Dysphagia: Terminology, structure, and process of the normal swallow Scott S. Rubin, Ph.D. Associate...

Dysphagia: Terminology, structure, and process of the normal swallow

Scott S. Rubin, Ph.D.Associate Professor, LSUHSC-NO

SPTHAUD 6218

The Swallow: Structure and processes

• Text for this semester -▫ Groher, M., & Crary, M. (2010). Dysphagia:

Clinical Management in Adults and Children (3rd Edition), Mosby/Elsevier.

▫ ISBN: 978-0-323-05298-6


•Presentation topics include:

▫SLP involvement

▫What is Dysphagia (definitions)▫Structures associated with swallow▫Neurological control of swallow▫Stages of normal swallow


▫According to ASHA Service delivery in the area of swallowing and

feeding (i.e., dysphagia) a significant portion of the caseload of speech-

language pathologists in health care settings. Respondents to the 2002 ASHA Omnibus Survey

reported –▫dysphagia services - provided by 90% of SLPs in

residential health care▫84% in hospitals▫50% in non-residential health care▫11% in schools.

In recent ASHA Speech-Language Pathology Health Care Survey (2002) -▫ respondents in adult health care settings reported

spending 31% of their time in the delivery of services related to dysphagia

ASHA Preferred Practice

•Link to ASHA Preferred Practice Patterns for the Profession of Speech-Language Pathology

• http://www.asha.org/docs/html/PP2004-00191.html

• Please familiarize yourself with it!!!

http://www.asha.org/docs/html/PP2004-00191.html

http://www.asha.org/docs/html/PP2004-00191.html


•What is Dysphagia? ASHA SID pronunciation - dysphagia (dis-FAY-

juh) Common: (dis-FA-juh) – for a good reason!

•Definitions -▫Somewhat vague and over inclusive?

Difficulty swallowing. (or feeding?)

▫Less debatable - A swallowing disorder; difficulty in swallowing

or the inability to swallow; condition in which swallowing is difficult or painful.


•What is Dysphagia?

Those with dysphagia may experience pain while swallowing. Some people may be completely unable to swallow or may have trouble swallowing liquids, various consistencies of foods, and/or saliva.

Eating becomes a challenge and filled with fear or anticipation of problems.


▫Dysphagia (continued)

Dysphagia may cause difficult in taking in enough calories (food and fluids) to nourish the body.

Lasting dysphagia can lead to serious health problems and death.

Also, if managed poorly by SLP – can contribute to poor outcome!


• Common classifications of dysphagia

• Oral phase–sucking, chewing, and moving food or liquid into the throat (usually subdivided to Oral Preparatory and Oral Transit)

• Pharyngeal phase–starting the swallowing reflex, squeezing food down the throat, and closing off the airway to prevent food or liquid from entering the airway (aspiration) or to prevent choking

• Esophageal phase–relaxing and tightening the openings at the top and bottom of the feeding tube in the throat (esophagus) and squeezing food through the esophagus into the stomach

• Topic for later presentation


• Associated Terminology ▫Penetration – Material moves into vestibule

above the true vocal folds▫Aspiration –Material breaches vocal folds into

trachea and potentially into lungs.▫Silent Aspiration – occurs but no signs/symptoms

The risk for aspiration is not limited to meal times. It can occur ANY TIME, day or night.Includes food, drink, medication, saliva, and vomit

• Potential Consequences of Aspiration ▫ Pneumonia (i.e., Aspiration Pneumonia)▫ Perminant Lung Damage▫ Death !


▫Dysphagia Triggers - Symptoms or signs that may signal the occurrence of aspiration Coughing – forceful exhalation of air

Choking – airway is blocked

GERD/Reflux – stomach contents come back up into esophagus or mouth

Much more terminology presented in context.

