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Phases of Swallowing

• Swallowing is a complex process where saliva, liquids, and foods travel from the mouth to the stomach
• Swallowing is typically divided into four phases:

Four Phases of Swallowing

• Oral preparatory phase
  • Food or liquid is manipulated to form a cohesive bolus, including actions like sucking liquids, chewing solid food, and manipulating soft boluses
• Oral transit phase
  • Begins with the posterior propulsion of the bolus by the tongue
  • Ends when the pharyngeal swallow is initiated
• Pharyngeal phase
  • Involuntary and reflexive, starting with voluntary pharyngeal swallow
  • Propels the bolus through the pharynx using involuntary contractions of the pharyngeal constrictor muscles
• Esophageal phase
  • The bolus is carried to the stomach through esophageal peristalsis

Cranial Nerves Involved in Swallowing

• Oral Preparatory:
  • Mastication: CN V (Trigeminal)
  • Gland Secretion: CN VII (Facial) and CN IX (Glossopharyngeal)
• Oral Transport:
  • Labial Seal: CN VII (Facial)
  • Tongue Retraction: CN V (Trigeminal)
  • Post Bolus Movement: CN XII (Hypoglossal)
• Pharyngeal:
  • Soft Palate Closure: CN V (Trigeminal), CN IX (Glossopharyngeal), CN X (Vagus)
  • Laryngeal Closure: CN X (Vagus)
• Esophageal:
  • Esophageal Opening and Constriction: CN X (Vagus)

Cranial Nerve Involvement in Oral Preparation

• Saliva production:
  • Submandibular (submaxillary) glands: CN VII (Facial)
  • Parotid gland: CN IX (Glossopharyngeal)
• Taste sensation:
  • Anterior 2/3 of the tongue, hard palate, soft palate: CN VII (Facial)
  • Posterior 1/3 of the tongue, tonsils, pharynx: CN IX (Glossopharyngeal)
  • Back of the oral cavity, 1/3 of esophagus: CNX (Vagus)
• Gag reflex and nasal regurgitation depend on the glossopharyngeal (CN IX) and vagus (CN X) nerves

Peripheral and Medullary Controls in Swallowing

• Muscles of the oropharynx: CN V (Trigeminal), X (Vagus), XII (Hypoglossal)
• Muscles of the hypopharynx: CN X (Vagus)
• Extrinsic muscles of the larynx: CN V (Trigeminal) and CN XII (Hypoglossal)
• Intrinsic muscles of the larynx: CN X (Vagus)
• Esophagus: CN X (Vagus)

Neurologic Controls of Swallowing

• Neuroregulation of swallowing involves activating multiple levels of afferent and efferent pathways throughout the nervous system
• The process involves cranial nerves, brainstem, cerebellum, and cortex
• Swallowing is not a truly reflexive, brainstem-mediated response; it varies with bolus type and size
• It is a patterned neurologic response influenced by control centers above the brainstem level.
• Peripheral muscles contract sequentially but adjust to different feeding activity
• An example is typical eating/drinking versus swallowing a pill

Signs and Symptoms of Adult Dysphagia

• Drooling and poor oral management of secretions or bolus
• Inability to maintain lip closure, leading to food/liquids leaking from the oral cavity (anterior loss of bolus)
• Ineffective chewing needing extra time to chew or swallow
• Food or liquid remaining in the oral cavity after the swallow (oral residue) Leaks from the nasal cavity (nasopharyngeal regurgitation)
• Feeling that food is "sticking" or experiencing "fullness" in the neck (globus sensation)
• Pain while swallowing (odynophagia)
• Vocal quality changes to wet or gurgly sounds
• Coughing or throat clearing
• Difficulty coordinating breathing with swallowing
• Developing acute or recurring aspiration pneumonia, respiratory infection, or fever
• Changes in eating due to avoidance of certain foods/drinks
• Weight loss, malnutrition, or dehydratio

Primary Goals of Feeding/Swallowing Intervention

For Adults:

• Support adequate nutrition and hydration
• Return to oral intake
• Integrate patient dietary preferences by consulting with caregivers, to ensure the patient’s daily living activities are factored in
• Determine the optimum support (e.g., posture, or assistance) to reduce burden on patient and caregivers that also maximizes the life quality
• Develop a treatment plan to improve swallow safety and efficiency

