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215 Cards in this Set

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Imaging techniques for the oropharyngeal region
Ultrasound, videoendoscopy and videofluoroscopy. Scintigraphy enables visualization of food being swallowed but not of the anatomy and physiology of the oropharygneal region during swallowing.
Image the oropharygneal region. Used to observe the oral cavity tongue function and to measure oral transit times and motion of the hyoid.
Ultrasound - limitations
Can't visualize the pharynx b/c of the mix of tissue types (cartilage, bone & muscle) in the pharynx. Limits the application of ultrasound to study of the oral stages of swallow, especially tongue function during swallowing & biofeedback for oral tongue exercises.
Examines anatomy of oral cavity & pharynx from above and examines the pharynx & larynx before and after swallowing.
Videoendoscopy - FEES/Flexiible Fiberoptic Exam (FFE)
Flexible scope inserted into nose to the level of the soft palate or below. Requires light topical anesthesic in the nose.
Vidoendoscopy - Oral stage and VP closure
Does not visualize the oral stage of swallow. If tube is positioned above soft palate, dynamics of VP closure can be observed, including inward movement of lateral and/or posterior pharyngeal walls & elevationand retraction of soft palate.
Videoendoscopy - pharyx
With endoscopic tue placed so that the tip is behing the tip of the uvula, pharynx is imaged before the pharyneal swallow triggers and again when the pharynx relaxes after the swallow. The moment the pharyngeal swallow triggers causes the pharynx to close around the endoscopic tube, blocking the image during swallow.
Simultaneous Videoendoscopy and Videofluoroscopy
Many important events ocure during the time the pharynx is closed around the tube, blocking the image during swallow. Can be identified from simultaneous videoendoscopy and videofluoroscopy
Videoendoscopy - limitations
Makes it difficult to define the exact nature of physiologic disorder and effectiveness of tx strategies. Can try to infer nature of physiology from location of residual food when endoscopic image returns, but this is based on symptoms rather than observ. of the swallow.
Rigid endoscopy
Rigid scope placed into mouth, which often provides better image than flexible endoscopy of the same pharyngel & laryngeal structures, but pt. can't swallow with scope in place.
Poor candidates for flexible endoscopy
Kids under 6 to 8 and adults with cognitive disorders or those who are agitated.
Videoendoscopy - advantages
When recorded on video, provides excellent superior view of pharyngeal anatomy, including relationship btwn. epiglottis, airway entrance, valleculae, aryepiglottic folds and pyriform sinuses.
Videoendoscopy - advantages
No radiation exposure.
Videoendoscopy - further uses
Can be used to test sensory awareness by touching pharyngeal and laryngeal structures; excellent way to observe vf's if tube is placed lower (at or below tip of epiglottis) and to assess oropharyngeal anatomy.
Videoendoscopy - further uses
Can be used to assess pt's ability to use airway closure techniques such as supraglottic swallow (easy breath hold) and super-supraglottic swallow (effortful breath hold) prior to, but not during,swallow.
Endoscopy - further uses
Can be used to provide biofeedback to the pt. who is having difficulty learning airway closure techniques. Pt. can observe their laryngeal movement while producing the easy and effortful breath hold.
Most frequently used technique in assessment of oropharyngeal swallowing. Usually uses a variety of food types and visualizes the patient initially in the lateral plane. Pt given liquid randing from 1 to 10 ml, then cup drinking, then pudding, then piece of cookie (to show mastication). If pt. complains of food-specific dysphagia, those foods should be given with barium.
Videofluoroscopy - history (i.e. Cinefluorography)
radiographic procedures have been used since 1900's. In 1930's devel. of flouroscopy permitted examination of the movement patterns of oral cavity, pharynx and esophagus during swallowing. Image, first called cinefluorography, allowed examination of movment patterns of bolus and structures in slow motion and frame by frame. Required more radiation exposure than now and required film development.
Videoflouroscopy - now
Recorded on videotape which also permits frame-by-frame analysis.
By recording numbers on each frame of the video using a video counter timer, swallowing studies canbe repeatedly examined in slow motion or frame by frame & specific frames of interest can be easily located.
B/c swallowing occurs rapidly with normal oral and pharyngeal transit times together taking approx. 1 - 2 seconds, slow motion analysis most helpful in defining movement disorders.
Info. provided by videoflourosopic studies
Bolus transit times, motility problems, amount and etiology of aspiration.
Videoflouroscopy - radiation
Does use radiation, but relatively low dose while the oropharyngeal region is fully viewed in alteral or P-A plane.
Videoflouroscopy - visualization (3 things)
Enables visualization of (1) oral activity during chewing & the oral stage of swallow; (2) triggering of the pharyngeal swallow in relation to position of bolus and (3) motor aspects of pharyngeal swallow including movements of larynx, hyoid, tongue base, pharyngeal walls & cricopharyngeal region.
Videoflouroscopy and pressure
Does not measure pressures generated during swallowing but does enable indirect observ. of pressure through speed of movement of the bolus in relation to structural motion.
Videoflouroscopy - Lateral View
Usually used initally to assess transit times or speed & efficiency of bolus movement and for better observation of aspiration.
Videoflouroscopy: P-A view
Airway overlies esophagus in this view, so identification of presence and etiology of aspiration dificult.
Modified Barium Swallow
Videoflouroscopic study designed to understand why person aspirates and to define optimal eating strategies for patient.
Modified Barium Swallow
Videoflouroscopic study. Once anatomic and/or swally physiologic abnormalities have been identified, introduce tx strategies during the study in order to facilitate safe & more efficient oral intake.
Treatment strategies to facilitate safe & efficient oral intake
Changes in head or body posture, heightening of sensory input prior to swallow. When possible, swallowing techniques designed to change aspects of swallow physiology, such as swallow maneuvers. Also test effects of changing bolus viscosity. Introduce during radiographic study to obtain direct evidence of intervention efficacy.
Nuclear medicine test where pt. swallows measured amounts of radioactive substances. During swallows, bolus imaged & recorded by gamma camera. Allows for amount of aspiration & residue to be measured, but physiology of mouth & pharynx not visualizeds so causes of residue and aspiration not identified. Largely used for research of oropharynx, not standard clinical tool.
Scintigraphy - esophageal diagnostic value
Can be diagnostic for esophageal aspects of swallowing dysfunction, esp. gastroesophageal reflux disorder. Amount aspirated and amount of oral and pharyngeal rediuse measured. If no aspiration and reflux suspected, pt. rescanned every 15 to 30 minutes for several hours. If no aspiration initally but after several minutes or hours material in airway and lungs revealed, reflux is the etiology for aspiration.
Nonimaging Procudures
Electromyography, electroglottography, Cervical Ausculation, Pharyngeal Manometry
Nonimaging Procudures
Provide a variety of types of info. about swallowing but don't result in pictures of the process or the food being swallowed. Most result in amplitude over time displays of the swallow parameters, such as pressure generated at specific locations in pharynx (manometry) or amount of electrical energy generated by muscle contractions (electromyography)
Electromyography (EMG)
Gives info. on the timing & relative amplitudes of selected muscle contraction during swallowing via placement of electrodes on muscles to be analyzed.
Electromyography (EMG) - studies in dogs, cats and monkeys
Pharyngeal swallowing was activated by stimulating the pharynx with a cotton swab or rapidly injected water or by stimulating the superior laryngeal nerve. No difference in temporal pattern, duration or amplitude of contraction of participating muscles in swallows elicited by the varying methods.
Surface Electromyography (EMG)
Application of electrodes to skin surface above muscles of interest. Records info. from muscles of the floor of mouth by placing electrodes on the soft tissue under the chin or from muscles involved in laryngeal elevation by placing an electrode above the thyroid on each side. Electrical activity of all of these muscles has been found to occur early in swallow. Surface EMG of these muscles has been used as a marker of the onset of swallow.
Suction cup and hooked-wired electrodes in EMG
Used to study pharyngeal wall activity during swallow. Hooked-wire used some to assess muscle function during swallow (superior pharyngeal constrictor study indicated electrical activity in this muscle was greatest for swallowing as compared to gagging, effortful bearing down, effortful articulation, falsetto, etc.)
Electromyography (EMG) and biofeedback
Electrical activity in muscles has been used as biofeedback during tx for patients w/ dysphagia. Typically involves surface EMG of the laryngeal elevators to illustrate duration of laryngeal elevation during Mendelson maneuver, as well as of effortful swallow.
Mendelson maneuver
Designed to improve the extent and duration of laryngeal elevation during swallow and thus to improve the extent & duration of cricopharyngeal opening during swallow.
EMG biofeedback and effortul swallow
Pt. can observe amount of electrical activity in submandibular muscles when producing a normal swallow vs. an effortful, hard swallow, squeezing hard with all of the muscles.
Electroglottography (EGG)
Designed to track vf movement by recording the impedance changes as the vf's move toward and away from each other during phonation. Can be modified to track laryngeal elevation which can be useful in determining onset and termination of pharyngeal swallow and in providing biofeedback on extent & duration of laryngeal elevation during swallows.
