14-Swallowing

Question 1

What are the 3 main phases?

Answer 1

• Oral phase
• Pharyngeal phase
• Esophageal phase

Question 2

Explain the oral phase

Answer 2

First phase
When you swallow you first:

1. Form a bolus in your mouth on the top of your tongue, your lips seal, the tongue holds your food and velopharyngeal port closes
   •The food or liquid is closed in your mouth
2. You chew and chew and your tongue moves it around; it gathers all of the food in a bolus until you feel ready to swallow

Question 3

What should you not see in the oral phase?

Answer 3

• Any leak into your nose or milk coming out your upper lip
• Any leakage going into the larynx
• No food pocketed in your cheek
• No food under the tongue

Question 4

T/F the oral phase does not need to be contained

Answer 4

False 
•Any leak into your nose or milk coming out your upper lip 
•Any leakage going into the larynx
•No food pocketed in your cheek 
•No food under the tongue

Question 5

What triggers the pharyngeal phase?

Answer 5

Is triggered as the bolus reaches the back of the tongue

the larynx comes up with all this massive closure

oFood is contained in a bolus in the middle of your mouth until you decide to swallow

Question 6

What are two important factors for pharyngeal phase?

Answer 6

Negative air pressure and the muscles

Question 7

Explain negative air pressure

Answer 7

• It helps drive the bolus backwards

* Because you’ve closed the velopharyngeal port and lip seal you have closed off air participating in this swallow

Question 8

What important muscles acts in the pharyngeal phase ?

Answer 8

First set of muscle?
o Tongue, the bowl flattens out and the food is compressed/pushed back into the pharynx.
o It presses up to the roof of the mouth, it squeezes from the front to the back

• First muscle of peristalsis
• Peristalsis = a snake–muscle are contracting and pushing the food to the back

To drive the bolus into the esophagus

Question 9

What is the single most important action in the pharynx to the swallow?

Answer 9

• Larynx lifts and closes
• Most critical part of the pharynx
• It must pick up because that’s how it closes most tightly
• It is a sphincter action and it has to lift and close

Question 10

Why is the lift and close action so important?

Answer 10

Your food will go down the trach = aspiration

Question 11

How is the larynx quadruple protected?

Answer 11

oThe tongue goes up and the epiglottis closes over the opening of the larynx (15:00)
•Moves backwards and covers the additus laryngeus or vestibule
oThe epiglottis closes backwards and aryepiglottic folds close in to make the seal
oThe false VF close up
oThe true VS close up

Question 12

What happens in the esophageal phase?

Answer 12

oCharacterized by even more closure
oThe esophagus is supposed to be a one way valve
oOnce food gets into the esophagus we are done

Question 13

If there’s problems in the esophageal phase what happens?

Answer 13

•If esophageal phase does not work and it comes back out
-if it goes into the trach we care
•If the larynx isn’t closing right we won’t be able to fix is but we need to know that it is happening

Question 14

Define aspiration

Answer 14

THAT SOMETHING HAS PENETRATED BELOW THE LEVEL OF THE TRUE VF

Question 15

T/F dysphagia can occur in all ages

Answer 15

true

-from neonatal care to old age

Question 16

what is swallowing

Answer 16

Swallowing is moving the food from the mouth to the stomach.

Issue at it’s foundation?
-from esophagus to pharynx it needs to be SAFE

Question 17

What is a safe swallow? what happens when the swallow does not work?

Answer 17

food goes into the esophagus and into the stomach

unsafe? through the esophagus into the trachea

Question 18

What are extrinsic muscles?

Answer 18

supporting and fixing the larynx into place

One attachment is outside the larynx and on is inside (to hyoid, thyroid, or thyrohyoid)

subgroups: suprahyoids and infrahyoids

Question 19

What are suprahyoids?

Answer 19

originate or insert above the level of the hyoid bone

**critical swallow muscles

Question 20

Name the suprahyoids? what do they do?

