Oral Stages of Swallowing (2)

1.Oral prepatory-reduce food to appropr consistencprepare for transportation.-

-tongue psoitions food to prepare bolus.

-reduction phase: bolus is chewed and mixed with Saliva

-bolus placement-bolus positioned for transport.

2. Oral Transport: to transport prepared bolus from anterior to posterior oral cavity for passage to pharynx.

-muscles of lips and cheeks contracted followed by tongue contraction against hard palate.

-as tongue and hard palate contact occurs, the soft palate elevates.

-palatal muscle contractions draw the velum superiorly and posteriorly against the nasophargeal mucosa and musculature.

Phargneal Phase

Reflexively triggered when bolus approaches palatoglossal folds.

1. Elevation and retraction of velum--complete closure of vp port

2. Elevation and anterior movement of hyoid and larynx

3. closure of larynx at true and false VF

4. opening of cricophargeal sphincter-allows food to pass into esphongus

5. ramping of tongue to deliver bolus to pharynx -back of pharyngeal wall moves forward

6. top to bottom pharyngeal contraction

Swallowing-Esophogeal phase

Goal is to carr the bolus through eso to the stomach using peristaltic movements (8-20 sec)

-the lower sphincter opens to facilitate transport bolus into the stomach

4 Stages of Swallowing

1. Anticipatory Stage

-respiratory adjusts, expiration ceases-in response to sensory information (smell, sight etc)

-salivation and prep to swallow

2. Oral Stage

3. Pharyngeal Stage

4. Esophogeal Stage

Food Consistencies

-regular food textures-skills WNL, no food restrictions

-mechanical soft-chopped/diced-as above but a rotary chew not present, no hard meats or crumbly foods

-mechanical soft- ground-reduction in oral transit, decreased or absent chewing, poor dental status, reduction in pharyngeal function

-pureed-decrease oral propulsion, swallow response delayed, decreased chewing, suspected pharngeal statis

Liquid Consistencies

-thin- physio WNL

-nectar thick- deceased oral propulsion, cricopharngeal dysphfunction, adequate swallow reflux

-honey thick-deceased oral prop, reduced phary perstalsis, crico pharyn dysfunction, decreased or absent chewing

Cranial Nerves for Swallowing

Cranial V-Trigeminal-

CN VII- Facial

CN IX- Glossopharyngeal

CN X- Vagus

CN XII- Hypoglossal

CN V-Trigeminal

-at level of the pons

-contains sensory and motor fibers that innervate the face

-important for chewing

-responsible for pharyngeal swallowing

CN VII-Facial

-sensory and motor fibers,

-important to orpharynx sensation

-taste to anterior 2/3 of the tongue

-helps to initiate saliva flow

CN IX-Glosspharyngeal

-sensory and motor fibers

-important for taste to posterior tongue

-sensory and motor functions of the pharynx

-primary saliva production

CN X-Vagus

-sensory and motor fibers

-taste to oropharynx

-sensation and motor function to layrnx and laryngopharynx

-important for AIRWAY PROTECTION!!!!

CN XII-Hypoglossal

-contains motor fibers that primarily innervate the tongue

-patients with CP have issues here so food gets everywhere

Facts about Swallowing

most oral phase dys assoc with left hemisphere

most pharyngeal phase dys  and aspiration assoc with right hemisphere lesions

What To Look for on a Medical Chart

-adv directive for health care

-admission info (demographic data, dx, insurance etc)

-history and physical

-physicians orders

-progress notes

-labs

-special reports (radiology, catscans, MRI's etc)

-rehab and therapy (PT, OT, SPeech etc)

-Multidiciplinary care

-GI/dietary

-audio/opth

-psych reports

Anatomy/Phys of Children

-infants: tongue fills oral cavity and fat pads narrow cavity

-hyoid bone and larynx is lower

-velum hangs lower

-soft palate closes to prevent nasal regurgitation

*study diagram of anatomy in notes

Anatomy/Phys of Adults for Swallowing

*study diagrams

Tongue- 5 parts

1. body

2. root

3. dorsum

4. blade

5. tip

Tongue-Intinsic Muscles (4)