Cervical Ausculation: Listening to & recording sounds of swallowing - limitations
Acoustic techniques limited by the few parameters of swallowing that can be studied, as many aspects of deglutition are silent. Also, no studies have been done to determine whether there are sound differences btwn. normal & disordered swallow.
Cervical Ausculation: Listening to & recording sounds of swallowing
Recording the sounds produced during swallow by putting small mic on surface of neck at various locations has identified some repeatable sounds in normals.
Cervical Ausculation: Listening to & recording sounds of swallowing - Click & Clunk
Click associated with opening of the eustachian tube, clunch associated with opening of UES. These are the most reliable sounds produced during swallowing.
Cervical Auscultation - Sounds of Respiration
Use stethoscope to listen to respiration & define inhalatory & exhalatory phases of respiratory cycle, as well as the moment when pharyngeal swallow occurs and in which part (inhalation or exhalation) of the respiratory cycle it occurs).
Cervical Auscultation - Sounds of Respiration
If secretions are in the airway before or after the swallow, they will be heard, as will any changes in secretion levels before & after the swallow. May be indicators of aspiration, so could be used as screening procedure.
Pharyngeal Manometry - procedure (1)
Requires solid-state pressure sensors that have fast enough frequency response to react to the rapid pressyre changes during the pharyngeal swallow. Pharyngeal transport of bolus takes less than 1 seconds (often 0.5 seconds)
Pharyngeal Manometry - procedure (2)
Pressure sensors encased in flexible 3 mm tube, placed transnasally so sensors are at tongue base, UES and esphagus.
Pharyngeal Manometry - procedure (3)
Generally requires concurrent videofluoroscopy in order to define etiology of pressure changes. Accurate interpretation requires visualization of bolus position in relation to sensors, as well as location of various structures in pharynx in relation to pressure sensors throughout swallow.
Pharyngeal Manometry - measurements
Allows measurement of intrabolus pressures and timing of the pharyngeal contractile wave. Also enables indirect exam of relaxation of cricopharyngeal muscle by identification of the drop in pressure at the UES in relation to the opening of the UES as seen on videofluorography. Pressure drop to 0 generally 0.1 seconds before the opening of the upper sphincter.
What instrumental procedure to use if understanding patient's pharyngeal anatomy is the goal?
Rigid videoendoscopy
What instrumental procedure to use if defining the presence (not cause) or aspiration is the goal?
Flexible fiberoptiic videoendoscopy (FEES)
What instrumental procedure to use if understanding pharyngeal physiology in relation to symptoms such as aspiration is the goal?
What instrumental procedure to use if measuring pressure generated during swallow is the goal?
Pharyngeal manometry in combination with videofluoroscopy
Symptoms (Ch 4)
Determined clinically and radiographically, they alert the clinician that swallowing is disordered and point toward the nature of the dysfunction.
Disorders (Ch 4)
The anatomic and/or neuromuscular dysfunctions are the actual disorders leading to the symptom for which treatment is designed.
Aspiration and Residue
Symptoms of a variety of disorders, not disorders themselves. Must educate others in this distinction so that symptomatic management is not used.
Lateral view
Lateral view of the oral cavity and pharynx permits examination and measurement of oral and pharyngeal transit times, pharyngeal delay time, movement patterns of the bolus and oropharyngeal structures in the oral prep, oral, pharyngeal and esophageal phases and the approximate amount and cause of any aspiration.
OTT (Oral transit time)
Time taken from the initiation of tongue movement to begin voluntary oral stage of swallow until the bolus head reaches the point where the lower edge of the mandible crosses the tongue base. Normally takes 1 to 1.5 seconds.
Pharyngeal delay time (PDT)
Begins when the bolus head reaches the point where the lower edge of the mandible crosses the tongue base and ends when laryngeal elevation begins.
Pharyngeal transit time (PTT)
Time elapsed from the triggering of the pharyngeal swallow (onset of laryngeal elevation as part of the swallow) until the bolus tail passes through the cricopharyngeal region of the pharyngoesophageal (PE) segment. Time is normally .35 - .48 seconds, a maximum of 1 second.
Lateral view of the oral cavity, pharynx and larynx
Also facilitates observation of whether aspiration occurs, estimation of the percentage of bolus aspirated and determination of the cause of aspiration. In P-A view, trachea and esophagus overlap each other and it is difficult to assess the occurrence and approximate amount of aspiration and the cause.
Most important step in eval and treatment
Relating the symptoms to actual anatomic or neuromuscular disorder. Normal mastication requires an intact mandible and maxilla and intact buccal and lingual musculature.
Oral prep stage
Designed to break down food into an appropriate consistency for the swallow, mix it with saliva and bring part of all of the food into a cohesive bolus ready for the swallow.
Oral prep stage disorder - Reduced Lip Closure
Symptom: Can’t Hold Food in Mouth Anteriorly – Closing lips and keeping them closed throughout the swallow to keep food in the mouth anteriorly requires nasal breathing. If patient is a mouth breather and keeps lips open during mastication and oral manipulation, should check patency of nasal airway. When food falls from mouth anteriorly, indication of reduced lip closure.
Oral prep stage disorder - reduced tongue shaping/coordination
Symptom: Can’t hold bolus – If patient has reduced ability to shape the tongue around the liquid or paste, will be unable to hold it in a cohesive bolus and material will spread throughout the oral cavity. During this period the soft palate is pulled down and forward against the back of the tongue, preventing material from entering the pharynx until the swallow is initiated. If soft palate can’t or doesn’t bulge anteriorly to contact back of tongue, food can be lost into pharynx prematurely. This premature loss of bolus over tongue base and into pharynx is normal during mastication but not with a liquid or paste bolus. It can result in aspiration before the swallow if the liquid falls over the base of tongue into the pharynx and open airway. Whether aspiration occurs depends on the amount and consistency of food given and exact posture of the patient.
Oral prep stage disorder - reduced tongue shaping/coordination
Symptom: Inability to hold a bolus is indication of reduced tongue coordination. Premature loss of liquid or paste into valleculae is indication of reduced anterior soft palate positioning and/or poor tongue control.
Oral prep stage disorder - Reduced Range of Tongue Motion or Coordination.
Symptom: Can’t form bolus – During mastication or while tasting material in mouth prior to swallow, food is normally manipulated and moved throughout the oral cavity. When individual is finished with mastication or oral manipulation, food is pulled together by the tongue into a single bolus to initiate the swallow. If reduced range or coordination of tongue movement, will have difficulty in pulling food back together into cohesive bolus and will be forced to initiate swallow with food spread throughout the oral cavity.
Oral prep stage disorder– Reduced Labial Tension/Tone
Symptom: Material falls into Anterior Sulcus - Food falling into anterior sulcus after it has been placed in oral cavity or as patient is chewing is an indication of reduced labial and facial muscle tone, which is responsible for closing the anterior sulcus and preventing food from lodging there.
Oral Prep stage disorder - Reduced Buccal Tension/Tone
Symptom: Material falls into Lateral Sulcus – Material falling into lateral sulcus as patient chews is indication of reduced muscle tension or tone in the buccal musculature, which normally closes the lateral sulcus and prevents material from lodging there by directing it medially towards the tongue.
Oral Prep stage disorder - Reduced Tongue Control
Symptom: Abnormal Hold Position – Normally, bolus is held between tongue and soft palate in prep for initiation of the oral phase of swallow, or on the floor of mouth in front of retracted tongue tip (dippers – approx. 20% of normal swallowers). If held on floor of mouth, tongue comes forward and picks up bolus and brings it onto surface of tongue as the swallow begins, which increases oral transit time. To hold and pick up the bolus, tongue must be able to shape itself around the bolus and seal the sides of the tongue to the lateral alveolar ridge. If tongue shaping is not possible, patient may hold bolus in abnormal position.
Oral Prep stage disorder - Tongue Thrust
Symptom: If bolus held against front teeth, likely that swallow will be accomplished with a tongue thrusting behavior (forward movement of tongue towards lips and central incisors, pushing bolus forward). Often tongue thrust so strong it pushes food out of oral cavity. Relates to neurologic impairments and seen in some patients with cerebral palsy and sometimes after stroke or head trauma.
Oral Phase
Consists of lingual propulsion of the bolus through the oral cavity. Under voluntary cortical control but plays a role in triggering of pharyngeal swallow. Oral phase begins with the lateral and anterior margins of tongue sealed against alveolar ridge. Anterior midline of tongue initiates backward movement of bolus with an upward, backward motion. Oral transit terminates when the pharyngeal swallow is triggered, which is normally when the head of the bolus reaches any point from the anterior faucial arch to where the lower edge of the mandible crosses the base of tongue. Triggered from sensory input to CN IX (glossopharyngeal).
Oral Transit Time
Normal oral transit is 1 to 1.25 seconds for all consistencies of materials swallowed.