Anatomy and Physiology of the Normal Swallow


• Cranial Nerves Important in Swallowing

▫CN V Trigeminal▫CN VII Facial▫CN IX Glossopharyngeal▫CN X Vagus▫CN XII Hypoglossal

▫ Each Nerve on following slides…

And … other nerves? Impact? – explore on own and have examples (could be on exam or comps)! Vision Smell Eye movement…



▫CN V -- Trigeminal sensory and motor- innervates the face important in chewing located at the level of the pons


• CN V – Trigeminal 3 Branches

Opthalmic V1(sens)Maxillary V2 (sens)Mandibluar V3 (mixed)

Sensory from forehead and eye – (over V1), cheek (over V2) and lower face and jaw (V3).

Motor for muscles of mastication, soft palate, mylohyoid , chin



▫CN VII -- Facial sensory and motor fibers important for sensation of oropharynx &

taste to anterior 2/3 of tongue


• CN VII -- Facial

• Facial nerve proper: The largest component of the facial nerve.

Voluntary control of the muscles of facial expression, as well as the posterior belly of the digastric, stylohyoid and stapedius muscles.

•CN VII -- Facial

•Nervous Intermedious carries rest of sensory fibers and autonomic information.

▫ Yellow = F. nerve Proper.

▫ Orange, Blue, Green =Nerv. Intermedious



▫CN IX -- Glossopharyngeal contains both sensory and motor fibers important for taste from posterior tongue,

sensory and motor functions of the pharynx


• Cranial Nerves Important in Swallowing▫CN IX – Glossopharyngeal

• It receives sensory fibers from: posterior one-third of the tongue, tonsils, Pharynx, middle ear, and the carotid body.

• Autonomic fibers to the parotid gland • It also supplies motorfibers to stylopharyngeus muscle and the upper pharyngeal muscles.


• Cranial Nerves Important in Swallowing▫CN X -- Vagus

contains both sensory and motor fibers important for taste to oropharynx, and

sensation and motor function to larynx and laryngopharynx.

important for airway protection

The Swallow: Structure and processes• CN X - Vagus - 3 branches

• Pharyngeal Nerve branch▫ Motor and sensory fibers▫ Motor to soft palate and pharynx▫ Sensory to lower pharynx

• Superior Laryngeal N. Branch – has 2 branches

• Internal laryngeal nerve ▫ Sensory from epiglottis and interior larynx

• External laryngeal Nerve ▫ Motor to cricothyroid muscle and inferior constrictor muscle

• Recurrent Laryngeal N.B.


• CN X - Vagus - 3 branches

• Recurrent Laryngeal Branch

Courses past larynx – neckand upper chest – thenfrom chest up to larynx

▫innervates all muscles of the larynx

(except Cricothyroid)


•Cranial Nerves Important in Swallowing

▫CN XII -- Hypoglossal contains motor fibers that primarily innervate

the tongue


▫CN XII -- Hypoglossal

To all Intrinsic Musclesof Tongue And all but one Extrinsic

Anatomy of Swallow


•Anatomy of Swallow•Skeleton

▫Hyoid Bone - attachment to epiglottis and strap muscles.

▫Thyroid Cartilage - anterior attachment of vocal folds. Posterior articulation with cricoid cartilage.


•Anatomy of Swallow•Skeleton

▫Cricoid Cartilage - complete ring. Articulates with thyroid and arytenoid cartilages.

▫Arytenoids - two cartilages which glide along the posterior cricoid and attach to posterior ends of vocal folds.


Divisions of Structure• Supraglottis - usually covered with respiratory epithelium

containing mucous glands. ▫ Epiglottis - leaf-shaped mucosal-covered cartilage, which

projects over larynx. ▫ Aryepiglottic folds - extend from the lateral epiglottis to the

arytenoids. ▫ False vocal cords - mucosal folds superior to the true glottis. Separated from true vocal folds by the ventricle. ▫ Ventricle - mucosal-lined sac,

variable in size which separates the supraglottis from the glottis.


