside" assessment) Instrumental assessments as appropriate •Identify normal and abnormal swallowing anatomy and physiology •Identify signs of possible disorders in oral and pharyngeal stages of swallowing Make decisions about management •Need to achieve a balance between concern for safety issues and quality of life •Develop treatment plans (compensatory- passive strategies such as chin tuck and chin lift, or head turn, restorative- trying to restore normal function such as vital stim) •Provide treatment, document progress, and determine dismissal criteria •Teach/counsel patients and families •Educate other professionals (teachers, nurses, OT, PT, nursing aides)

Cup drinking airway closure time? straw drinking: what happens?

Cup drinking •Lengthy airway closure (i.e., 5 -10 seconds) for sequential swallows •Sustained airway closure difficult for patients with respiratory issues cuzit requires them to stop breathing for too long Straw drinking •Velum lowered to create intraoral pressure/suction drawing liquid into oral cavity •Suction discontinued when bolus in oral cavity, velum elevates and oral stage initiated by tongue •Airway generally remains closed during sequential swallows

Oral phase problems include (10):

Decreased lip closure Anterior bolus loss Problems controlling ingested materials Problems biting or chewing Inefficient oral preparation (long duration) Delayed initiation of bolus movement Difficulty moving bolus to the back of mouth Inability to control bolus flow The presence of food in the oral cavity after a person has swallowed, residue §Food gets stuck in the persons cheeks, called pocketing

define deglutition define piecemeal deglutition

Deglutition: The act of swallowing including 1) oral stage (preparation and transfer), 2) pharyngeal, and 3) esophageal stages. You can treat the 1st two stages but only screen the 3rd Piecemeal deglutition: A bolus of a large volume is divided into two or more parts which are swallowed successively.

Epiglottis Valleculae

Epiglottis •Rests against the base of the tongue. •Inverts to protect airway once swallow is triggered. Valleculae •The wedge-shaped space formed between the base of the tongue and epiglottis is the valleculae. Food may fall into this pharyngeal recess before the swallowing reflex trigger.

Esophageal dysmotility

Esophageal spasm (cork screw appearance on right). More advanced dysmotility.

what should you evaluate?

Evaluate the motor and sensory aspects of the swallow Air-pulse stimuli are delivered to the mucosa around the aryepiglottic region (innervated by the superior laryngeal nerve) to elicit the laryngeal adductor reflex (LAR). A comprehensive FEES swallowing evaluation is then performed.

Normal persons routinely aspirate microscopic amounts of food and liquid Gross aspiration is _____ and may lead to _______ However, some persons tolerate aspiration better than others. Several factors influence the effects of aspiration:

Gross aspiration is abnormal and may lead to respiratory complications. However, some persons tolerate aspiration better than others. Several factors influence the effects of aspiration: •Quantity. Aspirating larger quantities is riskier. •Physical properties of the aspirate. •Pulmonary clearance mechanisms. Aspiration and penetration normally provokes a strong reflex cough. If sensation is impaired, "silent aspiration" may occur.

Trial Feeding Observation cont.

If laryngeal elevation and protective cough are adequate, proceed to food trials (NOTE: Not all clinical swallowing examinations should include food trials). Thin liquids, puree, and solids (NOTE: patient may not be appropriate for all consistencies- if they aspirate water and applesauce, stop exam). Start with volumes of 5-10 ml (5 ml = 1 tsp) Vary method of delivery (i.e.,. spoon, cup, straw) Volume changes precede texture changes The swallow evaluation may need to be deferred if the patient is not medically stable or awake enough for trials of food.

when can impairment occur in the phases? SLP manages what phases gastroenterologist manages what phase? some ppl have impairments that results in ______ some people have to ____________________ but this can cause difficulty maintaining... some people require an ______

Impairment can occur in one, some, or all of the three phases of swallowing due to structural abnormalities or physiological deficits. SLP manages oral preparatory, oral transit, and pharyngeal dysphagia's (e.g., oropharyngeal dysphagia); gastroenterologist manages esophageal dysphagia. Some persons have impairments that result in aspiration (food or liquid moves below the level of vocal folds into the airway). Some persons have to alter their diet to control the consistencies, but this can cause difficulty maintaining hydration and nutrition. Some persons require an enteral feeding tube for nutritional maintenance.