For Children

• Support adequate nutrition and hydration
• Determine optimum feeding techniques to maximize efficiency
• Collaborate with family, to incorporate preferences
• Help attain eating skill that are age appropriate and performed within a normal setting
• Reduce the risk of pulmonary complications
• Maximize life quality
• Prevent future issues with positive experiences for feeing, as much as possible, that depends on the child’s medical situation

Anatomy of Head and Neck for Swallowing

• Nasal cavity
• Hard palate
• Tongue
• Epiglottis
• Larynx (voice box)
• Trachea
• Includes:
  • Soft palate
  • Nasopharynx
  • Oropharynx
  • Hypopharynx
  • Esophagus

Esophageal Sphincters

• The esophagus is a muscular tube connecting the pharynx to the stomach, approximately 8 inches long and lined by mucosa
• It runs behind the trachea and heart, passing through te diaphragm to enter the stomach
• UES (upper esophageal sphincter): Also known as PES, consists of muscles at the top of the esophagus
  • The major component of UES is the cricopharyngeus muscle which prevents food and secretions from entering the trachea
• LES (lower esophageal sphincter): Consists of muscles at the low end of the esophagus
  • When closed, LES prevents acid and stomach contents from traveling backwards from the stomach

Valleculae and Piriform Sinuses

• Valleculae are lateral recesses at the tongue’s base alongside the epiglottis
• Piriform sinuses are lateral recesses between the larynx and the anterior hypopharyngeal wall
• The recesses serve as important anatomic landmarks when assessing pharyngeal swallow

Phases of Swallowing: Oral Transit

• Moving upward and forward, the tip of the tongue makes contact with the hard palate
• The area of the tongue-palate expands posteriorly, pushing food into the oropharynx
• The area of tongue-palate contact continues to increase as more food gathers in the valleculae
• Jaw reaches it maximum position and the tongue drops away from the palate
• A portion of food may remain in the valleculae

Oral Transit Additional Info

• Once prepared, the tongue tip elevates to block the oral pathway at the alveolar ridge, with the bolus held against the hard palate
  • The posterior tongue delivers the bolus
• Before the first posterior tongue movement, respiration stops, followed by arytenoid cartilage approximation
• Retraction utilizes extrinsic tongue muscles
• the tongue base uses positive pressure at the tail of the bolus by contacting the velum and posterior pharyngeal wall
  • This allows rapid movement through the pharynx toward the open UES
• The velum closes the nasopharyngeal opening by the levator veli palatini

Pharyngeal Phase Info

• Occurs when the bolus arrives at level of valleculae and ends when UES closes
• As bolus enters pharynx, the hyoid bone goes to the edge of the mandible
  • it Tilts to assist with protecting the larynx under base
• Pharyngeal constrictor narrows/shortens by constricting
  • Bolus propels into the esophagus

Additional Info.

• Hyoid bone allows the larynx to pull forward/upward, and rests under the tongue so it covers the air way
• The larynx lifts to (2-3 cm) on average as the epiglottis descends over the air way
  • bolus directed to esophagus
• Bolus directs towards the spaces to deflect it from the airway

Esophageal Phase Info

• Tasks require ordered function
• Action areas come within thee distinct zones: Proximal, striated muscle; Body; Specialized smooth muscle of distal end
• As bolus flows in, primary waves triggered by 1st section
• Motor rapid during activity
• As approches mid/distal, it become slower
• Force strongest at cervix
  • Accompanied by drop in pressure (relaxation) to allow bolus within

Esophageal Phase Additional Info

• A 2nd push will follow, and will grow distending to the esophagus, from point within body
  • Push is to help send solid food
• Longitudinal contraction that shortens by proximal-distal attachment

Esophageal Phase - Tertiary Contractions:

• contractions of the esophagus are random
  • Not peristaltic
• inefficient in assisting in bolus transport
• occur independent of swallowing activity but have been reported to occur more frequently in older adults
• may be the result of air trapped in the esophagus

Respiration during swallowing: Relevant anatomy

• Muscular constriction protects system by constriction of the laryngeal vestibule and downward placement of the epiglottis
• Vocal: base margin of laryngeal base
  • attached cartilage
• False holds: (vestibular holds separate cavities
• Extended base that goes into pharyngeal