Oral Phase Disorder - Apraxia of Swallow, reduced oral sensation
Symptom: Delayed Oral Onset of Swallow - Some patients with severe neurological impairments exhibit significant delay in initiating oral swallow when given a swallow command. Often bolus held in mouth with no lingual movement – may indicate severe swallow apraxia, reduced oral sensation or lack of recognition of the bolus as something to be swallowed (oral tactile agnosia of food). Can increase sensory stim for these patients by increasing pressure of the spoon on tongue as bolus is presented, using a cold, larger, stronger tasting, or textured bolus, which may cause the oral swallow to begin. Some of these patients will not react to liquid of pureed material places in mouth, but will begin chewing in response to small piece of cookie and will begin oral swallow after chewing.
Oral Phase Disorder - Apraxia of Swallow
Symptom: Searching Tongue Movement – Often accompanies severe oral apraxia. Symptoms include searching movements with tongue, exhibiting good range of motion but inability to organize front-to-back lingual and bolus movement, or, in some cases, simply holding the bolus w/o initiating any oral activity. Increasing sensory stim as bolus is presented or giving bolus with more distinct temp, flavor or texture may facilitate more organized tongue movement during oral swallow. Presenting bolus to patient on a spoon and allowing the patient to place bolus in their own mouth may facilitate oral activity. Refrain from giving any commands to swallow, b/c apraxia is usually worse when the target activity becomes highly volitional.
Oral Phase Disorder – Tongue Thrust
Symptom: Tongue Moves Forward to Start Swallow – When bolus is on tongue, normally tongue tip remains anchored against alveolar ridge and initiates swallow by lifting the midline sequentially in an upward and backward direction against the palate. At times, neurological impairment can cause tongue to thrust forward toward central incisors, sometimes pushing food from the mouth. Usually preceded by an abnormal hold of bolus against the central incisors or inability to hold bolus at all (as seen in cerebral palsy)
Oral Phase Disorder - Reduced Labial Tension/Tone
Symptom: Residue in Anterior Sulcus – If bolus lodges in anterior sulcus during oral phases, symptom of reduced labial-buccal muscle tension or tone.
Oral Phase Disorder - Reduced Buccal Tension/Tone
Symptom: Residue in Lateral Sulcus – If food falls or lodges in lateral sulcus during initiation of the oral stage of swallow, indication of reduced muscle tension or tone in buccal musculature.
Oral Phase Disorder - Reduced Tongue Shaping or Failure of Peripheral Seal of Tongue to Anterior and Lateral Alveolus
Symptom: Residue on Floor of Mouth – If food falls on lateral floor of mouth during attempts at oral transit, indication of reduced ability to shape and coordinate the tongue around the bolus and/or maintain contact of the tongue tip and sides of the tongue to the alveolus as the bolus moves posteriorly. Common with surgically treated oral cancer patients.
Oral Phase Disorder - Tongue Scarring
Symptom: Residue in Midtongue Depression – When food tends to lodge in a depression in the tongue’s surface, usually indicates scar tissue in the tongue. Usually tight and relatively immobile so when patient attempts to swallow, normal tongue tissue surrounding the scare can elevate and move but the scar tissue can’t, forming a deep crevice into which food will fall. Greater the lingual struggle to swallow, the worse the effect of the scar tissue and the greater the amount of food that collects in the depression. Scar tissue usually the result of surgical treatment for oral cancer or some trauma to mouth (knife, gunshot wound, etc.)
Oral Phase Disorder - Reduced Tongue Range of Movement or Strength
Symptom: Residue of Food on Tongue – If tongue range of movement is poor, food may sit on tongue surface or the hard palate and remain there despite numerous attempts to initiate swallow. Usually occurs with food of thicker consistency, since liquids tend to splash around oral cavity and collect in crevices rather than on tongue itself. Any stasis or residue of food on the tongue is an indication of reduced tongue range of movement. If it increases as food becomes more viscous, indication of reduced tongue strength.
Oral Phase Disorder -Lingual Discoordination
Symptom: Disturbed Lingual Contraction (Peristalsis) – In normal swallowing, tongue tip and sides remain in contact with anterior and lateral alveolar ridge, while the front and center of the tongue envelope the bolus and elevate and squeeze or roll bolus along the hard palate until it reaches the back of the oral cavity or pharynx. Thus, midline of tongue is elevating sequentially while squeezing against the palate, which is done in a single organized action. If sequential squeezing is in any way disturbed (i.e. tongue moves in random, nonproductive motions), normal smooth anterior-posterior movement becomes disorganizes. Distinct from repetitive lingual rolling motion often seen in PD patients.
Oral Phase Disorder - Reduced Tongue Elevation
Symptom: Incomplete Tongue-Palate Contact – In normal initiation of swallow, sequential front-to-back tongue-palate contact is made as the bolus is moved backward. If tongue-palate contact is incomplete, its an indication of reduced range of vertical tongue motion, which may also result in disturbances in lingual contraction or struggling behavior of the tongue.
Oral Phase Disorder - reduced tongue elevation or strength
Symptom: Adherence (residue) of food on the hard palate –
Normally, as tongue propels bolus posteriorly, only minimal food residue remains on the oral structures. When food collects on the hard palate and remains there after swallowing, it is an indication of reduced tongue elevation. If increased amounts collect as more viscous food is presented, its an indication of reduced tongue strength because increased lingual pressure is needed to propel more viscous food cleanly through the oral cavity.
Oral Phase Disorder - Reduced Lingual Coordination
Symptom: Reduced Anterior-Posterior Tongue Movement – Normal lingual propulsion of the bolus involves smooth front-to-back action of the midline of the tongue with the sides and tip of the tongue maintaining contact with the lateral and anterior alveolar ridge. If this smooth front-to-back action is interrupted or broken into multiple small tongue movements in the presence of normal range of motion, it’s a symptom of reduced lingual coordination.
Oral Phase Disorder - Repetitive Lingual Rocking-Rolling Actions – Parkinson’s Disease
Repetitive Lingual Rocking-Rolling Actions – Parkinson’s Disease: In normal swallow, midline of tongue produces a single upward and backward motion, propelling bolus posteriorly. Patients with PD show a typical tongue movement pattern characterized by a repetitive upward and backward movement of the central portion of the tongue. The posterior tongue, however, fails to lower at the appropriate time so the bolus can move only to the region of the posterior hard palate before it rolls forward again. The front tongue activity then repeats itself in an attempt to reinitiate the swallow. This repetitive front to back rolling motion of the tongue often lasts 10 seconds or more before a full swallow is initiated in patients with PD.
Oral Phase Disorder - Reduced Tongue Control
Symptom: Uncontrolled Bolus/Premature Loss of Liquid or Pudding Consistency into the Pharynx –Uncontrolled bolus or premature loss of liquid or pudding into the pharynx indicates that, during the oral prep phase prior to initiation of the oral stage, part or all of the bolus has already fallen over the base of tongue, prematurely, into the pharynx. If soft palate/back of tongue seal fails, part or all of the bolus can be lost into the pharynx prematurely. Premature loss of chewed food is normal (b/c soft palate seal to the back of tongue is broken by active tongue movement) but premature loss of liquid or pudding is abnormal.
Oral Phase Disorder - Reduced Linguavelar Seal
When part of the liquid or pudding bolus falls into the pharynx prematurely, it may lodge in the valleculae or pyriform sinuses, or may fall into open airway (depends on amount and consistency of food, as well as posture). Uncontrolled bolus and premature loss indicate reduced lingual control during oral prep or oral phase of swallow. May result in aspiration before the swallow since part of the bolus is in the pharynx before the pharyngeal swallow is triggered and while airway is open. Entry of the material into the pharynx does not trigger a pharyngeal swallow. Until the tongue propels the remaining bolus to the point where a pharyngeal swallow would be triggered, no pharyngeal swallow is triggered. While still in the oral prep or oral phase of swallow, the voluntary motor action may override sensory input from the food in the pharynx.
Oral stage disorder - fear of swallowing
Symptom: Piecemeal Deglutition – Indicates that, rather than swallowing the bolus in a single cohesive mass, patient swallows only one portion or piece of the bolus at a time (thus requiring 2,3 or more repeated swallows to empty the oral cavity). May be normal if bolus was very large (20 – 30 ml) but in modified barium swallow patients given small amounts of food that should be cleared from the oral cavity in a single swallow. May indicate fear of swallowing, as the patient carefully meters out small amounts to be swallowed for fear of swallowing an entire bolus and aspirating.
Oral stage disorder - Delayed Oral Transit Time (in seconds)
Normal OTT should last no more than 1 to 1.5 seconds, increasing slightly as bolus viscosity increases. Also increases by approx. 0.25 seconds in adults over 60. Reason for an abnormally slowed oral transit time should be defined according to disorder observed in the oral phase of swallow. Slow oral transit time must be considered in combo with pharyngeal transit time to determine the full duration of the oropharyngeal swallow. Speed of swallow through oral and pharyngeal stages is one important factor in determining if patient is going to get sufficient nutrition and hydration through the mouth.
Disorders in Triggering the Pharyngeal Swallow - Delayed Pharyngeal Swallow
Delayed pharyngeal swallow occurs when the head of the bolus enters the pharynx and the pharyngeal swallow has not been triggered. The presence of the bolus head below the point where the tongue base crosses the lower edge of the mandible increases the risk of aspiration if the pharyngeal swallow has not been initiated.