Pharyngeal Phase Pharyngeal delay - what is it? occurs if.. in patients over 60.... what happens if material rolls into the pharynx without a response? what should you measure? normal, mild, moderate, severe, and profound delays:

Inability to initiate the swallow in a timely manner. Occurs if the bolus rolls over the base of tongue beforethe swallowing trigger occurs. In patients over 60, the swallow should occur by the time the bolus reaches the valleculae. When material rolls into the pharynx without a response, the bolus may land in the valleculae, the pyriform sinuses , or airway, depending upon the amount of food given, consistency of the food, and patient's posture measure how long the bolus is in the pharynx before the swallow begins. Timed from the point the bolus head passes the swallow trigger site (ramus of the mandible intersects with base of tongue) until the pharyngeal swallow is initiated (where laryngeal and hyoid elevation begin as a part of the pharyngeal swallow). Pharyngeal swallow initiated within 1 second of propulsion of bolus from oral cavity is normal. Mild delay may be 1-3 seconds; moderate 3-6; severe 6-10; profound- absent swallow or pharyngeal swallow initiated greater than 10 seconds following propulsion of the bolus past vertical ramus of mandible.

Variations in Normal Anatomy with Aging

Increased mastication time- tongue not as strong Ossification of the thyroid and cricoid cartilages and hyoid bone increases - structures may appear more prominent during fluoroscopy 70+ years - larynx lower in neck •Reduced laryngeal elevation •Less movement (opening) of UES Incidence of cervical arthritis increases which may impinge on pharyngeal wall decreasing its flexibility. •Reduction in strength of pharyngeal constriction •May need to swallow a second time to clear residual material from pharynx after a swallow Oral transit stage is slightly longer in older adults •Changes in mass and contractile function of muscles

The "Normal" Swallow how many times do adults swallow per day?

Innate ability which is present in the developing fetus Necessary to maintain nutrition and hydration Adults swallow approximately 580 times daily unconsciously, decreases at night

Comprehensive Interview with Patient

Interview the patient and any information relevant to swallowing including history of dysphagia, weight loss, heartburn (reflux), voice changes, etc.

3 types of strokes what 2 things correlate with degree of swallowing impairment?

Ischemic stroke (thrombic/embolic) •Blockage in blood vessel resulting in loss of blood to area of the brain •Severity = where the blockage occurred and how large it was Hemorrhage stroke •A weakened blood vessel that ruptures and bleeds into the surrounding brain. Transient ischemic attack (TIA) •Produces symptoms similar to a stroke, but usually lasting only a few minutes and causing no permanent damage. *The size and site of the infarct (area of dead tissue resulting from failure of blood supply) correlates with degree of swallowing impairment.*

Left hemisphere cortical stroke is commonly associated with... Right hemisphere cortical stroke have more... Bilateral stroke: more than 50% do what? Patients with only small infarcts have lower occurrence of _____ compared to those with large infarcts

Left hemisphere cortical stroke is commonly associated with oral stage dysphagia. Right hemisphere cortical stroke have more pharyngeal and esophageal dysfunction, including longer pharyngeal transit, pharyngeal pooling, and a higher incidence of laryngeal penetration and aspiration. Bilateral stroke: more than 50% aspirate (stroke is usually unilateral). Patients with only small infarcts have lower occurrence of aspiration compared to those with large infarcts.

more variations from aging

Longer delay in triggering pharyngeal swallow Slight increase in oral and pharyngeal residue in individuals 60+ years Increased penetration, but no increase in aspiration in older adults (50+ years) Esophageal function deteriorates more significantly with age •Slower esophageal transit/clearance Sensitivity to taste is reduced •May effect nutritional choices •Medications can alter taste as well (e.g. tetracycline - antibiotic - metal taste) Artificial dentition

Materials Used in MBSS Use range of volumes and textures

Materials Used in MBSS •Barium sulfate in powder, liquid, or paste form -- Positive contrast agent appears as black on fluoroscopic image -- It's a contrast agent Use range of volumes and textures •Important to use a range of volumes and textures since normal swallowing mechanism adjusts to changes in texture and volume (5-20 mL) •5 mL is one teaspoon- do this to start •20 mL of liquid represents average drink from a cup

6 Red Flags from Review of Medical Records

Medical diagnoses associated with dysphagia Prolonged intubation/ tracheostomy Respiratory compromise/copious chest secretions Temperature spikes Pneumonia Unexplained weight loss/failure to gain weight

Trial Feeding Observation- Cost-Benefit Analysis what should determine the need and safety for conducting trial swallows? low risk high risk

Medical history and oral mechanism examination should determine the need and safety for conducting trial swallows. Low Risk: A patient who is attentive and cooperative, has no current respiratory problems or signs of physical distress, and has at least some laryngeal elevation would be a good candidate for trial swallows. High Risk:A patient with current respiratory problems, who is acutely ill, has a weak cough, cannot follow directions, suspected of having pharyngeal stage disorder, or decreased mental status and cooperation may not be a good candidate.

