Dysphagia Quiz 1

Front 1

Definition of Swallowing

Back 1

*The semiatomatic motor action of the muscles of the respiratory and gastrointestinal tracts that propels food and liquids from the oral cavity into the stomach.
*Results not only in transporting food to the stomach, but clears the mouth and pharynx of secretions, mucus, and regurgitated stomach contents
*Swallowing is nutritive, but also protects lower airways.

Front 2

Anatomy Involved in Swallowing

Back 2

*Coordination of 31 muscles, 6 cranial nerves, multiple levels of CNS including the brainstem and cerebral cortex. (If there is a lesion, it can confuse swallowing coordination)

Front 3

Frequency of Swallowing

Back 3

*Varies with activity: greatest during eating, least during sleeping (up to 20 minutes)
*580 swallows a day (adults)
*Respiration always stops during swallowing (impossible to do both, saliva accumulates if there is no swallow)

Front 4

Dysphagia

Back 4

*Difficulty moving food from mouth to stomach (breakdown anywhere from mouth to stomach)
*All behavioral, sensory, & preliminary motor acts in prep for the swallow, including cog. awareness of the eating situation, visual recognition of food and physiologic responses to smell and presence of food (even bringing food to mouth-apraxia).

Front 5

Populations at Risk of Dysphagia

Back 5

*CVA (stroke)
*head/neck cancer
*dementia
*neurogenic diseases/conditions (ALS, MS, CP, Parkinsons)
*cleft lip/palate
*developmental disabilities *premature infants
*scleroderma (autoimmune, affects jaw motion and digestive tissues)

Front 6

Signs/Symptoms of Dysphagia

Back 6

* Inability to recognize food
*Difficulty placing food in the mouth
*Inability to control food or saliva
*Unintentional weightloss
*Wet, gurgly voice quality
*Increased pharyngeal/chest secretions after a meal
*Regurgitation (food doesn't make it to the stomach and comes back up. not vomit, which goes to stomach)
*Sensation of food sticking
*Cough, before, during or after swallow
*Frequent cough toward end of meal or after a meal
*Recurrent pneumonia (big red flag)
*Heartburn
*Failure to gain weight or develop on expected trajectory (infants-big red flag)

Front 7

How Patients are ID'd for Swallowing Evaluation

Back 7

*Self
*Family member
*Screening tool
*Patient pathways (esp. stroke)
*Medical Staff (nurses, doctors, dietitions)

Front 8

Dysphagia Screening

Back 8

*Quick way to ID patient who needs a full swallow eval
*Look for signs/symptoms that a patient is at risk
*Merely identifies presence/ absence of risk or symptoms
*SLP's don't screen (anyone can do), they evaluate (because you can't bill for evaluation)

Front 9

Complications of Dysphagia

Back 9

*Pneumonia
*Failure to thrive
*Dehydration
*Malnutrition
*Weightloss
*Secondary infection (result of poor nutrition)
*Airway obstruction
*Death

Front 10

Dysphagia Team

Back 10

*SLP (needs doc to refer patient, patient cannot refer themselves)
*MD
*RN (SLP give regimen to nurse to ensure care)
*dietitian (can monitor patient/food)
*patient, neonatologist, geneticist (syndromes), radiologist (MBS)
*pharmacist (dysphagia can be caused by meds, or meds in combination)
*ENT (cricopharyngeus up)
*GI (cricopharyngeus down), *OT/PT (adaptive equipment)

Front 11

General Patient Safety

Back 11

*Dysphagia is risky, so safety is important
*Aspiration kept to a minimum
-patient should not aspirate on more than 10% of a bolus when interventions are used, and should be restricted from eating that consistency
-avoid obstruction and keep boluses small
-high risk or suspected high risk patients should be referred for instrumental evaluation
-50% aspirators don't cough in response to aspiration
-40% aspirators not ID'd on bedside swallow eval
(SLP's role is to ID aspiration problem; don't stop giving food bc patient aspirates. small volume and give recs)

Front 12

*Label Diagram

Back 12

print and label the diagram on pg. 13 of notes.

