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61 Cards in this Set
- Front
- Back
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How often does the average person swallow?
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>1000x/day
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What purposes does swallowing serve?
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-eating
-drinking -train mucus and saliva |
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What are the structures used in swallowing?
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-nose, hard & soft palates, lips, tongue, teeth, salivary glands, pharynx, esophagus
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What are the four phases of swallowing?
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-Oral preparatory phase
-Oral phase -Pharyngeal phase -Esophageal phase |
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Describe the Oral Prep. phase of swallow
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-voluntary
-mechanical (chewing, mix with saliva) -bolus in front, tongue keeps it against hard palate -airway open, nasal breathing -lips closed, cheeks tense -timing duration is variable |
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Describe the Oral Phase of swallow
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-voluntary until VERY end
-tongue tip on alveolar ridge -inspiration inhibited -bolus is moved to back of mouth by ant-->post rolling motion of tongue -swallow reflex triggered at end -lasts 1 sec. |
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Which phases of swallowing can we teach the most compensatory strategies for?
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-Oral Prep
-Oral |
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Describe the pharyngeal phase of swallow
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-begins as bolus is forced into the pharynx
-involuntary -airway must close to prevent aspiration -many simultaneous actions: velum raised, tongue retracts, pharynx narrows, paristalsis occurs -most critical stage of the swallow |
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What actions are taken to protect the airway during the pharyngeal stage of swallow?
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-larynx and hyoid pulled up and forward
-true and false VFs close -epiglottis drops over larynx |
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Describe the esophageal phase of swallowing
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-involuntary
-bolus is moved down esophagus via parastaltic waves -larynx lowers to normal position -respiration resumes -8-20 secs long |
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Describe the importance of interneurons in swallowing
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-responsible for the programming and coordination of the swallow sequence
-coordinate swallow with airway reflexes |
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Describe the VSG interneurons
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-ventral (just above nuc. ambig.)
-controls oropharynx -receives sensory info and cortical info -also involved in pre-swallow/swallow initiaion -activated by the DSG, then activates motor control (ipsilateral) -monitors neural firing pattern |
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Describe the DSG interneurons
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-dorsal (nuc. tractus solitarus)
-involved in triggering, shaping, and timing of swallow -activates the VSG |
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Describe the purpose of saliva
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-mixes with bolus to provide lubrication in swallow
-dilutes food/drink -maintains healthy oral tissue (manages bacteria, pH balance) |
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Describe the contents of saliva
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enzymes: digest starches
mucus: lubricates -produce about 1.5 liters each day |
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Describe the Central Pattern Generator
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-afferent input: get info from periph. sensory mech.
-efferent output: sends info to muscles of pharynx from central pattern generator -interneuronal network: interneurons responsible for swallowing motor program -located in reticular formation |
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What purpose do the cranial nerves (in general) serve in swallowing?
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-excitatory and inhibitory signals to muscles of oropharynx
-receive periph/sensory info -modify swallow sequence -profide feedback to phar. muscles/mucosa |
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Which cranial nerves are involved in the afferent componant of the CPG?
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V
IX X |
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Which cranial nerves are involed in the efferent component of the CPG?
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XII
X |
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What is the purpose of the hypoglossal nucleus in swallowing?
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-arranged // to the tongue muscles innervated by hypoglossal nerve
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What is the role of the nuc. ambig. in swallowing?
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-Rostral: motor to esophagus, pharynx, larynx
-Caudal: motor to larynx and pharynx -Intermediate: neurons of pharynx and soft palate -->separation allows for adjustments to swallow to be made (sequence, not all one action!) |
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Describe the neural receptors responsible for stimulating swallow (location, innervation)
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-located in oropharynx
-stimulated by bolus moving backward in oral cavity -innervated by IX (keeps swallow going) and SLN of X (initiating swallow) |
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What is the purpose of the nucleus tractus solitaries in the pharyngeal phase of swallow
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-contains all afferent fibers for initiation and facilitation of swallow
-connected to SLN of X |
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What can affect the swallow motor sequence in the pharyngeal stage?