The velum and pharynx motor sensory and motor

Motor: •The velum should be observed at rest and during phonation •Have the patient repeat the syllable train "ah" •Look for symmetrical elevation of velum •The pulling of the palate to one side suggests unilateral brainstem pathology Sensory and Motor: •Elicit a gag reflex by stroking the pharyngeal mucosa or back of the tongue with a cotton-tipped applicator or tongue depressor (looking for soft palate elevation and lateral pharyngeal wall come to midline) •Sensory reflex •Elevation of velum, contraction of the pharyngeal walls, and cough response (VF closure)

Indications for FEES Procedures

Need to assess fatigue or swallowing status over a meal Need objective information on secretion management Need a prolonged therapeutic exam with sufficient time to try out different maneuvers, food consistencies, etc. Severe dysphagia with very weak or possibly absent swallow reflex and/or very limited ability to tolerate any aspiration (e.g., brainstem stroke, tube-fed for prolonged period, very poor pulmonary status, or, poor immunologic status) To visualize the larynx directly for signs of trauma or neurological damage and assess laryngeal competence post-intubation or post-surgery Changes in vocal quality choking on salvia - fees is good

NPO PO Dysphagia

Nil per os (NPO): nothing by mouth Per os (PO): oral administration Dysphagia: Impairment in the ability to swallow because of neurological or structural problems that alter the normal swallowing process, rendering person unable to safely eat or drink. - saliva, food, liquid, and medication -Patient may/may not be aware of problem

2 Types of Evaluation Procedures

Non-Instrumental •Admission Swallow Screen (Non-Diagnostic) •Clinical Bedside Examination (Diagnostic) Instrumental Exam •Videofluoroscopy/Modified barium swallow study (Diagnostic) •Fiberoptic Endoscopic Evaluation of Swallowing (Diagnostic)

Normal swallowing transit times are______ on thicker food More difficult to maintain cohesive bolus for _____ liquids compared to ______ liquids penetration is more common with _______ liquids than _______ As bolus viscosity increases, transit becomes more reliant on... However, a more ______ bolus is forgiving when timing of swallow and coordination are impaired. Thicker foods also heighten....

Normal swallowing transit times are slower on thicker food. More difficult to maintain cohesive bolus for thin liquids as compared to thicker liquids. •Penetration more common with thin liquids than thick. As bolus viscosity increases, transit becomes more reliant on muscular strength and constriction. However, a more viscous bolus is forgiving when timing of swallow and coordination are impaired. Thicker foods also heighten sensory awareness.

Radiation Safety Occupational dose limits Average exposure for Americans is The dose limit applicable to pregnant workers is what do you need to wear for safety?

Occupational dose limits (5,000 millirem per year). •Average exposure for Americans is 360 mrem per year The dose limit applicable to pregnant workers is 50 millirem per month once pregnancy is declared by the employee (500 millirem for the entire pregnancy). Wear dosimetry badge or ring (if concerned about hands being near field) - The personal dosimeter should be worn between the chest and waist, since the x-ray tube head is most often positioned at this height. Additional Protective Gear: •Lead apron is worn by SLP •Thyroid shield

Oral residue- Nasal pharyngeal regurgitation-

Oral residue- Note of any residue left in the oral cavity following the swallow (except for sequential swallows.) This may be due to reduced lingual strength, ROM, coordination or lack of sensation. The buccinator muscles may also be weak or due to xerostomia (dry mouth). Nasal pharyngeal regurgitation- Liquids may come up into the nasopharynx due to reduced closure of the velopharynx either secondary to soft palate dysfunction or defective function of the superior pharyngeal constrictor.

