1
Q
name the 4 stages of swallowing
A
- oral prep stage
- oral stage
- pharyngeal stage
- esophageal stage
2
Q
T/F
the swallow is NOT segmental - what happens during one phase will affect the others
A
true
3
Q
T/F
impairment can occur in any one or more phases
A
true
4
Q
name the 2 tubes
A
oral cavity
pharyngeal cavity
5
Q
name the pumps
A
oral tongue
base of tongue
pharyngeal constrictors
traction forces
6
Q
name the valves
A
lips (close)
velum (close)
larynx (close)
UES (open)
7
Q
what are the two binary goals of pharyngeal phase
A
- seal the airway
- move food through esophagus
8
Q
T/F
epiglottis is a valve
A
false
9
Q
what are traction forces
Think pharyngeal phase
A
Hyoid-pharyngeal excursion pulls UES open
pharyngeal constrictors squeeze bolus moving down pharyngeal cavity
10
Q
major events of oral prep stage
A
- sealing of oral cavity: close lips and posterior tongue to velum
- mastication of bolus
- mixing bolus with saliva
- piecemeal deglutition
11
Q
what is piecemeal deglutition
A
occurs in oral prep stage
def: dividing bolus into pieces for transport to pharynx
12
Q
Muscles used in oral prep phase
A
- Obicularis oris
- Buccinator
- Tongue sensation
- Tongue muscles
- Mastication muscles
- Salivation
13
Q
explain what happens during contraction of palatoglossus during oral prep stage
A
- palatoglossus contraction –> CN X vagus
- elevates posterior tongue to seal velum
14
Q
During oral prep stage:
Obicularis oris: CN and function
A
- CN VII facial nerve
- controls lip opening and closing and lip seal
15
Q
During oral prep stage:
Buccinator: CN and function
A
- CN VII facial
- contracts surface of cheeks to keep bolus on teeth and prevent pocketing
16
Q
During oral prep stage:
Tongue sensation: CN and function
There are 3 CNs
A
- CN V trigeminal,
- CN VII Facial
- CN IX glossopharyngeal
- determines taste, size, texture, location of bolus
17
Q
During oral prep stage:
Tongue muscles: CN and motor function
A
- CN XII hypoglossal: alter shape and tone of tongue to move bolus during oral prep stage
- CN X vagus: elevates posterior tongue (contraction of palatoglossus) to seal velum
*hypoglossal is purely motor
18
Q
During oral prep stage:
Mastication muscles: CN and function
A
- CN V trigeminal (V2 & V3)
- masseter, temporalis, medial & lateral pterygoids contract and relax to facilitate chewing breaking down bolus
19
Q
During oral prep stage:
Salivation: CN and function
There are 2 CN
A
- CN VII facial, IX glossopharyngeal
- both innervate salivary glands
- lubricates and dilutes bolus
- saliva maintains the bacteriostatic environment important for QoL
20
Q
T/F
Oral seal during the oral prep stage (tongue to vellum) is constant
A
false
oral seal is not constant
21
Q
What is vallecula
A
space between base of tongue and epiglottis
22
Q
T/F
the chewed bolus can commonly collect in vallecula during oral prep and this is not a sign of impairment
A
true
23
Q
Major events in Oral Phase
A
- bolus is propelled from oral cavity to pharynx (posterior movement)
- soft palate elevation
- voluntary opening of pharynx (velum lifts while posterior tongue depresses)
- early hyoid elevation (anticipating pharyngeal phase)
24
Q
What’s the difference between the oral seal (tongue to vellum) in the oral prep stage vs the soft palette elevation in oral stage
A
During oral prep phase the tongue and vellum connect to keep bolis inside oral cavity
During oral phase the vellum elevates while posterior tongue depresses allowing bolus to enter pharynx
25
During oral stage:
Superior pharyngeal constrictor - CN and function
- CN X vagus
- contracts to facilities forceful closure around elevated velum (further protection against nasal regurgitation)
26
During oral stage:
Mylohyoid muscle - CN and function
- CN V3 trigemenal (third branch of CN V)
- begins anterior hyoid elevation in preparation of pharyngeal phase
27
T/F
Pharyngeal phase is most complex
true
28
T/F
the primary function of pharynx is swallowing
false; primary function is breathing
29