Front 13

Anatomic Structures of Swallowing

Back 13

*Oral cavity (MBS interested in tongue)
*Pharynx (Base of tongue)
*Larynx (epiglottis)
*Esophagus (trachea, VF, thyroid, cricoid cartilage)

Front 14

Oral Cavity

Back 14

*Lips (help propulsion, pressure)
*Teeth (exist, how many?)
*Hard Palate/Maxilla
*Soft palate/Velum (posterior nasal bump is where connect)
*Uvula (dangles from soft palate)
*Mandible/Jaw
*Floor of mouth (muscular area under tongue: digastric, mylohyoid (floor), geniohyoid
*Tongue (oral part)
*Faucial Arches (two each side, anterior and posterior, palatine tonsils located between the two arches)

Front 15

Sulci of Oral Cavity

Back 15

Sulci=spaces created between structures
*Anterior sulci (front of mouth between lip and teeth)
*Lateral sulci (sides of mouth between lip and teeth)

Front 16

Muscles of the Floor of the Mouth

Back 16

MGD=All control hyoid bone.
*Mylohyoid
*Geniohyoid
*Digastric

Front 17

Importance of the Hyoid Bone

Back 17

*Horse shoe shaped bone forms the foundation of the tongue
*Located in the base of the tongue, key for swallowing
*Does not articulate with any other bone
*Suspended in soft tissue by the FOM* muscles

Front 18

Importance of the Larynx

Back 18

*Suspended from the hyoid by the thyrohyoid ligament.
*Thyrohyoid muscle (muscle attaches at lamina of thyroid cartilage and inserts into hyoid)
*Moves in concert with the hyoid unless it is stabilized by other muscles, when you pick up a heavy object, you stabilize/close the larynx (valsalva technique)

Front 19

Importance of the Tongue

Back 19

*Almost entirely muscle
*Oral tongue
-tip
-blade
-front
-center
-back
*Pharyngeal (we don't see)

Front 20

Importance of the Roof of the Mouth

Back 20

*Hard palate/maxilla (separated by posterior nasal spine to soft)
*Soft palate
-palatoglossus (raise back of tongue)
-palatopharyngeus (pulls pharynx and larynx)
-levator palatini (elevates soft palate)
-superior pharyngeal constrictor (helps close off soft palate 4 swallow)
*Uvula (muscular as well, closes off during swallow)

Front 21

Salivary Glands

Back 21

*Three major salivary glands
-parotid (side, largest)
-submandibular (jaw)
-sublingual (below tongue)
*Minor salivary glands
*Produce two kinds of fluid
-serous=watery to wash food down
-viscid=sticky to gather particles and lubricate
(head/neck cancer patients may have only one type of saliva, which may impede swallowing)

Front 22

Importance of Saliva

Back 22

*Maintain oral moisture
*Reduce tooth decay through enzymes (if gland is removed, have more tooth decay, reflux)
*Assist in digestion
*Neutralize stomach acid is refluxed into the digestive tract (saliva is a base, esophagus, esp. towards mouth doesn't like acids).

Front 23

Pharyngeal Structures

Back 23

*Constrictor muscles, 3 sets that come around in a circle. Start in the back and have anterior attachment,
-Superior
-Medial
-Inferior
*Attach anteriorly to
-Pterygoid plates of sphenoid bone
-Soft palate
-Base of tongue
-Mandible
-Thyroid cartilage
-Cricoid cartilage: helps control cricopharyngeus muscle

Front 24

(pharyngeal) Importance of Glossopharyngeus Muscle

Back 24

*Point of attachment inferior fibers of superior constrictor to the tongue base
*Thought to be responsible for base of tongue retraction and simultaneous anterior bulging of the posterior pharyngeal wall at the base of tongue level (need posterior pharyngeal wall to approximate close to base of tongue to allow pressure to build and swallow to occur)

Front 25

(pharyngeal) Pyriform Sinuses

Back 25

*Fibers of the inferior constrictor muscle attach to the sides of the thyroid cartilage anteriorly forming spaces on each side. (lateral and inferior to larynx)
*End inferiorly at the cricopharyngeus muscle (like sulci in throat)
*Floor of pyriform s. is cricopharyngeus muscle

Front 26

(pharyngeal) Cricopharyngeus Muscle

Back 26

*Part of the inferior constrictor muscle
*Attached to the posterolateral surface of the cricoid lamina
*State of tonic contraction, loses contraction somewhat during sleep-can cause heart burn at night (on lateral surface of lamina, ALWAYS closed tightly, except when we swallow, it relaxes)

Front 27

(pharyngeal) Upper Esophageal Sphincter / Cricopharyngeus Sphincter

Back 27

*Formed from the inferior pharyngeal constrictor and cricopharyngeus muscles, always closed at rest.
*2-4 cm zone of increased pressures (very high pressure)
*Pressure increases during inhalation to prevent airflow into esophagus (pressure prevents food from coming up from stomach)
*Relaxes at the appropriate moment to allow a bolus to pass into the esophagus during a swallow.