Disorders in Triggering the Pharyngeal Swallow - Symptoms
Most patients with delayed triggering of the pharyngeal swallow complain of difficulty swallowing liquids. Liquids are usually swallowed in larger volumes (10 – 20 ml) and will splash into the pharynx rapidly. If the pharyngeal swallow has not been initiated as the liquid passes the tongue base, there is increased risk that the liquid will enter the open airway before the pharyngeal swallow has been activated.
Disorders in Triggering the Pharyngeal Swallow - Delayed triggering vs. premature bolus loss
During pharyngeal swallow delay, bolus may land in the piriform sinuses, valleculae, or the open airway. Where the bolus rests during the delay is a result of gravity, head posture and food consistency and is not the major symptom of a pharyngeal swallow delay. The critical symptom of delay is the location of the bolus head (i.e. it has progressed too far down into the pharynx before the pharyngeal swallow is activated. Bolus head must be differentiated from premature bolus loss. The bolus head is the leading edge of the main portion of the bolus, where premature loss occurs during the oral prep or oral stages as part of the bolus breaks away and falls over the tongue base. Premature bolus loss is not a delay in triggering the pharyngeal swallow.
Disorders in Triggering the Pharyngeal Swallow - Critical symptom
The critical symptom of delay is the location of the bolus head (i.e. it has progressed too far down into the pharynx before the pharyngeal swallow is activated.
Disorders in Triggering the Pharyngeal Swallow - Risk of aspiration
If bolus reaches pyriform sinuses before the pharyngeal swallow trigger there is increased risk of aspiration as the pharyngeal swallow is activated because the pyriform sinuses are significantly shortened as the pharynx and larynx elevate during the pharyngeal swallow. If the pyriform sinuses fill with food or liquid during the delay in triggering the pharyngeal swallow, as the pharynx and larynx initially elevate, the contents of the pyriform sinuses are at high risk of being dumped into the airway.
Disorders in Triggering the Pharyngeal Swallow - Chin Down Posture
When bolus falls to pyriform sinuses a chin-down posture may be less helpful, as it affects the anterior-posterior pharyngeal dimensions (narrows the laryngeal entrance and the distance between the epiglottis and pharyngeal wall and the tongue base and the pharyngeal wall. These changes occur above the level of the pyriform sinuses. Chin-down posture doesn’t change the degree of pharyngeal shortening that occurs during swallow or prevent the contents of the pyriform sinuses from emptying into the airway if the bolus reaches the pyriform sinuses.
Disorders in Triggering the Pharyngeal Swallow - Pharyngeal delay vs. cricopharyngeal disorder
Sometimes the swallow in which the bolus falls into the pyriform sinuses during pharyngeal delay is misdiagnosed as a cricopharyngeal disorder or “late opening” of the cricopharyngus. This is wrong, because the sphincter isn’t opening because the swallow center or central pattern generator in the brainstem (medulla) has not programmed it to open (entire pharyngeal swallow has not been triggered).
Disorders in Triggering the Pharyngeal Swallow - Duration of pharyngeal delay
Duration of pharyngeal delay should be noted in radiographic studies to serve as a baseline measure against which treatment effects can be defined. The delay is timed from the initial video frame showing the bolus head passing the point where the lower edge of the mandible crosses the tongue base until the first frame where the pharyngeal swallow is initiated (where laryngeal and hyoid elevation begin, as these are the first events in the pharyngeal swallow, they serve as a trigger of the pharyngeal swallow and are followed by activation of the pharyngeal swallow).
Disorders in Triggering the Pharyngeal Swallow - Struggle behavior associated with delay
During a pharyngeal swallow delay, many patients struggle to stimulate a swallow and in the struggle behavior move their tongue base forward and backward to lift the larynx up and down. These are not the same movements seen during the pharyngeal swallow. When timing the delay, the movements of the larynx up and down as the oral tongue and tongue base are moving to try to stimulate a swallow are not part of the pharyngeal swallow and should not be identified as such. It is easy to identify triggering of the pharyngeal swallow by watching the swallow as it progresses and reversing the videotape in slow motion until the larynx first comes back to rest. Any laryngeal movements prior to the actual pharyngeal swallow should be considered part of the delay.
Normal pharyngeal delay
Pharyngeal delay is minimal (0 to 0.2 seconds) in normal young adults and the pharyngeal swallow often triggers as the bolus head reaches the anterior faucial arch. In normals over 60, there is a prolongation of the delay by 0.4 to 0.5 seconds. Triggering usually occurs where the bolus head passes the point where the lower rim of the mandible and the tongue base cross.
Abnormal pharyngeal delay - adults
A delay of more than 2 seconds or a shorter delay where aspiration occurs is considered abnormal.
Abnormal pharyngeal delay - children
Pharyngeal triggering and delay time in infants and young children is different from adults b/c bolus may be collected in the valleculae before the pharyngeal swallow is triggered. In infant, abnormal delay is more that 1 second between the last tongue pump and the onset of the pharyngeal swallow, or aspiration occurring during bolus collection.
Pharyngeal Stage
Begins when the pharyngeal swallow is triggered as the bolus passes the anterior faucial arch or the back or base of tongue and continues until the bolus passes through the cricopharyngeal region (the UES). Normal pharyngeal transit time is a maximum of 1 seconds regardless of age or material swallowed. For small volume swallows, pharyngeal transit time is approximately 0.32 seconds and increases as volume increases.
Disorders in pharyngeal stage - Reduced Velopharyngeal Closure
Symptom: Nasal Penetration During Swallow – when VP closure is inadequate, material can backflow into nose during swallow. VP closure during swallow only lasts for a fraction of a second as the bolus passes the VP port. If nasal backflow occurs later in the swallow it may be a result of a dysfunction farther down in the pharynx. If bolus can’t pass through pharynx into esophagus, food (especially liquid) will often move back up as a result of any struggling action in the pharynx and at that moment the VP port is normally open, since VP closure is complete only as the bolus passes the nasopharynx. When a patient complains of nasal leakage of food, complete exam of the pharynx during swallow is warranted.
Disorders in pharyngeal stage - Pseudoepiglottis
After total laryngectomy some patients have a fold of mucosa at the base of the tongue which appears to be an epiglottis when viewed radiographically in the lateral plane. Can look benign when viewed anatomically at rest because it collapses against the base of tongue and leaves an open pharynx posteriorly. However, when patient attempts to swallow, whatever contraction occurs in the pharyngeal constrictors will pull the tissue fold posteriorly and narrow the pharynx so the patient can barely move any food past the pseudo epiglottis. Important to assess the effect of this tissue fold on swallow function physiologically during fluoroscopy rather than depending on anatomic only exam.
Disorders in pharyngeal stage - Cervical Osteophytes
Symptom: Bony Outgrowth from Cervical Vertebrae – At times they can be long enough to interfere with the swallow by narrowing the pharynx, or they may direct the bolus toward the airway entrance. Also may cause patients to have sensation of swallowing disorder (something there when they swallow). Should always scan cervical vertebrae for any abnormalities during radiographic study.
Disorders in pharyngeal stage - Unilateral Pharyngeal Wall Weakness
Symptom: Residue on One Side of the Pharynx and in Pyriform Sinus – If one side of the pharynx is weak, food tends to cling to that pharyngeal wall and collect in the pyriform sinus on that side. This is visible in the A-P view.
Disorders in pharyngeal stage - Reduced Pharyngeal Contraction Bilaterally
Symptom: Coating on the Pharyngeal Walls After the Swallow – After swallow in normals, only minimal or no residue of material is left in the pharynx. Older normal individuals exhibit only a slight increase in residue. Amount of coating varies some with the type of barium used. Some types of barium contrast agents cause a greater amount of pharyngeal coating than other types. In general if pharyngeal structures are merely lightly coated with barium after swallow, considered normal. If a significant amount of residual material is on the pharyngeal walls, as judged by the density of the material remaining, this is considered abnormal and a symptom of reduced pharyngeal contraction bilaterally. In normals, would dry swallow immediately after the food swallow to clear this residue. Important to watch for this or attempt at this to assess awareness of the residue. When a large amount of residue remains in the pharynx after swallow, patient is at risk for aspiration following the swallow if he inhales any of the residue.
Disorders in pharyngeal stage - Reduced tongue base posterior movement
Symptom: Vallecular residue after Swallow – When bolus tail reaches the tongue base and/or vallecular level during the normal swallow, tongue base moves posteriorly to contact the anteriorly bulging pharyngeal wall. Approximately 2/3 of the distance between the tongue base and posterior pharyngeal wall at rest is encompassed by the posterior tongue base movement and 1/3 by the anterior movement of the posterior pharyngeal wall. Clearance of the valleculae largely appears to be the result of the tongue base movement. When vallecular residue is noted, tongue base movement should be observed carefully to determine if it makes complete contact with the anterior bulging pharyngeal wall. If large amount of residue in the valleculae, patient may be at risk of aspirating some or all of the residue during respiration after the swallow. If patient is aware of residue, should attempt dry swallow in an attempt to clear it.