Premature spillage- due to.. what is it? what might prevent the person right recognizing the spill? this can lead to... how can you test this? Individuals may have difficulty positioning the bolus on the tongue due to

Patients have premature spillage due to poor bolus control. Premature spillage is escape of the bolus over the tongue base before the swallow trigger occurs. Sensory deficits may prevent the patient from recognizing the spill or impending spill. This can lead to penetration or aspiration before the swallow. This can especially be seen if you ask the patient to "hold the food in your mouth until I ask you to swallow" and if you notice that the food has escaped over the tongue. Individuals may have difficulty positioning the bolus on the tongue due to weak, uncoordinated or jerky tongue movements.

define penetration and aspiration what can aspiration lead to signs of aspiration silent aspiration

Penetration: Food, liquid or material reaches but does not pass through the vocal folds. Aspiration: occurs when food, saliva, liquids, or vomit is travels through the vocal folds into the airway and the lungs. •Can lead to "aspiration pneumonia" Clinical signs of swallowing dysfunction/problems include: coughing, choking, gagging, runny nose, wet vocal quality, color changes, congestion, weight loss, and/or failure to thrive. Silent aspiration occurs in 40%-67% of patients with dysphagia Silent laryngeal penetration and aspiration of liquids are reported to be more common in right hemisphere than in left hemisphere strokes

Reduced laryngeal elevation - The larynx should elevate about... - Laryngeal elevation facilitates... and this would cause some.... Zenker's diverticulum Weakness of the soft palate and superior pharyngeal constrictor may lead to...

Reduced laryngeal elevation- The larynx should elevate about 2 cm. Laryngeal elevation facilitates epiglottic inversion and UES opening. There would be some pyriform residual. Zenker's diverticulum Weakness of the soft palate and superior pharyngeal constrictor may lead to the nasal regurgitation of food.

Oral Mechanism Exam - Supplemental Observations Not part of oral motor exam, but can make the following clinical observations at this time. 7 things

Respiratory Patterns •Rest breathing- how many times they breathe in an out per minute (12-16 cycles per minute) •Monitor for signs of respiratory distress •Observe timing of swallow and coughing •Observe timing of swallow and breathing (inhalation vs. exhalation) •Duration of comfortable breath hold •1,3,5 seconds •Peripheral oxygen saturation levels (concentration of oxygen in the blood) (below 90% is bad) --Measured my pulse oximetry (look for SPO2on vital monitors) •Ventilatory pattern (Rapid rates of more than 40 cycles/min) may make it difficult to close airway for sufficient time during swallow.

The Dysphagia Team (8)

SLP Parents/caregivers Physicians: neurologist, pulmonologist, ENT, radiologist, gastroenterologist Nursing Occupational therapist Registered dietician Respiratory therapist Consultation specialties: social worker, psychologist

Signs vs. Symptoms of Dysphagia

Signs •Behavioral observations made by SLP Symptoms •Perceptible change in body function noticed by patient Structured questionnaire may be helpful

Swallowing Evaluation

Some patients may need to be referred for an instrumental swallowing evaluation(MBSS or FEES) following a bedside clinical evaluation. It is common for precautions (such as no oral intake or dietary precautions) to be put in place while the patient is waiting for further assessment.

4 Signs of Dysphagia

Stasis •Stoppage or slowed movement of bolus through aerodigestive tract (the shared pathway from mouth to where the tubes split) Residue •Material left in mouth, pharynx, or esophagus after swallow Aspiration •Entry into airway below the level of the vocal folds Penetration •Entry into laryngeal vestibule, above the level of the true vocal folds

Blood Supply to the Brain: Cerebrovascular Accident most common cause of oral-pharyngeal dysphagia:

Stroke is the most common cause of oral-pharyngeal dysphagia. Between 30-40% of stroke patients will show signs of significant aspiration. •20% of stroke victims die of aspiration pneumonia in the first year following stroke. •10-15% die in years following the stroke from aspiration pneumonia.

what 2 arteries supply the brainstem and cerebellum? is dysphagia more severe from a brainstem or cortical stroke?