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-sensory (afferent) info (texture, consistency of bolus, etc)
-peripheral feedback -->influences neurons in CPG |
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What are some of the etiologies of dysphagia?
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-neurologic disease
-surgeries -cervical osteophytes -decrease in saliva production (meds, etc) |
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What are some of the neurologic diseases/causes of dysphagia?
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-PD
-Huntington Dis. -ALS -MS -Strokes, TBI |
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What are some sureries which may results in a dysphagia?
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-tumor removal near swallowing centers
-cranial nerve surgery -BS surgery -heart surgery (RLN of X) |
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Describe cervical osteophytes and how they impact swallowing
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-bony growths on the front of the spine
-may push against the back of throat and make swallowing difficult -removed surgically |
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How can medications impact swallowing?
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-impacts on the parasympathetic nervous system (responsible for saliva production-->increase or decrease it)
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What are the effects of dry mouth on swallow?
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-loss of apetite (inc. risk of malnutrition)
-inc. risk of mucosal irritation -denture misalignment -dental caries -inc. risk of respiratory infection (more bacteria in mouth) |
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What is the sympathetic nervous system/purpose?
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-originates in the spinal cord
-projects to a muscle or gland -uses ACH and norepinepherine as neurotransmitters -"fight or flight" |
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What is the parasympathetic nervous system/purpose?
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-originate in the spinal cord and medulla
-CN III, VII, and X -projects to ganglia very close to target organ -uses ACH as neurotransmitter -"rest and digest" |
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How do the following drugs affect swallowing?
--anticholinergics? --antihistamines? --dopaminergics? --antipsychotics? |
-ACh: inhibit nerve impulses responsible for invol. movements of smooth muscle
-antihist: dry mouth -dopa: dry mouth, dyskinesias -psych: dry mouth, dyskinesia |
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What is a pharyngeal diverticulum?
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a process or sac-like nerniation of the mucosal layer through the wall of the pharynx
-develops from irritation of the mucosa -may get infected if food/bacteria builds up inside -require surgical removal |
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How can radiation tx cause dyphagia?
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radiation burns tissue, causes fibrosis
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What are two major red flags that a dysphagia may be occurring (in a pt. who is otherwise not complaining of hallmark symptoms)
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-weight loss (might be scared to eat, having trouble swallowing)
-aspiration (NOT a normal part of aging!) |
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What are some important aspects of client hx to collect in evaluating swallow function?
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-coughing/choking at meal time?
-need for abdominal thrust? -inc. throat clearing? -sensation of something in throat? -wet/hoarse voice? Details: when symps occur? where in throat? liquids, solids? gradual/acute onset? |
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What would suspect if the client has problems swallowing...
...solids? ...liquids? ....both? |
s: narrowing/constriction of pharynx
l: VF paralysis/weakness b: neurologic disease |
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What would you suspect if the client's dysphagia had a ___ onset?
-sudden? -gradual? |
sudden: due to trauma
gradual: due to progressive disorder/disease |
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What is GERD, and how does it affect the swallow mech?
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-Gastroesophogeal Reflux Disease
-chronic irritation, feels like something in throat -hx of GERD can lead to poor relaxation of esoph. sphincter (solid food dysphagia, diverticuli, aspiration of stomach contents) |
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What is the idea placement of the pt. when conducting a swallowing exam?
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-upright, with feet on solid surface
-eye level (or slightly higher) with clinician |
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What are some general observable characteristics to note in a swallowing exam?
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-symmetry and sensation on face
-obstruction of nares -strength and sensation of lips -jaw opening/closing, dentition, and mucous membrane of mouth -mobility, strength, and abnormalities (tremor, fassics) of tongue -soft palate elevation ("ah") -any saliva pooling in pharynx |
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How do you position a client to view the hypopharynx?
