Dysphagia: Terminology, structure, and process of the normal swallow - PowerPoint Presentation

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

Scott S. Rubin, Ph.D.Associate Professor, LSUHSC-NOSPTHAUD 6218Slide2

The Swallow: Structure and processes

Text for this semester -Groher, M., &

Crary, M. (2010). Dysphagia: Clinical Management in Adults and Children (3

rd

Edition), Mosby/Elsevier. ISBN: 978-0-323-05298-6 Slide3

The Swallow: Structure and processes

Presentation topics include: SLP involvement

What is Dysphagia (definitions)

Structures associated with swallow

Neurological control of swallow

Stages of normal swallowSlide4

The Swallow: Structure and processes

According to ASHAService 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 care84% 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 dysphagiaSlide5

ASHA Preferred Practice

Link to ASHA Preferred Practice Patterns for the Profession of Speech-Language Pathologyhttp://www.asha.org/docs/html/PP2004-00191.htmlPlease familiarize yourself with it!!!Slide6

The Swallow: Structure and processes

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.Slide7

The Swallow: Structure and processes

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. Slide8

The Swallow: Structure and processes

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!Slide9

The Swallow: Structure and processes

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 chokingEsophageal 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 presentationSlide10

The Swallow: Structure and processes

Associated Terminology Penetration – Material moves into

vestibule above the true vocal foldsAspiration –

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

!Slide11

The Swallow: Structure and processes

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.Slide12

Anatomy and Physiology of the Normal Swallow

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The Swallow: Structure and processes

Cranial Nerves Important in SwallowingCN V TrigeminalCN VII Facial

CN IX GlossopharyngealCN X VagusCN XII Hypoglossal

Each Nerve on following slides…

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

VisionSmellEye movement… Slide14

The Swallow: Structure and processes

Cranial Nerves Important in SwallowingCN V -- Trigeminal sensory and motor- innervates the face

important in chewing located at the level of the pons

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The Swallow: Structure and processes

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

, chinSlide16

The Swallow: Structure and processes

Cranial Nerves Important in SwallowingCN VII -- Facial  sensory and motor fibers

important for sensation of oropharynx & taste to anterior 2/3 of tongue Slide17

The Swallow: Structure and processes

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.Slide18

CN VII -- Facial Nervous Intermedious

carries rest of sensory fibers and autonomic

information.

Yellow = F. nerve Proper.

Orange, Blue, Green =

Nerv. IntermediousSlide19

The Swallow: Structure and processes

Cranial Nerves Important in SwallowingCN IX -- Glossopharyngeal

contains both sensory and motor fibers important for taste from posterior tongue, sensory and motor functions of the pharynx Slide20

The Swallow: Structure and processes

Cranial Nerves Important in SwallowingCN 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 motor

fibers to stylopharyngeus

muscle and the upper

pharyngeal muscles. Slide21

The Swallow: Structure and processes

Cranial Nerves Important in SwallowingCN 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 Slide22

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 pharynxSuperior 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.Slide23

The Swallow: Structure and processes

CN X - Vagus - 3 branches

Recurrent Laryngeal Branch

Courses past larynx – neck

and upper chest – then

from chest up to larynx

innervates all muscles of

the larynx

(except

Cricothyroid

)Slide24

The Swallow: Structure and processes

Cranial Nerves Important in SwallowingCN XII -- Hypoglossal contains motor fibers that primarily innervate the tongue Slide25

The Swallow: Structure and processes

CN XII -- Hypoglossal To all Intrinsic Musclesof Tongue

And all but one Extrinsic Slide26

Anatomy of Swallow

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The Swallow: Structure and processes

Anatomy of SwallowSkeleton

Hyoid Bone - attachment to epiglottis and strap muscles. Thyroid Cartilage - anterior attachment of vocal folds. Posterior articulation with

cricoid

cartilage. Slide28

The Swallow: Structure and processes

Anatomy of SwallowSkeleton

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. Slide29

The Swallow: Structure and processes

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. Slide30

The Swallow: Structure and processes

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 up

of muscle covered by mucosa. The vocal folds abduct for inspiration

and adduct for phonation& coughSlide31

The Swallow: Structure and processes

Divisions of Structure

Subglottis

-

below the vocal foldsSlide32

The Swallow: Structure and processes

Pyriform SinusSlide33

The Swallow: Structure and processes

ValleculaeSlide34

The Swallow: Structure and processes

Vallecula

Note aspiration in trachea.Slide35

The Swallow: Structure and processes

Review of Structures

Vallecula

Epiglottis

Upper Esophageal Sphincter (UES)

Lower Esophageal Sphincter (LES)Slide36

The Swallow: Structure and processes

Watch the structures!“Want that pizza to go?Slide37

The Swallow: Structure and processes

Glands

Parotid GlandLocated on side of face, anterior to mastoid tip and superior to the lower

Facial nerve passes through this gland. Slide38

The Swallow: Structure and processes

Submandibular GlandBeneath floor of the mouthSlide39

The Swallow: Structure and processes

Sublingual Glands - located below the mucous membrane of the floor of the mouth, adjacent to mandible and mylohyoid muscle. Slide40

The Swallow: Structure and processes

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. Slide41

Stages of the normal swallow

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Stages of the normal swallow

(Oral Prep Phase)

- Oral Phase

- Pharyngeal Phase

- Esophageal Phase Slide43

The Swallow: Structure and processes

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. Slide44

The Swallow: Structure and processes

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 Slide45

The Swallow: Structure and processes

Esophageal Phase Peristalsis carries the bolus through esophagus to the stomach.

The lower espohageal

sphincter opens.Slide46

Summary of the Swallow

“

Swallow Reloaded”Slide47

The Swallow: Structure and processes

FIGURE 1A.

ORAL Phase - The tongue initially forms the food bolus (green)

with compression against the hard palate.Slide48

The Swallow: Structure and processes

FIGURE 1B. PHARYNGEAL Phase Displacement of the food bolus into the pharynx by the tongue initiates deglutitionSlide49

The Swallow: Structure and processes

FIGURE 1C. ESOPHAGEAL Phase - Relaxation of the cricopharyngeal muscle (the physiological upper esophageal sphincter) permits movement of the food bolus into the proximal esophagus.Slide50

The Swallow: Structure and processes

The Swallow

Videofluoroscopy Segments Slide51

Dysphagia: SLP’s Role

Complete Honey Consistency – 1/3 teaspoon

Posterior movement backElevation and retraction of velumElevation and anterior movement of the hyoid and larynx

Bolus transported into

valleculae

Backward movement of the eppoglottisSlide52

Dysphagia: SLP’s Role

Ground meat 1/3 teaspoon ¼ cookieOral Preparatory Phase Pharyngeal Phase

2nd swallow – to clear material Slide53

The Swallow: Structure and processes

Videofluoroscopy Segments

link Slide54

The Swallow: Structure and processes

End Sequence – Go to next… #2