Final Exam – Study Guide PDF

Final Exam – Study Guide 1. Introduction to Swallow a. What is the difference between swallowing safety and efficiency? i. Safety = swallowing without aspiration or penetration. ii. Efficiency = Swallowing and not leaving behind residue. b. W...

Final Exam – Study Guide 1. Introduction to Swallow a. What is the difference between swallowing safety and efficiency? i. Safety = swallowing without aspiration or penetration. ii. Efficiency = Swallowing and not leaving behind residue. b. What is the difference between penetration and aspiration? i. Penetration = food or liquid enters the airway ABOVE the vocal folds ii. Aspiration = food or liquid enters the airway AT or BELOW the vocal folds 2. Swallowing Anatomy & Physiology a. Match the muscles involved in the swallowing process with physiologic events. (see table below) b. Match the muscles involved in the swallowing process with cranial nerves. (see table below) c. Respiratory-swallow coordination: (exhale, swallow, exhale) i. How can respiratory abnormalities impact swallowing? 1. Need to note down their respiratory status as it affects eating - these patients are at risk of a different pattern of aspiration, make have respiratory distress that leads to fatigue and influences swallow, trachs can effect swallowing function, may need to position patient in a different way due to trach ii. What are the mechanisms involved in airway protection during swallowing? 1. Elevation and anterior movement of hyoid and larynx (thyrohyoid muscle). 2. Closure of the larynx at four levels. a. Adduction true VFs b. Approximation Of Vestibular Folds (false VFs) c. Anterior adduction of arytenoids and arytenoids approximation to base of epiglottis d. Epiglottic inversion 3. Respiratory cessation a. Neural suppression of breathing at brainstem level (medulla) d. Neural control of swallowing: i. Why is the brainstem critical for swallowing? 1. controls movements involved in swallowing, and regulates breathing ii. What brainstem regions are important for swallowing?  1. Brainstem (medulla) Central Pattern Generator - Stimulate motoneurons in brainstem nuclei 2. Nucleus tractus solitarius (NTS) - produces sensory information related to swallowing 3. Nucleus ambiguus 3. Clinical Swallowing Examination (CSE) a. What are the goals of a CSE? i. FIRST step toward diagnosis of dysphagia and therapeutic process ii. Elucidate symptomatology iii. Examine sensory and motor aspects related to swallowing iv. Determine need and readiness for instrumental swallowing evaluation v. Determine safety for oral intake and diet recommendation b. What are the limitations of a CSE? i. Does not allow evaluation of entire swallowing pathway ii. Does not provide complete information of oral, pharyngeal, and laryngeal structures and function iii. Cannot provide information regarding timing, pharyngeal residue, penetration, and aspiration iv. Cannot identify physiologic cause of swallowing disorders v. Clinical guess: no definitive way to detect abnormal swallow physiology vi. Cannot develop adequate treatments without physiologic information c. What are the steps of a CSE? i. 1. Gather information (chart review, patient/family interview) ii. 2. Physical exam (respiratory and nutrition status, cog and speech-language, oral mech exam) iii. 3. Bolus trials (columns and consistencies, swallowing strategies) d. How do you access the cranial nerves involved in swallowing? i. CN V - open/close jaw, Jaw jerk reflex, sucking reflex, rooting reflex ii. CN VII - Close eyes, look up, raise eyebrows, pucker lips, smile, frown, puff out cheeks, wrinkle forehead, Imprecise articulation, asymmetry of face iii. CN IX - Gag reflex, hypernasality iv. CN X - Weak cough, glottal coup, control of volume, Breathy or hoarse voice v. CN XI - Turn head against resistance, Shrug shoulders vi. CN XII - Protrude tongue, move tongue laterally, lick lips, elevate tongue, depress tongue, Push against tongue between teeth and cheek against resistance, Imprecise articulation e. What physiologic components can we assess during a CSE bolus trial?  