Front 28

(pharyngeal) Structure of Esophagus

Back 28

*23-25cm long tube
*Normally collapsed
*Two layers of muscle: inner circular and outer longitudinal
*Proximal/ upper 1/3 is striated muscle
*Medial 1/3 is striated and smooth muscle
*Distal/ lower 1/3 is smooth muscle
*Bordered on each end with a sphincteric muscle
-upper esophageal sphincter proximally
-lower esophageal sphincter distally (boundary between esophagus and stomach)
*Traverses the neck, ches, diaphragm, and attaches at stomach
*In neck, sits behind trachea and shares a soft tissue wall.

Front 29

(pharyngeal) Lower Esophageal Sphincter

Back 29

*Junction of the esophagus with the stomach
*Primary purpose is to keep food, secretions and stomach acid in the stomach.

Front 30

(pharyngeal) Epiglottis

Back 30

*The most superior portion of the larynx is the epiglottis.
*Top 1/3 to 1/2 rests against the base of tongue
*Attaches to the hyoid bone by the hyoepiglottic ligament (divides epiglottis into left/right)
*Attaches to the thyroid notch by the thyrohyoid ligament

Front 31

(pharyngeal) Valleculae

Back 31

*Wedge-shaped space formed between the base of the tongue and epiglottis (makes "V" for valleculae, can trap food)
*Subdivided by the hyopepiglottic ligament into L & R
-gives a "scallop shaped" appearance on the A-P view (radiographic)

Front 32

(pharyngeal)Pharyngeal Recesses

Back 32

*Valleculae
*Pyriform sinuses
*Lingual tonsils occupy a small amount of space in the valleculae
-lingual tonsils on base of tongue can also collect food (lumps and bumps) can be large
*Laryngeal vestibule
-bounded by epiglottis, aryepiglottic fold (come down and around), and arytenoid cartilage. Ends at superior surface of the false vocal folds.

Front 33

Larynx

Back 33

*Functions as a valve to prevent food from entering the airway during swallow.

Front 34

(larynx) Aryepiglottic Folds

Back 34

*Contain aryepiglottic muscle, quadrangular membrane, cuniform cartilages.
*Attach to the epiglottis
*Extend laterally, posteriorly, and inferiorly to surround the arytenoid cartilages.
*Form the lateral walls of the laryngeal vestibule
*End inferiorly in the false vocal folds

Front 35

(larynx) Arytenoid cartilages

Back 35

*Positioned on the rim of the cricoid cartilage posteriorly
*Muscular pull on these cartilages controls movement of the true vocal folds
-Posterior cricoarytenoid muscle abducts (opens) the larynx and attaches to the posterior surface of the cricoid lamina
-Lateral cricoarytenoid attaches from the top edge of the cricoid cartilage at the side of the muscular process of the arytenoid and together with the interarytenoid muscles adduct (close) the larynx
*These tilt anteriorly during swallow due to the pull of the thyroarytenoid muscle fibers. (tilts whole thing toward base of tongue) Assists with airway closure.

Front 36

(larynx) False Vocal Folds

Back 36

*Form two shelves of soft tissue projecting anterior to posteriorly from the sides of the larynx. Form superior and lateral of vestibule, superior to TVF.

Front 37

(larynx) Laryngeal Vestibule

Back 37

*Space formed between the false vocal folds and the true vocal folds

Front 38

(larynx) True Vocal Folds

Back 38

*Composed of the vocalis and thyroarytenoid muscles
*Attached from:
-The vocal processes posteriorly
-The inside surface of the thyroid notch anteriorly
*Soft tissue structures when adducted (closed) effectively close the larynx
*Last level of airway protection before entering the trachea
*Arytenoid cartilages rock!

Front 39

(larynx) Laryngeal Strap Muscles

Back 39

*Omohyoid, sternohyoid, sternothyroid, and sternocleidomastoid suspend the larynx and trachea within the neck between the hyoid bone superiorly and sternum inferiorly
*These muscles together with the elasticity of the trachea allow the larynx to be elevated, pulled anteriorly, and/or lowered for various activities. (allows larynx to move in all directions)

Front 40

Four Phases of the Ph-Swallow

Back 40

*Oral prep phase
*Oral phase
*Pharyngeal phase
*Esophageal phase

Front 41

Oral Prep Phase

Back 41

*Sensory recognition of food is critical before any oral prep movements can be initiated. (recognize and something needs to be done-how to manage different food: cookie, water, hot coffee)
*Movement patterns will vary depending on what is being swallowed.
*Labial seal must be maintained to prevent food and liquids from falling from the mouth. lip seal keeps bolus contained in mouth and creates buildup of pressure. if food comes out, no nourishment.
*Tongue "cups" around liquid bolus with sides sealed against lateral alveolus to hold substance in place.