Disorders in pharyngeal stage - Scar tissue; Pharyngeal pouch
Symptom: Coating in a Depression on the Pharyngeal Wall – Collection of material in a depression on the pharyngeal wall may be an indication of the beginning of a pharyngeal pouch or scar tissue in the pharynx. If patient has a pharyngocutaneous fistula, the internal end of the fistula will often heal as a scar tissue depression which will collect material during and after the swallow. Patient is at risk for aspiration after the swallow (as with any large amount of pharyngeal residue).
Disorders in pharyngeal stage - Reduced Laryngeal Elevation
Symptom: Residue at top of airway - In normals, when pharyngeal swallow is triggered, larynx elevates and moves anteriorly to tuck itself under the base of tongue as a component of airway protection. During swallow, larynx elevates approximately 2 cm in normal young adult males. If laryngeal elevation during the swallow is mildly impaired, some residual material will remain on top of the larynx after the swallow. Pharyngeal contraction can’t completely clear material from the top of the airway when the larynx is in an abnormally lowered position, putting the patient at risk of aspiration of food sitting on top of the airway after swallow when they open the larynx to inhale after swallowing. As larynx elevates, arytenoids brought to a level where it is closer to the base of epiglottis and can tilt forward to contact the thickening base of the epiglottis and close the entrance to the airway. Therefore, moderately reduced laryngeal elevation can result in inability of the arytenoids to tilt anteriorly enough to make good contact with the epiglottic base, leaving the entrance to the airway slightly open and allowing penetration of the bolus into the airway entrance. If larynx doesn’t continue lifting to a normal degree and material has penetrated the airway entrance, the material will remain in the airway entrance and usually be aspirated after the swallow.
Disorders in pharyngeal stage - Compensation for reduced laryngeal elevation
Some patients can compensate for reduced laryngeal elevation by tilting the arytenoid more anteriorly than normal to close the airway entrance. Sometimes these patients begin arytenoid tilting before the swallow begins, thus closing the airway entrance preventively before and during the swallow. More often occurs with large volume swallows.
Disorders in pharyngeal stage - Reduced closure of the airway entrance (arytenoid to base of epiglottis and false vocal folds)
Symptom: Laryngeal penetration and Aspiration After the Swallow: Laryngeal penetration occurs when food or liquid enters the vestibule or entrance to the airway at any level but not below the superior surface of the true vocal folds. Aspiration involves entry of food into airway below the level of the true vocal folds. Both are symptoms of a variety of swallowing problems. Observation of either on an x-ray swallow should cause the clinician to identify the anatomic or physiologic cause.
Etiologies of Laryngeal Penetration
Can occur from a variety of etiologies. Bolus can penetrate to a variety of levels and may enter the airway at the level of the middle of the arytenoid cartilages, the level of the surface of the false vocal folds or the level of the true vocal folds. Penetration can occur if larynx lifts inadequately and thus leaves the airway entrance slightly open or if the arytenoids fail to tilt forward adequately to close off the entrance to the airway or if the larynx lifts too slow during the swallow. If the larynx lifts too slow but eventually lifts to its full range of motion, all of the penetrated material will usually be cleared from the airway entrance.
Etiologies of Laryngeal Penetration
In normals, when laryngeal penetration occurs, the material in the airway is squeezed out during the swallow as the larynx continues to lift and close inferiorly to superiorly. Penetration is a problem only when the larynx fails to lift adequately during the course of the swallow, and the penetrated material remains in the larynx after swallow and is then aspirated as the individual inhales following the swallow. Penetration may also occur if the bolus falls into the airway entrance before the pharyngeal swallow triggers; that is, penetration results from a delay in triggering the pharyngeal swallow. If the patient who has a delayed pharyngeal swallow has the vf’s closed during the delay, food or liquid may enter the airway entrance but not proceed further than the surface of the true vocal folds. When the pharyngeal swallow triggers and the larynx lifts and closes from the level of the true vf’s upward, this penetrated material is usually cleared efficiently from the airway.
Etiologies of Aspiration DURING swallow
Reduced laryngeal closure: During the pharyngeal phase, larynx closes at 3 levels: (1) the true vocal folds, (2) the arytenoid to base of epiglottis and false vocal folds (airway entrance) and (3) the aryepiglottic folds and epiglottis. The true vocal folds close as the larynx elevates about 50% of its full distance. If the larynx doesn’t close adequately from bottom to top during the swallow, material will enter the airway during the swallow. It will appear as if the larynx is offering no obstruction to the flow of material into the airway. This is the only etiology for aspiration during the swallow.
Disorders in pharyngeal stage - reduced anterior laryngeal motion; cricopharyngeal dysfunction; Stricture
Symptom: Residue (stasis) in both pyriform sinuses – Normally little or no residual material is in the pyriform sinuses after the swallow. When significant reside is in both, it is a symporm of reduced anterior laryngeal movement and/or cricopharyngeal dysfunction (UED valve dysfunction) or stricture at the level of the opening of the esophagus. All other aspects of the swallow, including the triggering of the pharyngeal swallow should be normal. If pharyngeal swallow hasn’t triggered, a cricopharyngeal disorder can’t be diagnosed.
Because anterior and vertical hyolaryngeal movement controls the cricopharyngeal opening and relaxation of the cricopharyngeal muscle is an enabling event, failure of this upper sphincter opening must be investigated further to determine which component is disordered. Usually, pharyngeal manometry must be combined with videofluoroscopy to assess these components.
Disorders in pharyngeal stage - generalized dysfunction in pharyngeal pressure generation during the swallow, not an isolated cricopharyngeal problem.
Symptom: Residue throughout the pharynx (valleculae, pharyngeal walls, in addition to residue in pyriform sinuses). Includes reduced posterior movement of the tongue base and reduced pharyngeal wall movement. Often, laryngeal elevation is also reduced.
Pharyngeal Transit Time (in seconds)
Normally it is less than 1 second regardless of patient age or food consistency. If slowed, must consider in combination with oral transit time to determine the full duration of the oropharyngeal swallow. The speed of the swallow through the oral and pharyngeal stages is one important factor in determining if a patient is going to get sufficient nutrition and hydration by mouth.
Cervical Esophageal Phase
Involves the initial peristaltic wave in the esophageal musculature. While the patient is being viewed radiographically in the lateral view, can observe this stage. If any question about the esophageal function and esophageal study (traditional barium swallow) should be done after the modified barium swallow is completed, or the patient should be referred to a gastroenterologist. In this way the patients ability to swallow without aspiration will have been established and the barium swallow can be performed safely. If patient can’t swallow safely w/o aspiration, esophageal exam can be postponed until the risk of aspiration is eliminated.
Treatment of Esophageal Phase
The esophageal stage can’t be modified in therapy, but postural changes are sometimes helpful. It is important that the swallowing clinician be aware of esophageal disorders because they can cause backflow of the material out of the esophagus into the pharynx, thus causing aspiration.
Disorders of Esophageal Phase - Esophageal-to-Pharyngeal Backflow
Sometimes observed on a modified barium swallow and is a symptom of a number of esophageal disorders, including achalasia or failure of the LES to relax, reflux, tumor, stenosis, etc. Backflow of material out of the esophagus into the pharynx requires UES opening to allow backflow to occur. Once material has come out of esophagus into pharynx it may overflow into the airway, causing aspiration and possibly symptoms of a pharyngeal swallowing disorder. One cause of backflow is gastroesophageal reflux. Patients with reflux my exhibit redness in the arytenoid area of the larynx on indirect laryngoscopy because the material overflowing into the airway contains stomach acid. They may also complain of burning sensation in pharynx and/or esophagus, or frequent gagging or coughing. Aspirated material that contains any gastric acid is more irritating to the lungs than aspirated saliva or food.
Disorders of Esophageal Phase - Tracheoesophageal Fistula
A fistula can develop in the soft tissue common wall between the trachea and esophagus. This fistula tract allows food entering the esophagus to flow back into the trachea. Patients with TE fistulae have symptoms similar to those of patients who aspirate after the swallow for other reasons (i.e. coughing after the swallow). May be referred to swallowing therapist for eval. Any time a patient with a hx of possible aspiration is referred for radiographic study and the modified barium results are normal, the radiographic study should be continued to evaluate the esophagus carefully to determine the presence or absence of a TE fistula. B/c fistula is usually located at the level of the 1st to 3rd thoracic vertebrae, the shoulders often shadow the radiographic image in the lateral plane. Patient shoulders should be turned diagonally while head and body remain in the lateral view. Swallows should be repeated with the patient in this position and the fluoroscopic tube lowered to the base of the cervical esophagus in order to visualize the fistula tract.
Disorders of Esophageal Phase - Zenker’s Diverticulum
A diverticulum is a side pocket that forms when pharyngeal or esophageal muscle herniates. Zenker’s diverticulum occurs in the area of the cricopharyngeal region or the UES. Theory of genesis is that a hypertonic cricopharyngueus muscle requires the patient to increase pharyngeal pressures to push food through the UES, causing the tissue to herniate over time. On x-ray, appears as a round balloon that fills with radiopaque material as the patient swallows. After swallow, it usually empties of material and material may fall into the airway, causing aspiration after the swallow.