Answer 20

they are laryngeal elevators and slightly forward and backwards to have a straight up motion

Digastricus
Mylohyoid
Stylohyoid
Geniohyoid

Question 21

Explain digastricus

Answer 21

•Extends the length of your jaw
•Deep to digastricus
•Elevates hyoid and moves down a little bit in contraction
•When it pulls up on the hyoid bone
oThe whole larynx goes UP
•Origin is the medial aspect of the border of the mandible (mastoid process) and courses inferior/posteriorly and inserts on a midline raphe

Question 22

Explain mylohyoid

Answer 22

this muscle forms the floor of the mouth.
•Elevates hyoid and moves down a little bit in contraction
•When it pulls up on the hyoid bone
oThe whole larynx goes UP
•Origin is the medial aspect of the inferior border of the mandible (mastoid process)

Question 23

Explain stylohyoid

Answer 23

a long and slender muscle that is lateral and superficial to the digastricus posterior belly (runs parallel)

• On contraction pulls anteriorly and up
• Long slender muscle
• Right next to posterior belly of digastricus—but slightly superior
• ORIGINATES from the styloid process (of the mastoid bone) runs anterior, inferiorly to insert on hyoid bone

oSticky outy of the styloid process

Question 24

Explain geniohyoid

Answer 24

• Runs the same course and anterior belly of digastricus
• Make a mylohyoid sandwhich
• Anterior belly is underneath, mylohyoid is in the middle with geniohyoid is ontop

**so - it is located superiorly to the mylohyoid

ORIGINATES from interior border of mandible (chin), courses posteriorly and inferiorly to ATTACH on the body of the hyoid bone

Question 25

What are the structures in the larynx?