The vertebral and basilar arteries supply the brainstemand cerebellum. brainstem

Pharyngeal Phase cont

Top to bottom contractions of pharyngeal constrictor muscles (peristalsis) is initiated. Airway Protection •Anterior Movement of the hyoid which then causes.. •Laryngeal elevation (up and forward) •Elevation and anterior movement of the hyoid and larynx. •Elevation contributes to airway protection. •Anterior movement contributes to mechanical opening of the UES. Close the entrance into the larynx: (cessation of breathing) •Occurs when laryngeal elevation is at 50% of its maximum

parts of the Laryngeal Vestibule

True vocal folds: Lateral cricoarytenoid muscle, thyroarytenoid muscle, and the interarytenoid muscles adduct (close) true vocal folds False vocal folds and aryepiglottic folds Arytenoids and interarytenoid fold

The major disadvantages of MBSS:

Use of ionizing radiation, therefore studies must be short (is the person fatguiedor optimally functioning during this 2 minutes of watching their swallow) Patient must be taken to radiology suite (people over 300lbs wont fit) Require the use of barium sulphate which alters the taste and texture of liquids and solid foods Cannot be used to evaluate management of secretions Limited access to technology outside of hospital setting Inconsistent interpretation amongst clinicians (reason for development of MBSImp)- only 50% of slpscaught residue on posterior pharyngeal wall

Vallecular residue-

Vallecular residue after swallowing is cleared as a result of posterior movement of the tongue base to contact the pharyngeal wall. The reduction in posterior tongue base movement leads to residue in the valleculae, which increase the risk of aspiration if the residue is in a large amount. Valleculae residue also occurs with reduced epiglottic inversion and reduced hyolaryngeal elevation. Patients are at greater risk of penetration or aspiration after the swallow due to residue. Can the patient clear the residual with subsequent swallows?

Esophageal Phase what happens first?

Velum lowers and respiration resumes (expiratory cycle) The anterior elevation of the larynx and cricopharyngeal opening are closely related.

Oral Preparatory Phase what is it/what happens duration: respiration: how to prevent food from spilling:

Voluntary stage of swallowing Begins as food or liquid enters the mouth Contain, manipulate, and prepare the food or liquid into a bolus Chewing (mastication) occurs to grind solid bolus into manageable texture •Requires coordination of lips, tongue, mandible Duration: variable depending on substance (depends on consistency of food) Respiration: normal through the nose (mouth closed) During this preparatory phase, the lips are closed anteriorly and the base of the tongue and the soft palate close the oral cavity posteriorly to prevent food spilling into the pharynx (see image on next slide).

Oral Transit Phase what happens? what 4 things are required? duration? respiration? what happens at the end?

Voluntary stage of swallowing a bolus is formed in the central portion of the tongue and then pushed posteriorly toward the pharynx with an anterior-to-posterior tongue elevation. Requires: - Tension in the cheeks (buccal muscles) to closure lateral sulci - Labial seal (orbicularis oris) - Intact lingual movement - Normal palatal lift Duration: <1.5 seconds (depending on consistency) Respiration: normal through the nose As the bolus reaches the anterior faucial pills (or valleculae or pharynx) the pharyngeal swallow reflex is triggered.

Indications for FEES Procedures cont

When transport positioning for fluoroscopy is problematic (e.g., member bedridden, weak, quadriplegic, obese, or on ventilator) Need to directly visualize the larynx - to assess vocal fold adduction for airway protection [e.g. problems secondary to in/extubation] When transportation to fluoroscopy is problematic (e.g., medically fragile/unstable member in an intensive care unit, cardiac or other monitoring in place, on ventilator, or, nursing/medical care must be with member) When transportation to the hospital is problematic (e.g., nursing home issues, including cost of transportation, resources needed to accompany member, strain on member, or, member fearful of leaving familiar surroundings, etc.) No radiation!

what do instrumental techniques provide? 2 commonly used approaches:

an objective, quantifiable measure of swallowing function (1) Modified Barium Swallow Study (MBSS) •Visualization of oral, pharyngeal and esophageal phases of swallow (can't see VFs) •Also called videofluorscopy swallow study (VFSS) •Most commonly used; "gold standard" (2) Fiberoptic Endoscopic Examination of Swallowing (FEES) •Visualization of pharyngeal phase before and after swallow •Also called nasal endoscopy, nasoendoscopy, flexible endoscopy, transnasal endoscopy - shows choking the best

when can aspiration occur?

before airway protection, during airway protection or after the swallow.