Disorders of Esophageal Phase - Reflux of Gastroesophageal Reflux Disease (GERD)
Reflux means backflow of food or stomach acid from the stomach to the esophagus b/c of failure of the LES to keep food in the stomach. Not usually diagnosed in modified barium swallow b/c it isn’t viewing the LES. If reflux suspected, refer to gastroenterologist.
Treatment of Esophageal Phase Disorders
Generally, tx of esophageal disorders is surgical or medical. However, there are times when a postural technique may facilitate swallow, such as in a Zenker’s diverticulum when head rotation to one side of the other may close off the entry to the diverticulum.
Posterior-Anterior View
P-A radiographic view allows the clinician to examine the symmetry of structures and function in the oral cavity and pharynx during deglutition and in the larynx during phonation. In approx. 80% of normal individuals, the bolus divides fairly equally to pass down the two sides of the pharynx into the esophagus, the other 20% swallow unilaterally. The P-A plane also allows assessment of oral functions during mastication and preparation to swallow.
Posterior-Anterior View of Oral Prep Phase
Can examine (1) ability of the tongue to lateralize material and (2) pattern of jaw motion in crushing the food during mastication. Shape of the tongue in holding the bolus prior to initiation of the swallow in the oral cavity can also be assessed. Side of the tongue should be in contact with the lateral alveolus with a central groove down midline surrounding the bolus.
Posterior-Anterior View of Oral Prep Phase Disorders: reduced mandibular movement
Symptom: Unable to align teeth – Some patients, particularly those who have had surgery to the lower jaw, will have difficulty putting the mandible into proper occlusion for chewing. Indicates reduced mandibular range of motion and usually occurs when there has been removal of part of the mandible.
Posterior-Anterior View of Oral Prep Phase Disorders: reduced tongue lateralization
Symptom: Unable to lateralize material with the tongue – During chewing, tongue lateralized food or moves it to the side of the oral cavity, placing it on the teeth. If can’t lateralize food from the midline, indicates reduced range of tongue movement laterally.
Posterior-Anterior View of Oral Prep Phase Disorders: reduced tongue elevation
Symptom: Unable to mash materials – If patient can’t lateralize food to teeth for chewing, may be asked to compensate by vertically crushing the food between the tongue and palate. If patient unable to accomplish this mashing, its an indication of reduced range of tongue elevation to the hard palate.
Posterior-Anterior View of Oral Prep Phase Disorders: reduced buccal tension/tone
Symptom: Material falls into the lateral sulcus – If material falls into the lateral sulcus as the patient is chewing, indication of reduced facial-buccal muscle tension or tone (which closes the lateral sulcus and throws food medially to the tongue during mastication).
Posterior-Anterior View of Oral Prep Phase Disorders: reduced tongue control
Symptom: Material falls to the floor of mouth – Food falling onto the floor of mouth while patient is chewing is symptom of reduced tongue control, particularly in the seal of the lateral margins of the tongue to the lateral alveolus.
Posterior-Anterior View Oral Prep Phase Disorders: Reduced lingual shaping and fine tongue control
Symptom: Bolus Spread Across Mouth – When liquid or paste bolus is placed in the oral cavity, tongue normally shapes around the bolus to hold it in a cohesive ball. After chewing, tongue normally pulls the food together into a single bolus and shapes itself around the bolus so the sides of the tongue are sealed to the superior lateral alveolar ridge. If patient unable to shape his or her tongue around the bolus (i.e. to elevate one or both sides of the tongue or form a central groove to contain the food), it is an indication of reduced fine control of the tongue.
Pharyngeal Phase assessed in the P-A view
Provides info on the unilateral nature of any pharyngeal swallowing disorder.
Posterior-Anterior View Pharyngeal Phase Disorders: unilateral dysfunction in posterior movement of the tongue base
Symptom: Unilateral vallecular residue – When food left in the valleculae on only one side after the swallow, it indicates dysfunction of one side of the tongue base or the pharyngeal constructors. This residue, if a large amount, may be aspirated after the swallow.
Posterior-Anterior View Pharyngeal Phase Disorders: unilateral dysfunction of pharynx
Symptom: Residue in one pyriform sinus – Residue in only one pyriform sinus after the swallow indicates unilateral dysfunction of the pharyngeal walls, which may result from neurologic or structural damage. When large amount of residue remains in the pharynx after the swallow, patient is at risk for aspiration after the swallow should any of the residue be inhaled or fall into the airway.
Posterior-Anterior View Pharyngeal Phase Disorders: Reduced Vocal Fold Adduction
With patient’s head tilted back to get the mandible out of view, vocal fold adduction can be evaluated. Patient should be asked to repeat “ah, ah, ah” rapidly and when the vocal folds are identified the patient should inhale, prolong “ah” for several seconds, inhale, then prolong “ah” for several seconds. This will reveal vocal fold abduction and adduction and allow the clinician to assess the symmetry of vocal fold movement, particularly on adduction. Reduced movement of one vocal fold indicates reduced laryngeal adduction and a possible unilateral adductor vocal fold paresis or paralysis. This may be a cause of aspiration during the swallow b/c the larynx may be unable to protect the airway during the pharyngeal swallow.
Posterior-Anterior View Pharyngeal Phase Disorders: Unequal Height of Vocal Folds
Occasionally, in partially laryngectomized patients, reconstructed larynx on one side may be at a vertical position different from that of the vocal fold on the unoperated side. Thus, when patient attempts to close larynx to protect the airway during swallow, even if both sides move well, the 2 sides of the larynx will not meet each other and airway closure is incomplete. Cause of aspiration during the swallow, b/c larynx isn’t closed sufficiently to protect the airway.
Difficulty moving food from mouth to stomach. Recently expanded by some to include all of the behavioral, sensory, and preliminary motor acts in prep for the swallow, including cognitive awareness, visual recognition of food and all the physiologic responses to the smell and presence of food (e.g. increased salivation).
Swallowing disorders - prevalence and onset
Occur in all age groups, as a result of a variety of congenital abnormalities, structural damage and/or medical conditions.
a)Can be acute as result of CVA
b)May worsen slowly as a result of tumors of the pharynx or progressive neurologic disease.
c)Patients may be aware and able to describe problem in detail or completely oblivious. Patients able to describe oropharyngeal swallowing disorders are typically highly accurate in their localization and description of the problem. Patients with esophageal disorders typically highly inaccurate in this description.
i)Esophageal disorders may have symptoms at the level of the actual physiologic or anatomic disorder or above the level of the gastrointestinal tract. This occurs because the patient may perceive the food collecting above the dysfunctional region. Some patients with esophageal problems may exhibit pharyngeal symptoms.
Feeding Therapy
Feeding usually limited to placement of food in the mouth, the manipulation of food in the oral cavity prior to initiation of the swallow (including mastication) and the oral stage of the swallow when the bolus is propelled back by the tongue. Feeding therapy attempts to improve the positioning of food in the mouth, manipulating of food in the mouth with the tongue, chewing a bolus of varying consistencies, recollecting the bolus into a collective mass prior to initiation of the oral stage of swallow and organizing lingual action to propel the bolus posteriorly (thus feeding techniques deal with oral prep and oral stages of the swallow that terminate when the pharyngeal phase is triggered).
Swallowing Therapy
Refers to the entire act of deglutition from placement of food in the mouth through the oral, pharyngeal and esophageal stages of the swallow until the material enters the stomach through the gastroesophogeal junction/LES. In swallowing therapy, techniques to reduce any delay in triggering the pharyngeal swallow and improve the pharyngeal transit time and the individual neuromotor actions comprising the pharyngeal stage of swallow and techniques (mentioned under feeding) used to improve the oral prep and oral stage of swallow.
Signs and Symptoms of Dysphagia
Inability to recognize food, difficulty placing food in 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, recurring pneumonia, weight loss w/o reason, gurgly voice quality or increase in secretions in the pharynx or chest after a swallow or towards the end of a meal, complaints of swallowing difficulties.
Purpose of Screening
Identifying the patient at high risk for oropharyngeal dysphagia
Screening procedures
Provide info on the presence or absence of symptoms of dysphagia including aspiration, inefficient swallowing (such as residual food left in the mouth or pharynx) or behaviors such as gurgly voice or coughing while eating.
Diagnostic procedures
Provide physiologic data, such as identification and measurement of the duration of a delay in triggering the pharyngeal swallow, poor laryngeal elevation or anterior motion, poor tongue base posterior motion and so forth.
Job is to identify the symptoms and, from the symptoms, identify the underlying abnormalities in anatomy or physiology that cause the symptoms.
Symptoms observed in diagnostic
The following symptoms of oropharyngeal dysphagia are often observed during a diagnostic assessment:
a) Aspiration (entry of food or liquid into airway below the true vocal folds)
b) Penetration (entry of food or liquid into the larynx at some level down to but not below the true vocal folds)
c) Residue (food that is left behind in the mouth or pharynx after the swallow)
d) Backflow is backflow of food from the esophagus into the pharynx and/or from the pharynx into the nasal cavity.