i. Oral containment, mastication/oral movements, oral transit duration, secretion ii. Initiation of pharyngeal swallow, reaction to food iii. Changes in respiratory rate iv. Breathing swallow coordination v. Total intake f. What physiologic deficits can we observe during bolus trials? i. Oral residue, aspiration/penetration evidenced by cough or choking, regurgitation of food 4. Instrumental Swallowing Evaluation a. What are the goals of MBSS? i. Determine if patient is swallowing safety when eating different consistencies b. What are the limitations of MBSS? i. Limited frequency and length of studies due to radiation exposure ii. Sampled in artificial eating environment iii. Does not allow assessment of secretion iv. Does not allow assessment of sensation of tissue v. Need a trained SLP and radiologist c. What are the advantages of MBSS? i. Dynamic study of swallow biomechanics (visualization from oral cavity to esophagus) ii. If recorded, unlimited review capabilities iii. Information about physiological impairments and effects of strategies d. What are the goals of FEES? i. Assess the patient’s ability to maintain airway protection over time during swallowing. e. What are the limitations of FEES? i. Does not allow evaluation of bolus management ii. Moment of swallow is not viewed iii. penetration/aspiration during swallowing cannot be visualized iv. Does not allow evaluation of some pharyngeal events (hyolaryngeal movement, LVC, BOT retraction, PES opening, epiglottic inversion) v. Indirect physiologic information (based on residue location, airway invasion) f. What are the advantages of FEES? i. Provides real-time visual feedback ii. Allows visualization of presence of secretion iii. Allows visualization of tissue and anatomic structures iv. Gives optimal information on residue  g. What does the PAS evaluate? (There is no need to memorize PAS levels; a table will be provided) i. PAS evaluates the severity of penetration or aspiration during swallow. 5. Swallowing Disorders in Adults a. Match swallowing deficits with physiology and muscles. (table above) 6. Dysphagia Management in Adults a. What are the goals of dysphagia intervention? i. Improve, maintain, or prolong swallowing function ii. Improve, maintain, or prolong associated physiologic reserve (cross- system) respiratory capacity, airway defense, physiologic capacity iii. Maximize oral intake iv. Facilitate least restrictive diet v. Maximize quality of life vi. Actively engage patient in their rehabilitation or maintenance program b. What are the differences between compensatory vs. rehabilitation swallowing strategies? i. Compensation: improve safety and efficiency of swallowing without directly targeting swallowing physiology. Rehabilitation: improve safety and efficiency of swallowing by directly targeting swallowing physiology. 1. Compensatory techniques: techniques, indications, and potential effects (contraindications). a. Diet modifications i. Techniques: change viscosity, alter texture, modify volume ii. Indications: delayed pharyngeal swallow, premature spillage, reduced oral control, reduced airway mechanism iii. Potential effects: improves bolus control in OC, decrease bolus flow in pharynx (requires more strength, may increase residue) iv. Considerations: thickened liquids may reduced compliance and negative effect on hydration, food not as appealing b. Sensory stimulation i. Techniques: taste (sour, citric bolus), temperature (cold, ice chips), tactile (carbonated bolus, increase bolus volume, increase downward pressure of spoon against tongue when presenting food), self feeding ii. Indications: delayed initiation of pharyngeal swallow, impaired oral sensation, NPO patients  iii. Potential effects: increased sensory awareness, improved pharyngeal swallow response and oral and pharyngeal transit times iv. Considerations: Increased bolus volume may increase the risk of aspiration in some populations c. Adaptive feeding equipment i. Techniques: utensils, dishes, cups/syringes ii. Indications: Upper extremity deficits that prevent iii. Self-feeding, Aspiration of high-volume thin liquids iv. Potential effects: increased sensory awareness, improved pharyngeal swallow response and oral and pharyngeal transit times d. Prosthetics i. Indication: inefficient VP closure, clef palate/oral cancer ii. Techniques: palatal lift, palatal obturator, palatal reshaping e. Postural changes i. Techniques: Changes in body/head posture to change dimensions of pharynx and direction of bolus flow ii. Potential effects: Eliminate or reduce aspiration, Improve oral