Review medications

can impact level of awareness/cognition and sensorimotor function. Sedative drugs cause disorientation or confusion and can negatively impact swallowing. Medications can cause xerostomia(drying of the mouth) can adversely affect swallowing. Some antipsychotic drugs can lead to dyskinesia (disordered movement) and dystonia (disordered muscle tone). How are medications presented? PO? If so, are they taken whole?

what can solid food cause? what type of material is more dangerous and why? what can cause serious damage to pulmonary tissue? what can cause bacterial pneumonitis?

fatal airway obstruction acidic because the lungs are highly sensitive to the caustic effects of acid. Aspirating refluxed acidic stomach contents Aspirating material laden with infectious organisms or even normal mouth flora

During pharyngeal bolus transit, risk of... duration respiration

food or liquid entering the airway •If material does enter the larynx, reflexive cough to expel it will occur in healthy individuals Duration: Pharyngeal stage lasts for approx. 1 sec Respiration: briefly halted (apneic moment) during pharyngeal phase

Comprehensive Interview with Patient Heartburn is often an indicator of...

gastroesophageal reflux •Reflux can be either gastroesophageal reflux (GERD) or laryngopharyngeal reflux (LPR) LPR = reflux that gets onto the VFs •Report of food sticking at level of cervical esophagus - screen for GERD (see GERD Questionnaire) •Hoarseness, chronic cough, and chronic throat clearing screen for LPR (see RSI Questionnaire)

MBSS what does the clinician need to decide?

how much of the standard protocol to complete for any given patient. For example: what do you do if a patient aspirates? •Do not continue providing same bolus consistency or volume if a patient is aspirating a significantamount of material. •Trace aspiration does not have the same health consequences as aspiration of larger amounts. •Do notcontinue if a patient becomes excessively fatigued or unresponsive.

what are the 2 views? what do you start in?

lateral (sagittal) A-P Always start in lateral view Then anterior-posterior view (allows us to do cursory esophageal screening- don't diagnose esophageal dysphagia) Theres normal curves in the esophagus (around aortic arch and descending thoracic aorta) Cant tell if someone is aspirating from AP view

oral mech exam (6)

looking at structure and function lips, cheeks (tension), jaw (have them open wide and move jaw left and right) Dentition and overall oral hygiene Lingual function The velum and pharynx Gag Reflex Laryngeal function (CN X)

Inadequate airway protection and velopharyngeal valving during the swallow - results in The underlying pathophysiology may be weakness or incomplete closure of the laryngeal structures(epiglottic inversion or vocal fold adduction). Sometimes, however, the problem lies with

misdirection of the bolus. Of these valves, the laryngeal valve is most critical, because it can lead to penetration or aspiration of material during the swallow. mistiming the bolus flow with airway closure. This problem is really an extension of the previously described problem of delayed or mistimed initiation of the swallow.

Trial Feeding Observation best posture? optimal position of food in mouth: utensils for placement: Environmental influences: etc:

posture: 90 degrees (45 makes bolus move too quickly) optimal position: mid tongue utensils: spoon, cup, straw environment: TV, talking while eating, poor fitting dentures - Safest consistency/ies - Optimum swallowing instructions - Difficulties with certain consistencies, choking, efficiency throughout mealtime

Dysphagia Cont'd: also includes problems such as Dysphagia is not a...

problems such as food/liquids 'sticking' in the throat or regurgitation of swallowed foods or liquids. **Dysphagia is not a disease, but a symptom of several different etiologies (e.g., neurological injuries, gastrointestinal disorder, disruption in the timing of events needed to swallow normally).**

Review the patient's current nutritional status.. what could they be receiving?

receiving alternative means of nutrition such as a Total Parenteral Nutrition (TPN)- all nutrition through blood supply (near clavicle) Peripheral Parenteral Nutrition (PPN)- getting nutrition but not a lot because they have smaller veins, Nasogastric (NG) Tube- from nose to stomach, Percutaneous Endoscopic Gastrostomy (PEG) Tube or G-Tube- goes right into stomach which can cause reflux, or Percutaneous Endoscopic Jejunostomy (PEJ) Tube or J-Tube- right into intestine but cant handle a lot of bolus at once

mechanics of coughing what do you need?

respiratory system, abdominal support and good vocal fold closure

which lung is more prone to aspiration and why? where is the aspiration in the lung?

right Right main bronchus is slightly wider and enters lung at more steep angle. Aspiration pneumonia often identified in the right middle and inferior lung lobes

•Aspiration after swallowing is the result of

stasis in the pharynx or UES. When the larynx opens (post-swallow) the food/liquid 'stuck' in the pharynx or UES leaks into the trachea.