Front 42

Tippers vs. Dippers (oral prep)

Back 42

*Tippers hold food between midline of tongue and hard palate with the tongue tip elevated (the whole time) and contracting against alveolar ridge (80%)
*Dippers hold food on the floor of mouth in front of the tongue (20%)
Both are normal, and you will see both on MBS.

Front 43

Liquids & Puree (oral prep)

Back 43

*Material is always pulled into a cohesive ball
*Holding the bolus anteriorly between tongue and anterior teeth is abnormal
*Semisolids (applesauce, pudding) may be lateralized before swallow through rotary movements of tongue and mandible before forming a cohesive bolus. always need a cohesive bolus.
*If there is no active chewing in this phase the velum is pulled down and forward sealing off the oral cavity from the pharynx. BC liquids move faster than solids and there is a greater choking hazard.
-If food moves too fast, person is breathing at the same time and may aspirate.

Front 44

Solids (oral prep)

Back 44

*Solid foods are always masticated through rotary lateral movement of the mandible and tongue (except pills, but they are special)
*Tongue positions food on teeth, sweeps the food outward.
*Upper and lower teeth meet to crush food.
*Food falls medially towards tongue, and is chewed until it is broken down and mixed with enough saliva to be swallowed.
-need sensory awareness in mouth to not bite tongue, not chew w/excess
*Tongue moves food back toward the teeth as mandible opens
*Cycle is repeated numerous times before forming a bolus and initiating a swallow.
*Food is also mixed with saliva during mastication
*Mastication of solids appears to be controlled by a central pattern generator. Peripheral feedback is important in positioning food on teeth to prevent injury to tongue.
*Tension in the buccal musculature closes off the lateral sulcus to prevent food particles from falling laterally into the sulcus
*Rotary tongue and mandibular motion continues until food has adequately cleared
*After chewing, food is

Front 45

Respiration and Sensation (oral prep)

Back 45

*During oral prepatory phase the larynx and pharynx are at rest.
*Airway is open and nasal breathing continues
*There are sensory receptors throughout the oral cavity including the tongue
-Provide info on bolus volume
-Temperature
-Taste

Front 46

The Bolus

Back 46

*Bolus volume will vary with viscosity of food
*Thin liquid volumes range from 1ml (saliva) to 17-20 ml (cup drinking/chugging)
*As bolus viscosity (thinkness) increases, the maximum volume swallowed decreases (can't chug a steak)
*If larger volumes are placed in the mouth, the tongue will subdivide food after chewing, forming only part of a bolus to be swallowed at a time
*Subdivided bolus rests on the side of the mouth for subsequent swallow. Sometimes clients w dementia forget.

Front 47

Oral Phase

Back 47

*This phase is initiated when the tongue begins to move the cohesive bolus posteriorly
*For dippers, the tongue moves forward, lifts bolus onto the tongue and into the dipper position in a smooth action.
*Tongue at midlien sequentially squeezes the bolus against the hard palate, moving it posteriorly.
*Sides and tip of tongue remain firmly anchored against alveolar ridge. tongue against hard palate and lips creates seal.
(just bc you have an abnormal swallow doesn't mean it's not functional. when we take meds/pills we have to think about swallowing, which makes it more difficult. feels as if it's stuck, but vagus nerve doesn't localize well.)
*Central groove is formed in the tongue (gravity moves food down like a slide)
*Tongue to palate pressure increases as viscosity increases, requiring greater muscle activity.
*Negative pressure is created by slight inward movement and increased tension of the buccal musculature which helps to propel the bolus posteriorly.
*Takes less than 1-1.5 secons to complete (may i

Front 48

Pharyngeal Phase

Back 48

*When the leading edge (tip) of the bolus passes the point between the faucial arches (anterior) and crosses the lower rim of the mandible, the oral phase is terminated and the pharyngeal phase begins.
*There is no pause in bolus movement as the pharyngeal phase initiates. smooth transition between phases.
*Can't see this at a bed side assessment, all we can describe is what we see.
*The hyoid and larynx move superiorly and anteriorly
*Ramping of the base of tongue to deliver the bolus into the pharynx
*Base of tongue retraction to contact the anteriorly bulging posterior pharyngeal wall (any time two structures move together, they create pressure)
*Cricopharyngeal opening to allow bolus materials to pass. (pull on cricopharyngeus=open esophagus for materials to pass through)
*Top to bottom contraction of the pharyngeal constrictors
*Pharyngeal transit time from initiation of pharyngeal swallow through the upper esophageal sphincter is normally 1 second or less.