T/F
swallowing occurs during apnea (cessation of breathing)
True
trachea is closed during swallow (larynx is closed)
30
Pattern of 80% of healthy swallowing
Exhale --> Swallow/Apnea --> exhale
31
Pattern of 20% of healthy swallowing
Inhale --> Swallow/Apnea --> exhale
32
T/F
Always exhale after swallow to protect airway
true
Inhale after swallow may lead to aspiration
33
T/F
Once inititated, Pharyngeal phase, is irreversible motor event
true
34
Why is Pharyngeal phase complex
- swallowing configuration is secondary to breathing
- fast b/c apnea must be short
- involves both activation and inhibition of muscles in coordinated fashion
- involuntary
35
T/F
Faucial pillars separate oral cavity and oropharynx
true
36
T/F
Motor inputs trigger pharyngeal swallow
False
sensory inputs are the trigger
37
Where in the pharynx does the sensory trigger occur
- as bolus passes the faucial pillars
- or as bolus is lower in pharynx: MBSImp component 6 scores of 1,2,3
- also verbal cueing may improve swallow trigger located making it higher in oropharyngeal tract
38
Pharyngeal phase major events
- jaw stabilization
- bolus transfer to pharynx
- hyo-laryngeal elevation
- Laryngeal vestibule closure (epiglottis to arytenoids) including true and false vocal folds closure
- pharynx shortens and constricts
- UES opens
39
T/F
In pharyngeal phase, the false VFs close first followed by the true VFs
false
True closed first and false close 2nd -> bottom up!
40
In pharyngeal phase what muscles control the opening of UES
Suprahyoid muscles pull hyoid and larynx in a superior and anterior trajectory:
- mylohyoid (CN V): superior movement and elevation
- geniohyoid (CN I): primary anterior (forward) movement
Cricopharyngeal relaxation
41
During pharyngeal stage:
muscles of mastication - function and CN
CN V trigeminal
stabilize jaw and assist in contracting tongue muscles because tongue needs to contract against stable force
42
During pharyngeal phase:
tongue muscles- function and CN
CN XII hypoglossal
- propel bolus posteriorly
- tongue base retraction
43
During pharyngeal stage:
Superior, middle, and inferior pharyngeal constrictors
CN and function
CN X vagus
propel bolus through sequential pharyngeal constriction
44
During pharyngeal phase, name 3 muscles and innervating CN that shorten the pharynx decreasing the distance the bolus travels
Palatopharyngeus (CN X)
Salpingopharyngeus (CN X)
Stylopharyngeus (CN IX)
Collectively known as longitudinal pharyngeal muscles
45
Name the 3 muscles collectively known as longitudinal pharyngeal muscles and function
Palatopharyngeus (CN X)
Salpingopharyngeus (CN X)
Stylopharyngeus (CN IX)
shorten the pharynx decreasing the distance the bolus travels
46
In pharyngeal phase what two muscles pull hyoid and larynx in a superior and anterior trajectory and what's the function
Suprahyoid muscles pull hyoid and larynx in a superior and anterior trajectory:
- mylohyoid (CN V): superior movement and elevation
- geniohyoid (CN I): primary anterior (forward) movement
function: opening of UES
47
Pharyngeal phase:
Laryngeal muscles function and CN
CN X
- activate laryngeal ADDuctors
- stop posterior cricoarytenoid for true then false vocal fold ABduction
48
Name the 3 laryngeal muscles important in pharyngeal phase and the function
- transverse arytenoids
- oblique arytenoids
- lateral cricoartenoids
- activate laryngeal ADDuctors
- stop posterior cricoarytenoid for true then false vocal fold ABduction
49
T/F
Open UES is the default position
False
Closed/sealed UES is default position
50
Pharyngeal phase:
Cricopharyngeus function and CN
CN X
- tonic contraction helps to keep UES closed in default position
- inhibition of contraction begins in pharyngeal phase
- works in conjunction with hyo-laryngeal elevation traction forces to open UES
- contraction resumes when bolus has completely passed into esophagus
-
51
In pharyngeal phase, what 4 thing occur in protection of airway
*safety of swallowing*
- hyo-laryngeal elevation