Esophageal Phase Once bolus enter esophagus,... no contraction?? symptoms: duration: respiration:

the UES contracts/closes Bolus is propelled through the esophagus to the stomach by an involuntary wave-like contractions (peristalsis). Lower esophageal sphincter relaxes to allow food to enter the stomach. Sphincter does not relax satisfactorily, results in a condition called achalasia (cricopharyngeal bar -Symptoms: regurgitation of food, cough, heartburn, difficulty swallowing Duration: 8-20 seconds, can be influenced by age (often increase in duration in elderly population) Respiration: normal through nose and mouth

Comprehensive Interview with Patient Changes in voice quality such as hoarseness, strained, or breathy vocal quality may represent... Also consider dysarthria as this would mean the patient has a... also want to check for... Take note if the patient has had any recent changes in...

vocal fold dysfunction (paresis/paralysis). •neurological problem •Nasality- check this b/c you wannacheck the function of the velum Take note if the patient has had any recent changes in overall health, any history of respiratory infections, any changes to his or her smell, taste, or food intake, any problems with unplanned weight loss or dehydration, or if extended time is needed to consume a meal.

Consistencies to test during MBSS

•1) Liquids- test this first Thin liquids •50% liquid barium/50% water Thickened liquids • Nectar-thick, honey-thick, pudding-thick • Varibar - barium sulphate premixed to honey, nectar, pudding consistencies 2) Puree- applesauce consistency 3) Solid (chewable food such as a graham cracker- barium paste is spread on top) 2 swallows per consistency recommended

illness Community-Acquired Pneumonia (CAP) acquired from.. who can it affect? causes problems such as... 4 causes of CAP:

•Acquired from normal social contact, as opposed to be acquired during hospitalization. •CAP is a common illness and can affect people of all ages. •CAP often causes problems such as difficulty breathing, fever, chest pains, and a cough. •Causes of CAP include bacteria, viruses, fungi, and parasites.

illness: Nosocomial Pneumonia

•Also called hospital-acquired pneumonia •Bacteria infection acquired during first 48 to 72 hours following hospital admissions •Often the cause of death following admission to ICU

Selected Medications That May Affect Swallowing

•Antidepressants (drying to mucosa, drowsiness) •Antipsychotics (dyskinesia's, altered mental status, muscle rigidity) •Antihistamines (drying to mucosa, sedative) •Anticholinergics (dry mouth, reduced appetite) •Anticonvulsants (dry mouth) •Antibiotics (inflammation) •Sedatives (CNS depressant, drying of mucosa) •Diuretics (dehydration, drying to mucosa) •Corticosteroids (Myopathy, weakness, dystonia, drowsiness)

Laryngeal function (CN X)

•Assess the patient's volitional cough (strength and quality -wet/dry) •A weak volitional cough can be an indicator of vocal fold deficits. •Volitional cough is elicited by asking the patient to cough with as much force as possible •An abnormal volitional cough has been described as being either "weak" or "wet/gurgly" •Voice quality during sustained 'ah'

Comprehensive Interview with Patient Any reported change in eating habits:

•Avoid certain consistencies •Excessive chewing to avoid globus sensation •Fatigue when eating certain foods •Lengthened meal durations •Change in social eating habits due to episodes of choking or regurgitation Patient can complete self-report inventories such as EAT-10, Dysphagia Questionnaire (see Moodle)

The major advantages of MBSS:

•Can see where the swallowing difficulty is occurring.- can see all 3 phases of swallow •Can determine if the person is penetrating or aspirating. •Can determine how changes in positioning and consistency of food affect swallowing.

Review medical history

•Congenital disease •Neurologic disease (whatsthe course of the disease?) •Surgical procedures •General anesthesia (requires endotracheal tube)- paralyzes you diaphragm when you are on anesthesia

Trial Feeding Observation what to observe during swallow and after swallow

•Containment of bolus in oral cavity, duration of oral stage, laryngeal elevation, presence of coughing, throat clearing, changes in breathing, changes in amount of secretions, changes in voice quality •After the swallow, the patient should be observed for a minute or more to see if there is a delayed cough response. 3% drop in spo2 is concerning and means they are probably aspirating

Pyriform sinuses when could food fall into the pyriform sinuses?

•Fibers of the inferior pharyngeal constrictor attach to the sides of the thyroid cartilage anteriorly, a space is formed between these fibers and the sides of the thyroid cartilage. These spaces are known as the pyriform sinuses. •Food may fall into the pyriform sinus before or after the swallow.

illness: Aspiration Pneumonia what five things could it be from? it can happen in the absence of... damage to swallowing mechanism may.... acute or chronic aspiration a result in...