Answer 25

``` True VF False VF Aryepiglottic folds Epiglottis Arytenoids (you can't see these) Cuneiform ```

Question 26

Name the places and spaces

Answer 26

1. Valleculae - Common place for food to be pocketed 2. Pyriform sinuses 3. Aditus laryngeus, aditus, or vestibule - The triangular space 4. Anterior commissure 5. Posterior commissure

Question 27

What constrictors are in the VP port

Answer 27

1. Superior pharyngeal constrictor a. Participates with closing the velopharyngeal port 2. Middle constrictor a. Squeezes food away from the mouth into the esophagus 3.Inferior

Question 28

What are the infrahyoid muscles?

Answer 28

they're laryngeal depressors 1. Sternohyoid 2. omohyoid 3. thyrohyoid 4. sternothyroid

Question 29

Explain sternohyoid and what it does

Answer 29

* ORIGINATES the posterior surface of the manubrium (sternum)—and courses straight up from the inferior body of hyoid bone * Strap muscle * Downward pull

Question 30

Explain omohyoid and what it does

Answer 30

• Starts on the scapula courses anteriorly and superiorly and moves up to the hyoid bone

Question 31

Explain thyrohyoid and what it does

Answer 31

* A cheating muscle because both attachments are in the larynx * Looks like a infra but acts like a supra * It is both intrinsic and extrinsic elevators * When it contracts it pulls larynx up to hyoid bone * Originates from thyroid lamina courses upward to the inferior portion of hyoid bone

Question 32

Explain sternothyroid and what it does

Answer 32

1. Originates from the medial aspect of the manubrium and first rib first 2. A little more centered

Question 33

What are the risks for dysphagia?

Answer 33

a. Lack of muscle control/function i. Especially with lack of muscle function goes with lack of sensation b.Lack of sensation c. Lack of swallow reflex i. Cough/clear reflex

Question 34

What are dysphagia terms?

Answer 34

Aspiration Penetration Residue Blackflow

Question 35

Explain pentration

Answer 35

i. The food may be sitting at the level of the true VF ii. Because the food is in the vestibule iii. Not below the level of the true—its AT the level

Question 36

explain residue

Answer 36

i.What’s left over in the laryngeal area ii. Can also be what’s left behind in the mouth 1. If it’s sitting on the tongue 2. But if it’s in the cheek or under the tongue = pocketed iii.Could Potentially hanging on the posterior pharyngeal wall

Question 37

Explain backflow

Answer 37

i. Referring to the esophageal phase ii. Food or liquid has gone into the esophagus and it’s coming back up again—it never got to the stomach 1. We care about the fact that it is possibly being aspirated 2. Because it is leaking from the esophagus into the pharynx which is why it is an aspiration risk

Question 38

What does a bedside clinical assessment show?

Answer 38

:Yes/no evaluation for aspiration i. Typically identifies that the patient is aspirating, but not why. 1. But then you do a study to determine why: what’s happening where?

Question 39

What does MBS stand for? what does it focus on?

Answer 39

Modified Barium swallow (MBS) i.Looking at the larynx= Laryngeal function ii. Most popular eval iii. an x-ray

Question 40

What do you specifically look at in a MBS?

Answer 40

Looking at lateral view of how they manipulate the bolus in the oral phase, when the pharyngeal phase triggers, when or does the larynx move up, does the tongue propel the bolus into the pharynx, is does the epiglottis close over? 1. Does food penetrate or aspirate? 2. Is there residue left in the pharynx or oral cavities ?

Question 41

What are you looking for in a barium swallow?

Answer 41

i. Once you determine there’s a swallowing eval this is the most typical physiological examination ii. Looking for Esophageal function 1. Looking for upper esophageal function 2. Opening of LES into the stomach iii. Peristaltic function Anterior, posterior, and lateral view Need radiologist

Question 42

What is another type of endoscopic eval ?

Answer 42

FEES | Fibroptic endoscopic eval of swallow

Question 43

What is FEES

Answer 43

ii. Can be done by a SLP no radiologist necessary iii. Scope goes through the nose pass/lower to the level of the velopharyngeal port and watch the patient swallow iv. Anterior, posterior, and lateral view

Question 44

Both FEES and MBS are designed to show what?

Answer 44

how and where the breakdown 1. Where is the abnormality in the anatomy and/or physiology 2. And give you an idea for treatment strategies might be 3. You can test the structures a. You can go through a list of treatment strategies and probe to see what works 4.But remember MBS is an x ray

Question 45

What are the signs and symptoms of aspiration

Answer 45

i. Coughing after swallowing ii. History of pneumonia iii. Diagnoses that put the patient at greater risk iv. Food squirting out the tracheostomy v. Some sort of neuroligcal disease that lead to paralysis, paresis, lessened sensation vi. Stroke or TBI

Question 46

What are some items on the checklist for dysphagia screening?

Answer 46

i. Is there a history of recurrent pneumonia? ii. Radiation iii. Prolonged intubation 1. Nerve damage iv. Gurgle voice 1. Sounds like liqud on the VF v. Coughing vi. Poor awareness vii. Not swallowing viii. Reduced laryngeal lifting ix. Significant fatigue x. Voice changes xi. Multiple swallows with one spoonful of applesauce xii. Anything that can lead to tissue not function the way it should

Question 47

In the physiological evals how many consistencies do you use?

Answer 47

Swallow At least 3 consistencies of food used in the evaluation i. Thin liquid 1. Hardest to manage, keep in a bolus, keep from leaking ii. Thick liquid or sort of a pudding 1. Apple Sauce iii. Nectar iv. Barium on a cracker

Question 48

What are some treatments of swallowing or swallowing maneuvers ?

Answer 48

a. Head positioning i. Chin position 1. Up a. Let gravity help you pull it down 2. Down a. Close of velecullae and piriform sinus ii. Head turn 1. Depending on paralysis b. Laryngeal manipulation c. Food alterations d. Multiple swallows i. Simple but effective e. Swallow-cough i. They don’t feel penetration and aspiration ii. If the cough clears the aspiration this is great! f. Food then a sip of liquid to clear, etc.