*reponsible for fine motor movements

-superior lingitundal muscle

-inferior lingitunal muscle

-transvers muscle

-verticle muscle

Tongue-Extrinsic Muscles (4)

1.palatoglossus

2. genioglossus

3. styloglossus

4. hyoglossus

Lip/Face Muscle Contributions

-lip seal around bottle, spoon etc

-blowing bubbles

-sucking

-chewing and left/right movement of bolus

-keeping bolus contained in oral cavity

-filling your mouth with food or liquid

Palatal and Pharyngeal Muscles (5)

1. levator veli palatini

2. tensor veli palatini

3. uvula

4. palatoglossus

5. palatopharngeus

Jaw Muscles-Mandibular Elevators (3)

1. Temoralis

2. Masseter

3. Internal pterygoid

Jaw-Mandibular depressors (4)

1. external pterygoid

2. mylohyoid

3. geniohyoid

4. anterior belly of the digastric

* jaw muscles are very important fo rmounth opening in pre oral stage and containing and preparing bolus in oral prep stage

Pharyngeal Constrictors

1. superior pharyngeal constrictor

2. buccinator

3. stylohyoid

4. stylopharyngeus

5. cricopharyngeus

6. interior pharyngeal constrictor

7. middle pharyngeal constrictor

8. styloglossus

9. supior constrictor

Swallowing Eval

Obtain info about:

-current med dx

-patient's med status

-oral anatomy

-respiratory funtion and relationship to swallowing

-labial control

-lingual conrol (bolus)

-palatal function (nasal regurgitation)

-pharyngeal wall contraction (peristalsis)

-laryngeeal control (airway protection)

-client's ability to follow directions

-resposne to oral stim

- reactions and symtoms during swallowing

Alertness Levels

1. alert: fully awake and interactive

2. lethargic: need constant stimu/attention is reduced

3.abtonded:btw lethargic and stupor

4.stupor: semi coma, only responds to persistent and vigorous stimulation

5. coma: unable to arouse

What to Do First in Eval

1. review patients chart: med hitory, complications, medications, alertness, code status etc

2. Have an initial impression of patient's alertness levels: posture, endurance, awareness of your presence, conversing etc

3. respiratory status

4. tracheostomy tubes, intubation, mech ventilation

Code Levels

1. full code

2. partial-some lifesaving stuff

3. do not resusitate

4. no code status

Dysphagia Evaluation

a. posture

b.oral motor functions: range of motion, strenght, symmetry, speech intelligibility etc

c. laryngeal function: voice quality, pitch, cough/throat clearing etc

d. trial intake of food and liquid consistencies

     -trial foods:pureed, ground, chopped, reg

     -trial liquids: honey thick, nectoar thick, thin

e. oral prep phase assessment: feed self, hold cup, posture

f.oral phase assess: lip closure, drooling, bolus formation, transit time, chewing, any coughing etc, reflexive patterns (abnormal: tongue thrust, rooting, suckle----protective: gag, cough, palatal elevation)

g.pharyngeal phase: larngea excursion, coughing (before, after or during), vocal quality, swallow time

h.other clinical findings

I.SLP DX impressions

J. Recommendations

Evaluation Recommendations

-diet: po vs NPO

-assign safest food/liquid consistencies

-how to take meds

-supplemental recommendations: level of assistence, positioning etc

-dysphagia therapy plan recommendations:

  indirect-no food but oral facilitation exercises

  direct- with trial PO's of food and liq with oral facilitations exercise and strategies

   compensatory swallow strategies

Order of testing liquids

1.empty spoon

2.ice chips

3.thin liq by tsp (you first, then patient)

4.Cup sips, try with straw too

5.move to nectar thick--if induces coughing try honey thick

Order of Food/solids

1. pureed or apple sauce

2. chopped fruit in cup

3. crackers

Screen versus Eval

Screening is used to determine if a comprehensive swallow eval is necessary and to obtain evidence of:

-signs of dysphagia (coughing, throat clearing etc

-any history of pneumonia

-identify by chart review the existence of dx's that suggest high risk for dysphagia