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-head tilted backward
-protrude (or pull out) tongue -mirror placed to view larynx and base of tongue -have pt. say "ee ee" to elevate larynx |
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How does videoflurospopy help evaluation swallowing problems?
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-identify elements of swallow mech. that may have been compromised after surgery
-view timing of bolus transit -view swallowing gestures -movement of structures in swallow -aspiration |
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What is the goal of head and neck cancer surgery? What variables affect the tx of cancer?
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-remove tumor and leave "clear margins" of healthy tissue
-tumor size/location and involvement of other structures affect surgery |
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When should pts be eval'd for dysphagia, re: cancer surgery?
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-evaluate at various points post-op, as skills will change and evolve and needs will change (re: care and rehabilitation)
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What are some effects of head and neck cancer surgery?
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-loss of tissue
-defective structures -can be difficult to predict swallow functionality -reconstruction techniques affect the character and severity of resulting dysphagia |
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What are some of the possible effects of oral cavity surgery?
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-microstomisa (sm. oral cavity) can result if (parts of) lips are removed
-changes in lip sensation -can remove up to 1/2 the lower lip w/o serious functional consequences -may have nerve damage affecting lip functionality |
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What are some possible side effects of surgery of cancer of floor of the mouth?
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-issues with hyoid elevation /tongue stabilization
-difficulty with bolus movement/prep (loss of overall tongue mobility) -may lose tongue bulk |
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What are some problems with reconstruction surgery of the floor of the mouth (re: swallowing)?
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-tongue must be able to contact hte post. pharyngeal wall to manipulate bolus
-loss of tongue bulk may affect bolus manipulation -pt. may need to eat in smaller bites or position food on one side |
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What are some of the effects of loss of tongue bulk on swallow?
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-impede movement of the bolus
-anterior: probs with bolus manipulation, bolus formation, propelling bolus back (needs to contact hard palate) -posterior: affects pharyngeal phase (lack strength to propel bolus into upper esophagus |
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What factors need to be considered in reconstructing the tongue?
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-mobility!
-bulk! -->both affect the swallow! Try to preserve where possible! |
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How does mandible removal affect the swallow?
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-alveolar nerves run through mandible, may be affected
--loss of sensation to ipsi. teeth and lower lip -loss of chin shape -hyoid may not elevate (poor phargyngoesophageal opening) |
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What can occur with cancer of the palates?
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-result in oral nasal fistula
-enlarges the oral cavity -opening between oral/nasal cavity: bolus can enter nose, bolus manipulation is difficult, propelling bolus into pharynx difficult |
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How might pharyngeal cancer affect the pharyngeal phase of swallow?
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-weakness of pharyngeal peristalsis
--lack of pressure needed to propel the bolus --difficulty clearing bolus from pharyngeal cavity |
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What problems can occur with reconstruction of the pharynx?
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-may tether pharynx to other part sof throat (SEVERE dysphagia!)
-best if pharynx can remain a separate structure |
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What is the purpose of a supraglottic larygectomy?
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-removes cancers of epilogttis or false VFs
-usually includes removal of hyoid bone, laryngeal ventricles -airway protection severely compromised (rely only on true VFs) -swallow training required |
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What structures remain with a partial laryngectomy?
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-reconstruct a voicing source using residual tissues after cancerous portions are removed
-no need for stoma -might use false VFs to create speech |
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What are the consequences of a total largyngectomy on swallow?
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-must rely on base of tongue puching against pharyngeal wall to move bolus
-pumping action of tongue required to open the pharyngoesophageal sphincter (no longer opens, larynx cannot elevate) |
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What are the effects of cancer of the base of the skull on swallow?
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-loss of cranial nerve function
-affects bolus prep and movement -effects are dependent on which CNs are affected |
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What is xerostomia
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dry mouth
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