Complications of Dysphagia
Pneumonia, malnutrition and dehydration may be symptoms and complications, resulting from unsafe swallowing which causes aspiration and the risk of pneumonia or inefficient swallowing which results in an insufficient amount of food or liquid reaching the stomach.
Restriction on eating foods of certain consistencies
Aspiration larger than 10% per bolus should place restriction on eating that type of consistency of food by mouth.
Nasogastric feedings
Patients who can not swallow any food consistency without approximately 10% aspiration require nasogastric feedings.
Silent Aspirators
Use of radiographic exam in addition to bedside exam will allow for identification of silent aspirators (those who aspirate food or liquid without any coughing or other visible or audible sign – about 50% of patients). Research has shown that clinicians fail to identify approximately 40% of patients who aspirate during a bedside exam.
Purposes of Radiographic eval
Identify the anatomic and physiologic causes of aspiration and thus is necessary to identify the presence of aspiration, define the etiology of aspiration, examine the immediate effects of selected treatment procedures and design appropriate therapy and determine the best method of nutritional intake (oral, nonoral, or combo).
Roof of mouth
Formed by the hard palate/maxilla, soft palate/velum and the uvula
Soft Palate movements during swallowing
May be pulled down and forward against the back of the tongue by the palatoglossus muscle in the anterior faucial arch or may be elevated and retracted to contribute to velopharyngeal closure by a combo of muscle pulls (including the palatopharyngeus in the posterior faucial arch, the levator palatal muscle and the fibers of the superior pharyngeal constrictor).
Floor of mouth
Formed by mylohyoid, geniohyoid and anterior belly of digastric, all of which attach to the body of the mandible anteriorly and the body of the hyoid bone posteriorly.
Oral Tongue
Tip, blade, front, center and back (see fig. 2.5). Oral tongue ends at the circumvallate papillae. Active during speech and the oral stages of swallow. Under cortical control/voluntary neural control. Innervated by CN 12, the hypoglossal nerve.
Tongue Base
Begins at the circumvallate papillae and extends to the hyoid bone. Active during the pharyngeal stage of swallowing, is under control of brainstem/involuntary neural control coordinated in the medullary swallow center. Can be placed under some degree of voluntary control. Innervated by CN 10, the vagus nerve.
Palatine tonsils
Between the anterior and posterior faucial arches(easily viewed during an oral exam)
The spaces formed between the alveolus and cheek or lip muscles both superiorly and inferiorly. Sulci are between the lips and the maxilla and mandible and between the cheeks and maxilla and mandible (see figure 2.3, p. 15).
Salivary glands
3 large glands on each side - Parotid, submandibular and sublingual . Produce thick, viscid, mucous like fluid as well as a thin, serous, watery fluid (this type produced by the parotid gland, all other glands produce both types – submandibular typically more of the serous fluid and sublingual typically more of the mucous.
Serves to maintain oral moisture and reduce tooth decay, assists in digestion and is a natural neutralizer of stomach acid that may reflux in the esophagus.
Pharynx – pharyngeal structures involved in deglutition
The 3 pharyngeal constrictors (superior, medial and inferior) which form the posterior and lateral pharyngeal walls. Fibers comprising these muscles arise from the median raphe and run laterally to attach to bony and soft tissue structures, including the sphenoid bone, soft palate, base of tongue, mandible, hyoid bone, thyroid and cricoid cartilages – all of these structures form the anterior wall of the pharynx.
Pharynx - glossopharyngeus muscle
Inferior fibers of the superior constrictor that attach to the tongue base are known as the glossopharyngeus muscle, which is most likely responsible for tongue base retraction and simultaneous anterior bulging of the posterior pharyngeal wall at the tongue base level.
Pyriform sinuses (pharyngeal structures)
Spaces formed between the fibers of the inferior constrictor and the sides of the thyroid cartilage that the inferior constrictors attach to. They end inferiorly at the cricopharyngeal muscle, which is the most inferior structure of the pharynx.
Cricopharyngeal muscle
The most inferior structure of the pharynx. Cricopharyngeal muscle fibers attach to the posterolateral surface of the cricoid lamina. They prevent air from entering the esophagus during respiration. During sleep the muscle loses tonic contraction.
The cricoid lamina and cricopharyngeal muscle fibers. Secondary to preventing air from entering the espophagus during respiration, the UES reduces the risk of material backflowing from the esophagus and into the pharynx. The UES is a 2 to 4 cm zone of elevated pressure capable of withstanding pressure of up to 11 cm of water in the esophagus. Has the greatest pressure immediately prior to swallowing and during inspiration. The increase in pressure during inhalation ensures that no air is pulled into the esophagus. At the appropriate moment during swallowing, the UES opens to allow the bolus to pass into the esophagus.
A collapsed muscular tube about 23 to 25 cm long with a valve at each end – the UES at the top and the LES at the bottom. This is in contrast to the pharynx, which is a part of the upper airway and is an open cavity except during the moment of the pharyngeal swallow when the larynx closes. Esophagus passes through the neck (sits behind the trachea), chest, then the diaphragm to attach to the stomach.
Marks the boundary between the esophagus and the stomach, with the primary purpose of keeping food and secretions, including stomach acid, in the stomach.
Duspends from the hyoid bone by the thyrohyoid ligament and thyrohyoid muscle. Thus, when the hyoid elevates and moves forward the larynx will move up and forward unless it is stabilized by other muscles.
Epiglottis and larynx
Top-most structure of the larynx is the epiglottis. Top 1/3 to ½ of the epiglottis rests against the base of the tongue and attaches to the hyoid bone by a ligament (hyoepiglottic ligament). The base of the epiglottis is attached by ligament to the thyroid notch.
The wedge shape formed between the base of the tongue and the epiglottis. It is subdivided by the hyoepiglottic ligament so that on an anterior-posterior radiographic view, it appears “scallop shaped”. The valleculae and the two pyriform sinuses are known as the pharyngeal recesses or side pockets, into which food may fall and reside before or after the pharyngeal swallow triggers.
Lingual tonsils
Take up a small amount of the valleculae space and lay against the base of the tongue.
Laryngeal vestibule/additus
Opening of the larynx – bounded by the epiglottis, aryepiglottic folds and arytenoid cartilage and ends at the superior surface of the false vocal folds.
Aryepiglottic folds
Intrinsic laryngeal structure. Contain the aryepiglottic muscle, quadrangular membrane and cuneiform cartilages. Attached to the lateral margins of the epiglottis and run laterally, posteriorly and inferiorly to surround the arytenoid cartilages. Form the lateral walls of the laryngeal vestibule.
Arytenoids (intrinsic laryngeal structures)
On the rim of the cricoid posteriorly. Muscular pull on the arytenoids controls movement of the true vocal folds.
Anterior Tilting of Arytenoids
The 2 arytenoids also tilt anteriorly during swallowing, which is thought to result from the pull of the thyroarytenoid muscle fibers. The anterior tilting contributes to the closure of the airway entrance.
Lateral cricoarytenoid muscle
Attaches from the top of the cricoid cartilage at the side to the muscular process of the arytenoid and the interarytenoid muscles (attaching between the 2 arytenoid cartilages) adduct the arytenoids and close the true vocal folds across the top of the airway.
Posterior cricoarytenoid muscle
Attaches from the posterior surface of the cricoid lamina to the muscular processes of the arytenoid, which opens/abducts the arytenoids and the true vocal folds for respiration.
False Vocal Folds
The aryepiglottic folds end inferiorly in the false vocal folds. The false vocal folds are 2 shelves of muscle and connective tissue running anteriorly and posteriorly immediately above the level of the true vocal folds. They are superior but parallel to the true vocal folds. They form shelves of soft tissue projecting from the sides of the larynx anteriorly to posteriorly (as do the true vocal folds).
Laryngeal ventricle
The space that is formed between the false and true vocal folds.
True Vocal Folds
Composed of the vocalis and thyroarytenoid muscle and are attached from the vocal processes of the arytenoids posteriorly to the inside surface of the thyroid lamina laterally and to the thyroid notch anteriorly. They form two more shelves of soft tissue that, when adducted or closed, project into the airway and effectively close the larynx. The true vocal folds are the last level of airway protection before entering the trachea.
Last level of airway protection before entering the trachea.
True vocal folds
3 levels of sphincters in the larynx
Formed by the epiglottis, aryepiglottic folds, arytenoids, base of the epiglottis, false vocal folds and true vocal folds. Capable of completely closing the larynx from the pharynx and preventing penetration of food or liquid during swallowing
Mean deglutition frequency
580 swallows/day
Swallow of saliva in the pharynx
Usually doesn’t include any oral prep or oral stage.
Oral Prep Phase
When food is manipulated in the mouth and masticated if needed, reducing it to a consistency ready for swallow. When placed in the mouth, a liquid bolus has a certain degree of cohesiveness that may be maintained as the bolus is held between the tongue and the anterior hard palate in preparation for the pharyngeal swallow. The tongue cups around the liquid bolus. With food, it may be held between the midline of the tongue and the hard palate with the tongue tip elevated and contacting the alveolar ridge or on the floor of the mouth in front of the tongue (tippers vs. dippers).