*should only take 10-15 minutes

Coughing

Before Swallow: indicates premature spillage from oral cavity

During Swallow: indicates absense/delay swallow

After ":indicates residue from oral cavity or in pharyngeal recesses

What happens when esopx funtion  is impaired?

retention of food and liquied in eso after swallowing

impaired opening of LES

body of esophagus may be obstructed a web, stricure or tumor

overactivity of muscultature may result in esophageal spasm--reduece effectness of food transport

GERD is a closly related prob--at risk for reflux esophaitis and peptic strictures

Sings and Symptoms of Esophogeal Stage Dysphagia

sensation of food sticking in chest or throat

drooling

unexplained weightloss

change in dietary habit

chest pain

hoarseness

Some Causes of esophageal stage impairments

-primary motility disorders: Webs, Achalasia (failure of LES to relax)

-secondary motility disorders: scleroderma, reflux esophagistic, radiation, MS, ALS

-Infectious Causes: fungal(mono), bacterial (TB), parasitic(chagas disease), viral (herpes)

-Metabolic: diabetes, Amyloidosis

Point with Finger to location of bolus

-patients with oropharyx dysphagia point proximal to larynx

-patients with esophageal dysph localize distal to larynx

Medications that may impair esophogeal function

Inflammation:

-tetracycline

-doxycycline

-iron preparations

-potassium

Impaired motility:

-anticholinergics

-calcium channel blockers

Esophagitis:--related to immunosuppression

-corticoasteroids

Other: botux, anti-anxiety drugs, muscle relaxants

Honor Article

Achalasia

Failure to relax, referring esp to sphincter muscle of esophogus

Cervical Auscultation

Listening to the sounds of swallowing, usually with a stethoscope.

Deglutition

The act of swallowing

Diverticulum

A curcumscibed pouch or sac occurig normally or created by herniation from the wall of a tubular organ

Electroglottography (EGG)

Use of electrodes which transmit and receive high freq signals. to measure temporal aspects of the phary swallow

Electormyography

Procedure used to record muscle group electrical activity.--can detect vocal cord paralysis.

Fenestrated Trach Tube

Trach tube which allows air to pass upward into the larynx.

Fiberoptic Endoscopic Eval of Swallowing (FEES)

Examination of pharyng swallow via a fiber optic nasopharyngolarngoscope.--intorduce for swallowing by Susan Langmore.

Need to be certified to use.

Laryngeal Elevation

Occurs as the tongue is retracted during the swallow. 

Normally larynx rises 1-1 1/2 vertebrae during swallow.

Mendelsohn Maneuver

A tech use to increase the opening of the CP sphincter during swallowing--

patient instructed to hold larynx elevated while swallowing.

Modified Barium Swallow

Another term for videofluoroscopy--an x ray procedure involving the use of video equip to diangnose swallowing disorders and aspiration.

NPO

Nothing Per Oral

PE Segment

Pharyngeal-esophogeal segment of the esophogus also known as the cricopharyngeal muscle or upper esophageal sphinter (UES)

Penetration

Bolus entering the larngeal vestibule during the act of swallowing but NOT entering below the true vocal folds.

Peristalsis

Alternate contractions and relaxations of the muscle walls o fthe intestinal tract or pharynx.

PEG

Percutaneous endoscopic gastrostomy-

A tube which allows feeding to be delivered directly to the stomach rather than going through the nose or thoat.

Pharyngeal Manometry

A procedure which elaluates the speed and pressure changes within the pharynx as the bolus moves through to the esophagus.

Stasis

Residue in the orpharngeal complex after swallow.

Supraglottic Swallow

Tech use to protect breathing tube from stuff entering during swallow. 

Hold Breath, swallow, then cough.

Super supraglottic Swallow

Tech recommeded for reduced airway entrance.

Inhale and breath very tightly bearing down. 

Keep holding your breath and bearing down during swallow.

Cough when finished.

Tongue Base Retraction

Forceful movement of the base of the tongue against posterior phary wall to move material through the pharynx.

Vallecullar Space

Space in the upper part of the pharynx formed by the tongue and epiglottis.  Site where food reidue can collect when swallowing is impaired.

Valleculae

Wedge shaped space formed btw the base of the tongue and epiglottis.