•Food, liquid, secretions, pills, or reflux from stomach pass into the airway belowthe level of the true vocal folds. •Absence of injury to muscles/nerves, most people sense the foreign matter and cough to expel it. •Damage to swallowing mechanism may reduce sensitivity or reflexive cough. •Acute or chronic aspiration can result in pulmonary infection.

Check the patient's respiratory status

•Notes from Respiratory Therapy, or results of chest x-rays must be reviewed (if available) •Infiltrates in the lungs may represent aspiration, especially in the right middle and lower lobes. •Is the patient on oxygen? •Is the patient, or has the patient been recently intubated? (endotracheal intubation)-

MBSS Observations: what 11 things are you looking for?

•Oral preparatory phase (containment of bolus anteriorly and posteriorly) •Oral transit of materials (is there residue left on tongue or palate) •Velopharyngeal functioning (did barium get in nasal passage) •Airway protection (hyoid and laryngeal elevation) •Pooling in valleculae, piriform sinus, or laryngeal vestibule •Presence of oral, pharyngeal, or esophageal residue •Cricopharyngeal (UES) function •Number of swallows to clear bolus (piecemeal deglutition) •Occurrence of aspiration/penetration (say which consistency this happened with) •Esophageal phase of swallow •Response to varied textures/viscosity, compensatory movements

•Previous swallowing studies (i.e., MBSS/FEES)

•Previous swallowing studies (i.e., MBSS/FEES) •24-hour Ph probe for presence/absence of reflux (quantifies gerd)

Esophageal Phase 3 Dysphagia characteristics

•Structural abnormalities in esophagus •Decreased esophageal motility or contraction •Inadequate opening of lower esophageal sphincter (bolus cannot move into stomach) •Excessive opening of the lower esophageal sphincter, allowing backward flow of contents from stomach to esophagus (reflux) Esophageal stage you just screen Looking for slow movement through the esophagus (should take 8-20 seconds)

Three pharyngeal constrictors what is the bolus carried by?

•Superior pharyngeal constrictor(SPC)- The elevation and contraction of the velum results in the complete closure of the velopharyngeal port, this action is facilitated by the contraction of the SPC, which narrows the pharynx. • •Medial and inferior pharyngeal constrictors- Initiation of pharyngeal peristalsis occurs. The bolus is carried by the sequential peristaltic action of the middle and inferior pharyngeal constrictors through the pharynx to the cricopharygneal muscle (upper esophageal sphincter). •-uses a wave like motion to push the bolus to the esophagus

Hyoid & Larynx where is the hyoid/what is it attached to? The larynx is connected to the hyoid via the... If hyoid elevates and mores forward, the larynx will...

•The hyoid is suspended in soft tissue •Attached anteriorly to mylohyoid, geniohyoid, and anterior belly of digastric muscle •Attached posteriorly to stylohyoid and posterior belly of digastric muscle •The larynx is connected to the hyoid via the thyrohyoid ligament and thyrohyoid muscle •If hyoid elevates and mores forward, the larynx will elevate and move forward as well

Lingual function

•The tongue is required to form a bolus and transport the bolus to the oropharynx. •Visual observation of the tongue at rest should be conducted first. •Patients with a history of oral cancer may have a partial or total glossectomy (check sensory awareness) •Look for presence of atrophy and/or fasciculation's (indicates lower motor neuron disease), or spasticity (indicates upper motor neuron disease). •Test tongue mobility, strength (protrude and lateralize against resistance).

Pharyngeal Phase The swallow reflex triggers a series of sequential (overlapping) responses:

•Velum raises and retracts to seal off the nasal cavity this prevents nasal regurgitation and a good pressure In the pharynx Superior pharyngeal constrictor contract and the velum raises to close off the nasal passage

coughing indicates that there is something in the... what is it called when the person doesn't cough

Coughing means something got into the vestibular space Silent aspiration and penetration are when they don't cough

oral phase paired salivary glands

Submandibular glands •65% of saliva •CN VII • Parotid glands •25% of saliva •CN IX Sublingual glands •10% of saliva •CN VII

Substances with taste associated with greater activation of swallowing- ______ tastes elicit greater effort than other taste does temp affect norma l swallow? Carbonated beverages:

Substances with taste associated with greater activation of swallowing-related muscle regions Sour tastes elicit greater effort than other taste No consistent evidence that temperature affects normal swallowing Carbonated beverages •Frequency of aspiration •Pharyngeal transit time •Pharyngeal retention