Front 49

Velopharyngeal Closure

Back 49

*Variable closure pattern among individuals
*Soft palate elevates and retracts to completely close the VP port and prevent bolus material from entering the nose.
*Inward movements of posterior and lateral pharyngeal walls (moves forward to meet VP)
*Anterior bulging of the adenoid pad
*Enables build-up of pressure in the pharynx.
*Food moves to a place of higher pressure to lower pressure, if nasal cavity is not closed, food will go there.
*Children may use adenoids to create pressure to swallow (VP problems)
*Functional swallow is possible without velopharyngeal closure only if all other aspects of the swallow are completely normal.

Front 50

Pharyngeal Phase: Laryngeal Component

Back 50

*Laryngeal closure at multiple levels to prevent bolus materials from entering the airway.
-True vocal folds
-False vocal folds
-Tilt of arytenoids to meet with the base of the epiglottis
-Epiglottic inversion
*If one level fails, there is backup. last thing to happen is tilt. If one level fails, you can still have a functional swallow.

Front 51

Elevation and Anterior Movement of the Hyoid and Larynx

Back 51

*Commonly reffered to as hyolaryngeal excursion
*Larynx and hyoid move anteriorly by pull of floor of mouth muscles.
*Hyoid elevates approx. 2 cm (anteriorly and superiorly)
*Elevation contributes to closure of airway.
*Forward movement contributes to opening of the UES.
*If this is compromised and the hyoid doesn't move superior, might have breathing problems while eating.

Front 52

Closure of Larynx

Back 52

*Downward, forward, inward rocking movement of arytenoid cartilages which narrows laryngeal opening.
*Larynx is elevated and pulled forward
*Elevation thickens the base of the epiglottis to assist with closure.
*Airway entrance is closed for 1/3-2/3 of a second during single swallows for a normal adult. During sequential swallows the airway may be closed for 5 seconds or more (chugging/straw, problem with muscle weakness/COPD)
*Closure at the level of the vocal folds occurs when the larynx has elevated to approximation 50% of it's maximum elevation.
*Breathing always wins over swallowing.

Front 53

Tongue Base and Pharyngeal Wall Action

Back 53

*As the pharyngeal swallow initiates, the tongue base assumes a ramp shape directing food into the pharynx (sliding board).
*Tongue base retraction and pharyngeal wall contraction occur when the bolus tail reaches the base of tongue level.
*Base of tongue and posterior pharyngeal approximate causing pressure to build.
*With contact, contraction continues progressively through the pharynx to the upper esophageal sphincter.
*During transit, bolus should move smoothly without hesitiation.
*Bolus will generally divide at the valleculae
-in 20% of individuals it will be directed to only one side. The two portions rejoin at the level of the opening of the esophagus.
*Purpose if epiglottis appears to be to direct the food around the airway rather than over the top of the airway.
*When the pharyngeal phase is over there should be little or no residue left over, even in older individuals.

Front 54

Cricopharyngeal Opening

Back 54

*Occurs by a complex series of actions
*Tension is released on the muscular sphincter.
*.1 second later, laryngeal anterior/superior motion opens the sphincter. That is pulled open by the motion of the larynx.
*Leading edge (tip) of the bolus reaches the sphincter as it opens.
*Pressure within the bolus widens the opening.
*As the bolus passes through the sphincter, the larynx lowers and the cricopharyngeus returns to some level of contraction. Pull on cricopharyngeus widens and allows materials to pass. As it passes, the hyoid is coming back to rest.

Front 55

Esophageal Phase

Back 55

*Begins when the bolus enters the esophagus at the UES and ends when it passes into the stomach at the lower esophageal sphincter (gastroesophageal junction).
*Normal esphageal transit time varies from 8-20 seconds. Need pressure buildup to move bolus from top to bottom.
*Peristaltic wave begins in the top of the esophagus, pushes the bolus ahead of it, and continues in sequential fashion until the LES opens to allow the bolus to enter the stomach.