Respiration during swallowing info

• Linked their anatomy by mouth-pharynx, and relations w/ brainstem
• Inhibited when swallowed
• Flow inhibition normal begins at the start
  • Pause happens
• short cycle to stop action of the chest Air tail goes UES to start down action
• Pattern will change upon age
• Exhaling: buildup of subglottic pressure that separates the vocal folds
• Burst to to remove material lodged in the airway

Swallow and normal aging info

• Age 65+
  • sensory/perception changes to muscle issues in lung
• Loss strength durations
• Reduced capacity in lungs
• Health issues can alter biometrics

Dysphagia risk factors for CDE

• CDE in the US has 12m
• 3 factors that risk dysfactions:
  • Clinical history
  • Age 70+
  • Frailty + decline in doing activities
• Fraility is loss in ability
• Presby is healthy adult
• Sarco is low muscle and strength, which leads to loss stamina

Terminology: Undernutrition

• Poor status complicates safety
• mass of muscle/ speed in performance of impact to swallow
• Contribute lip and tongue force:
• Generation of pressure, this dysfuction also occurs in tongue
• loss in nutrition occurs too
• issues can lead to negative eating, which hits nutrition

Adult neurologic disorders - Cortical functions

• swallowing function comes from human cortex function
• Found lateral lobes/insular to be associated with feeding.
• ganglia comes along stroke issues
  • Lesions in functions of sensing

Cortical hemispheric lesions info

• Stroke affects the parietal lobe w/ sensory
• the primary also has interconnections Important for movement

Hemispheric info for control

• functions are both
• impair that hemisphere, back up exists
• Occur thru time
• function has stroked ability to swallow post problems severe dysphagia from strokes

Subcortical: Basal brain

• Regulate muscles and stability
• Affect ganglia that affect ability w/ movements
• Delay initiations, and slower movements
• disrupts movements disruptions can occur during movement or stroke

Stroke facts

• 2 considerations:
  • location and damage; this helps to better understand how the stroke has impacted them
• Patient has high chance of stroke (50)
  • High testing for evaluation in order to find problems
• Within 6wks, patients regain ability
  • outcomes get poorly if there is prolonged time period with the evaluation results, risk in take of feeding/airway
• As patient gets better, so as long as medical treatment can change
• The stroke resolves, or recovery can occur upon it
  • persisting issues

Dementia

• A hallmark would to be decrease in memory and abstract thinking, or personality shifts
• loss is the first indication of swallowing issue
• common cause in dementia in patients
  • Deficiencies motor for control
• Mild slow abilities with rinsing
• Treat in dysphagias and give comfort.

TBI (Traumatic Brain Injury)

• Typically stems in deficits
• Patients affect 60-90% of distributed actions
• Assess in factors to see the problem present within in function and ability to use scales for treatment
  • pneumatic air: early in course
• severity is high
  • high risk

TBI deficits

• Tube in test
  • cognition affected and physical ability
• w/ morbid, feeding will indicate that problems occur in injury, which is a good sign

PD: (Parkinson)

• slow progressive gait and structure that tremors will appear in stability/ stiffness
• common issues include low or high ability to use air ways and low reporting factors
• Sialorrhoea is commonly an issue along with high problems and inordination
• abnormalities occur in delivery through esophagus

Brain stem

• Head affect and movement is disrupted when damaged UMN and LMN function
  • damage: flaccid
• Alternating will side of the body
• Facial w/ movement
• Home stem or issues due from strokes: Facilitate coordination among various factors with swallow functions with low or high outcomes in general

Swallowing impairment: Brainstem

• stroke that has 2 factors: coordination and weakness, system has to give its sensor that deficits exist “Incomplete swallow”
• Incoordination is when swallowing occurs as a breathing stage or the other
  • weakness happens when the muscle is gone

Cerebellum

• Low role of cerebellum in swallowing is poorly understood, however:
  • Imaging studies – bilateral cerebellar activation during volitional swallowing Clinically, cerebellar damage results in:
• Ataxia
• Tremor
• Deflection can mess up flow

LMN: Amyotrophic Lateral Sclerosis (ALS)

• Slow progressive damage that causes terminal issues
• will get progressively failure w/ cognitive or change factors
• structure in nervous affects mixed problems
• Body muscle is used in body that can come during issues of movement or function

Muscle disease and swallowing impairment

• The muscles used during system and function has (weaken muscles, contribute to dysarthria) Polyneuropathy
• Myasthenia gravis
• Inflammatory muscle diseases
• Muscular dystrophy.
• Understand for all in general and function to see where impacts The end