- true VF closure
- false VF closure
- epiglottis to arytenoid seal
52
In pharyngeal phase, what 6 things occur to open UES
*efficiency of swallowing*
- tongue propulsion
- pharyngeal contraction and shortening
- hyo-larngeal traction forces
- gravity
- cricopharyngeal relaxtion
- negative pressure
53
Safety of swallowing vs Efficiency of swallowing
safety - airway protection
efficiency - bolus cleared through pharynx with no residual bolus left behind
54
Two major events of Esophageal Phase
- bolus transported down esophagus to stomach
- LES relaxes moving bolus into stomach
*longest phase of swallowing
* out of SLP scope
55
T/F
Swallowing phases are independent and segmental
False
- Not segmental
- phases overlap and influence the other
- can be bidirectional
56
Summary of Physiological events (4 steps)
1. prepare bolus and keep in mouth
2. push bolus posteriorly
3. initiate involuntary pharyngeal swallow
4. open UES
57
T/F
Dysphagia can occur anywhere from mouth to lower esophageal sphincter
true
58
T/F
Dysphagia is a disease
False
is a symptom of a disruption to the head neck muscles, their innervation or coordination
59
T/F
there is a one to one relationship of food going into lungs and pneumonia developing
false
there is risk!
60
Causes of dysphagia
- neurological
- structural of head and neck space
- head and neck cancer
- aging
- meds, respiratory compromise
61
Non-Degenerative Neurological causes of dysphagia
- vascular
- trauma
-neoplastic (brain tumor)
-congenital (CP)
-Iatrogenic (medically induced)
62
Degenerative (Progressive) Neurological causes of dysphagia and % of prevalence
- Dementia (~30%)
- Movement disorders like PD (50%), Huntingtons (85%)
63
Degenerative (Relapsing-remitting) Neurological causes of dysphagia and % of prevalence
Multiple sclerosis (34%)
64
T/F
Dysphagia occurs 100% in all ALS patients
true
65
What is penetration
- bolus in laryngeal vestibule ABOVE VFs
- safety of swallow
- sensory response is to swallow (if no swallow will likely lead to aspiration)
66
What is aspiration
- bolus BELOW level of VFs
- safety of swallow
- sensory response is to cough (if no cough = silent aspiration (this is a sensory impairment))
67
What are the two common places for bolus collection
- vallecula: space formed b/w base of tongue and epiglottis
- pyriform sinus: bilateral pockets adjacent to UES
68
What is residue
bolus that remains in the pharynx AFTER the swallow is complete (when pharynx is in breathing configuration)
- residue is at high risk for aspiration post swallow
69
ABC's of safety of swallowing
Aspiration
Below
Cords
70
the epiglottis moves in response to what two movements
larynx elevation
tongue base retracting
71
During oral prep stage:
Tongue sensation
CN and function
CN V trigeminal
CN VII facial nerve
CN IX glossopharyngeal
all 3 determine the taste, size, texture and location of bolus
72
Tubes
oral cavity and pharyngeal cavity
73
Valves
lip valve - closes
velum - close
larynx/airway - close
UES - opens
74
Pumps
allow for movement of the bolus through the oral and pharyngeal cavities
oral tongue - pushes bolus posterior
pharyngeal constrictors and longitudinal pharyngeal muscles - constrict and squeeze the bolus and push it down
traction forces - the hyolaryngeal excursion that pulls UES open (as hyoid moves, the larynx is pulled along with it. due to muscles connections, the hyoid moves up and forward pulling UES open)
75
T/F
whole swallow is initiated based on bolus sensation in the pharynx
True
76
True or false
the vagus nerve innervates the circopharyngeus muscle, once relaxed it opens the UES
True
77
What do CN 9 and CN 10 do
CN 9 is mainly sensory supplying the mucous membranes of the soft palate and pharynx; it serves as the afferent limb of the gag reflex. In addition to supplying thoracic and abdominal viscera the CN 10 innervates the muscles of the pharynx, palate and vocal cords and so controls phonation and swallowing.
Dysphagia
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