Divisions of Structure• Glottis – • true vocal folds attach to the thyroid cartilage at the anterior commissure. • The posterior commissure is mobile, as the vocal folds attach to the arytenoids. • Motion of the arytenoids effectsabduction or adduction of the larynx.• The bulk of the vocal fold is made upof muscle covered by mucosa. • The vocal folds abduct for inspiration and adduct for phonation& cough


Divisions of Structure

▫Subglottis - below the vocal folds


Pyriform Sinus


Valleculae


Vallecula

Note aspiration in trachea.


Review of StructuresValleculaEpiglottis

Upper Esophageal Sphincter (UES)

Lower Esophageal Sphincter (LES)


•Watch the structures!

“Want that pizza to go?


•Glands

▫Parotid Gland▫Located on side of face,

anterior to mastoid tip and superior to the lower

▫Facial nerve passes through this gland.


•Submandibular Gland▫Beneath floor of the mouth


•Sublingual Glands - located below the mucous membrane of the floor of the mouth, adjacent to mandible and mylohyoid muscle.


• Minor Salivary Glands - small collections of salivary gland tissues are scattered throughout the oral mucosa, and can also be seen in the pharynx, supraglottis, nose and sinuses.

Stages of the normal swallow

Stages of the normal swallow

(Oral Prep Phase)

- Oral Phase - Pharyngeal

Phase - Esophageal

Phase


▫Oral Phase Oral Preparatory

Goal: reduce food to a bolus and position it for transport

Initial transport (the bolus lacement) - tongue positions the food to ready it for reduction

Reduction phase - bolus is chewed & mixed with saliva

Bolus placement - bolus is positioned for transport

Oral Transport The prepared bolus is transported

from anterior to posterior oral cavity for passage to the pharynx.


Pharyngeal Phase Complete closure of velopharyngeal opening. Hyoid & Larynx begin their superior ascent Epiglottis begins to fold down – back.

▫(to clarify - the epiglottis tilting or folding back and down is as the result of surrounding structures’ movement – i.e., larynx elevating, contracting mouth floor, & hyoid moving up and back) .

Tongue base to posterior pharyngeal wall contact Top to bottom contractions of pharyngeal constrictor

muscles Continued superior movement of hyoid & larynx Laryngeal closure starts from bottom up Continued down-folding of epiglottis to inverted

position Anterior movement of hyoid Relaxation of cricopharygeus muscle & opening of

upper esophageal sphincter region


Esophageal Phase Peristalsis carries the bolus

through esophagus to the stomach.

The lower espohageal sphincter opens.

Summary of the Swallow

“Swallow Reloaded”


• FIGURE 1A. ORAL Phase - The tongue initially forms the food bolus (green) with compression against the hard palate.


• FIGURE 1B. PHARYNGEAL Phase Displacement of the food bolus into the pharynx by the tongue initiates deglutition


• FIGURE 1C. ESOPHAGEAL Phase - Relaxation of the cricopharyngeal muscle (the physiological upper esophageal sphincter) permits movement of the food bolus into the proximal esophagus.


•The Swallow

•Videofluoroscopy Segments

Dysphagia: SLP’s Role Complete Honey Consistency –

1/3 teaspoon

•Posterior movement back•Elevation and retraction of velum•Elevation and anterior movement of the

hyoid and larynx •Bolus transported into valleculae•Backward movement of the eppoglottis

http://www.d.umn.edu/csd/video/sa3.mov





http://www.d.umn.edu/csd/video/whole.mov

Dysphagia: SLP’s Role

•Ground meat 1/3 teaspoon ¼ cookie

•Oral Preparatory Phase

•Pharyngeal Phase

•2nd swallow – to clear material

http://www.d.umn.edu/csd/video/gb.mov

http://www.d.umn.edu/csd/video/ga.mov

http://www.d.umn.edu/csd/video/gc.mov

http://www.d.umn.edu/csd/video/gd.mov


•Videofluoroscopy Segments

•link

http://www.d.umn.edu/csd/video/swallowing.htm


•End Sequence –

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