Mastication in the oral prep phase
Rotary lateral movement of the mandible and tongue. The tongue positions material on the teeth, the upper and lower teeth meet and crush the material, then the food falls medially toward the tongue, which moves the material back onto teeth as the mandible opens. This cycle occurs many times before a bolus is formed and the oral phase initiated. In addition to the cyclic movement during mastication, the tongue mixes food with saliva. Lots of sensory feedback involved here – sensing the food, positioning the bolus on the teeth, preventing injury to the tongue during chewing. After chewing, the tongue pulls food into a bolus before the oral stage is initiated. During active chewing, the soft palate is not pulled down and forward, making premature spillage normal and common (not normal with liquids or pudding type pastes).
Larynx and Pharynx during oral prep stage
Larynx and pharynx are at rest during the oral prep stage, airway is open and nasal breathing continues. Thus, if part of the bolus trickles into the pharynx, it can fall into the open airway. In this case the pharyngeal stage of swallow doesn’t trigger and it falls into the larynx.
Oral Phase
When tongue propels food posteriorly until the pharyngeal swallow is triggered. Initiated when tongue begins posterior movement of the bolus. If held in dipper position, tongue tip moves forward and lifts bolus onto tongue into the tipper position.
Oral Phase Tongue Movement
Tongue movement during this phase has been described as a stripping action, with the midline of the tongue sequentially squeezing the bolus posteriorly against the hard palate. Can also be described 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 and tip remain firmly anchored against the alveolar ridge and a central groove is formed in the tongue, acting as a ramp or chute for food to pass through as it passes posteriorly.
Increased viscosity and oral stage
As food viscosity thickens, pressure of the oral tongue against the palate increases requiring greater muscle activity as thicker foods require more pressure to propel them cleanly and efficiently through the oral cavity and pharynx. Negative pressure is also created by slight inward movement and increased tension of the buccal muscles in propelling the bolus back.
Pharyngeal Phase
When pharyngeal swallow is triggered and bolus is moved through the pharynx.
Physiological activities resulting from pharyngeal triggering
Elevation and retraction of the velum and complete closure of the vp port to prevent material from entering the nasal cavity; elevation and anterior movement of the hyoid and larynx; closure of the larynx at all 3 sphincters (true vf, laryngeal entrance [i.e. false vf, anteriorly tilting arytenoids and thickening of the epilottic base as the larynx elevates], and the epiglottis) to prevent material from entering the airway; opening of the cricopharyngeal sphincter to allow material to pass from the pharynx into the esophagus; ramping of the base of the tongue to deliver the bolus to the pharynx followed by tongue base retraction to contact the anteriorly bulging posterior pharyngeal wall; and progressive top to bottom contraction in the pharyngeal constrictors.
Closure of the larynx
Begins at the level of the vocal folds and progresses up the laryngeal vestibule. Closure is effected from below upwards, with the content of the laryngeal vestibule being expressed into the pharynx. This clears any penetration (entry of food, liquid, etc. into the airway at the level of the top surface of the true vf’s). During closure of the airway at the vestibule there is a downward, forward, and inward rocking movement of the arytenoid cartilages which narrow the laryngeal airway. At the same time, the larynx is elevated and pulled forward. The elevation thickens the base of the epiglottis and assists with closure of the laryngeal vestibule. In normal adults the airway is closed for approximately 1/3 to 2/3 of a second during single swallows and 5 seconds or more during sequential cup drinking. VF closure occurs when the larynx has elevated to approximately 50% of its maximum elevation.
Cricopharyngeal opening
Occurs by a complex series of actions. First, tension in the cricopharyngeal muscular portion of the sphincter is released. Approx. 0.1 second later, laryngeal anterior superior motion is seen to begin to open the sphincter; thus, the sphincter is yanked open by the motion of the larynx resulting from the upward and forward pull of the floor of the mouth muscles. The head of the bolus reaches the sphincter as it opens and the pressure w/in the bolus widens the opening. As the bolus passes through, the larynx lowers and the cricopharyngeus muscle returns to some level of contraction.
Lack of pharyngeal swallow triggering
If the oral tongue propels the bolus posteriorly and no pharyngeal swallow is triggered, the bolus will likely be propelled by the tongue into the pharynx where it may rest in the valleculae or pyriform sinuses. Liquids may splash into the pharynx and open airway. No pharyngeal swallow actions occur until the pharyngeal swallow is triggered, so the bolus may rest in the valleculae until the trigger or, depending on consistency, may drain from the valleculae down the aryepiglottic folds into the pyriform sinuses or airway. It may or may not be expectorated from the airway, depending on the sensitivity of the larynx and trachea.
Esophageal phase
When esophageal peristalsis carries the bolus through the cervical and thoracic esophagus and into the stomach. Esophageal transit time is from the point where the bolus enters the esophagus at the cricopharyngeal juncture/UES until it passes into the stomach at the gastroesophageal juncture/LES. Normal transit time varies from 8 to 20 seconds. The peristaltic wave begins at the top of the esophagus and pushes the bolus ahead of it and continues in sequential fashion through the esophagus until the LES opens to allow the bolus to enter the stomach.
Velopharyngeal Closure
Varies from person to person, may involve some elements of elevation and retraction of the soft palate, inward movement of posterior and/or lateral pharyngeal walls and anteriorly bulging adenoid pad. VP closure enables the buildup of pressure in the pharynx. Functional swallowing is possible without VP closure if all other physiologic aspects of the pharyngeal swallow are normal, particularly the tongue base and pharyngeal wall movement and contact.
Elevation and Anterior Movement of the Hyoid and Larynx
During swallow the larynx and hyoid bone elevate and move anteriorly by the pull of the floor of mouth muscles (anterior belly of digastric, mylohyoid and geniohyoid) and laryngeal elevator (thyrohyoid). The elevation contributes to the closing of the airway entrance and the forward movement contributes to the opening of the UES.
The UES region is a musculoskeletal valve made up of the cricopharyngeus muscle and the cricoid cartilage.
The LES is a muscular sphincter that relaxes to open and contracts to close. It is designed to keep food and stomach acid in the stomach to prevent reflux of backflow of food from the stomach into the esophagus.
Pharyngeal swallow in the infant
Similar to that of adults with two exceptions: laryngeal elevation is much reduced since the larynx is anatomically elevated under the tongue base and doesn’t need to move upward. Also, the posterior pharyngeal wall is often seen to move much further anteriorly.
Changes in oropharyngeal swallow physiology noted in normals over 60
They tend to more frequently hold the bolus on the floor of mouth and pick it up with the tongue tip as the oral stage of swallow is initiated (i.e. dipper swallow). The oral stage of swallowing is slightly longer as is the normal delay in triggering the pharyngeal swallow. Very small increase in the frequency and extent of oral or pharyngeal residue. Penetration of material into the laryngeal vestibule is reported as increasing in frequency with age, but no increase in aspiration in normal adults. Esophageal function deteriorates more significantly with age so that esophageal transit and clearance are slower and less efficient.
Excess laryngeal and hyoid movement(the difference between necessary movement and actual motion).
Reduction in reserve with age
Reduction in reserve and flexibility in neuromuscular control has been found to characterize normal aging of the motor system. These characteristics put the older people at increased risk for developing swallowing problems if they become physically weak.
Apneic Period
During swallow, the airway closes for a fraction of a second and there is no respiration. The apneic period usually corresponds to the closure of the airway during the pharyngeal stage of swallowing and the cessation of chest wall movement. The duration of airway closure increases as bolus volume increases.
Small vs. Large volume swallows
A small volume (1 – 3 ml) swallow is characterized by an oral phase followed by a pharyngeal swallow triggering, the pharyngeal phase and then the esophageal phase. A large volume swallow (10 – 20 ml) is typically characterized by simultaneous oral and pharyngeal activity.
Cup Drinking
If sequential, it has early airway closure and some pre-elevation of the larynx as the cup is approaching the lips with airway closure extending across all of the sequential swallow. Duration of airway closure on cup drinking may last from 5 – 10 seconds depending on the number of consecutive swallows produced.
Straw Drinking
Bolus is brought into the mouth via suction created in the oral cavity. To create the suction, soft palate is lowered against the back of the tongue and the muscles of the cheek and face contract and create suction intraorally to bring material into the mouth. When material has reached the mouth, suction is discontinued and the soft palate elevates as the oral stage of swallow is initiated by the tongue. Thus, straw drinking simply modifies food placement into the mouth. If straw drinking on inhalation (dangerous) will see suction timed with inhalation.
Chug without swallowing. Pull larynx forward which opens the UES volitionally, hold breath to close airway at the larynx and literally dump material through the oral cavity and pharynx by gravity into the esophagus and stomach.
Components of all swallows
Components that must be present are (1) oral propulsion of the bolus into the pharynx; (2) airway closure; (3) UES opening; (4) tongue base-pharyngeal wall propulsion to carry the bolus through the pharynx and into esophagus.