and pharyngeal transit times, Improve bolus clearance iii. Reclined position 1. Use when discoordination of pharyngeal swallow, Incomplete pharyngeal constriction (Residue) 2. Effects: Uses gravity for bolus transfer from OC to pharynx, Decreases gravity in pharynx (Decreases speed of bolus) iv. Head extension 1. Use when inefficient bolus transport/lingual motion (increased transit time) 2. Effects: uses gravity to transport bolus from OC to pharynx (facilitates oral clearance and bolus propulsion), reduces airway protection 3. Consideration: Patients with impaired airway protection mechanisms (Poor laryngeal elevation, Reduced LVC), Patients  with cervical abnormalities or neck contractures v. Side-lying (stronger side down) 1. Use when reduced pharyngeal contraction (unilateral pharyngeal residue) 2. Effects: Reduces effects of gravity (Slows bolus flow), Directs bolus to stronger hemipharynx (Emphasizes pharyngeal contraction) 3. Considerations: GERD (need to elevate upper body) vi. Chin-tuck 1. Use when Premature spillage, Delayed pharyngeal swallow, Poor airway mechanism 2. Effects: Narrows oropharynx (Widens vallecular space, Pushes BOT toward PPW), Narrows laryngeal inlet (Pushes epiglottis posteriorly, Enhances LVC) 3. Considerations: may increase residue in vallecular space, Poor lip control will cause anterior loss, Inefficient lingual motion will affect bolus propelling, patients w/ cervical abnormalities vii. Head tilt (strong side) 1. Use when Unilateral facial/oral weakness AND Unilateral pharyngeal weakness (Unilateral residue) 2. Effects: Utilizes gravity to direct bolus to stronger side (Facilitates oral control, Increases sensation and motor strength) 3. Considerations: bilateral weakness, opposite oral and pharyngeal side weakness viii. Head turn (weak side) 1. Use when Unilateral pharyngeal weakness, Unilateral residue PS, lateral channels, PPW Unilateral VFs paresis/paralysis 2. Effects: Narrows weak pharyngeal side (Decreases residue), Redirects bolus to  stronger side, Decreases UES pressure (Facilitates UES opening) 3. Considerations: Patients with cervical abnormalities that prevent head turn, Can be used in combination with chin-tuck 4. f. Others i. Multiple swallows - Reduce/clear oral and pharyngeal residues ii. Alternate solids and liquids - “Liquid wash”, Reduce/clear residue iii. Small bites/sips - control bolus flow, reduce reside iv. Reduce distractions - turn off TV, remove non-food items from dining table, limit visitors during mealtimes, use cue cards with strategies v. Train caregiver - 1:1 training, provide handout g. Maneuvers (both compensatory and rehabilitative) i. Supraglottic (inhale & hold breath, put food in mouth and swallow - while holding breath, cough after swallow and swallow again) 1. Use when reduced airway protection at VF level, aspiration after swallow due to penetration 2. Effects: Promotes VFs adduction before/during swallow, Clears laryngeal vestibule of penetrated material 3. Considerations: Patients with respiratory difficulties may not be able to complete the maneuver, Patients with cognitive deficits ii. Super-supraglottic (inhale, hold breath, bear down as you swallow - while holding breath), cough after swallowing and swallow again) 1. Use when reduced airway closure at laryngeal vestibule level (aspiration before/during swallow) 2. Effects: Promotes VFs adduction before/during swallow, Enhances LVC (Arytenoids tilt forward) 3. Considerations: Not indicated for patients with coronary artery disease, Patients with  respiratory difficulties or cognitive deficits may not be able to complete the maneuver iii. Effortful swallow (Swallow with effort, squeezing your tongue, Swallow with effort, squeezing your throat) 1. Use when decreased tongue base retraction (residue vallecula), reduced laryngeal elevation 2. Effects: Increases lingual pressure on bolus, Improves pharyngeal pressure, Improves BOT retraction, Reduces residue valleculae, Improves hyolaryngeal excursion, Airway protection, Improves UES opening 3. Considerations: fatigue w/ some patient populations (e.g., ALS), best when taught with biofeedback iv. Mendelsohn - initiate a swallow, at peak of swallow don’t let larynx drop by squeezing throat muscles (hold for 3 sec) 1. Use when decreased hyolaryngeal excursion and duration, Reduced/delayed UES opening, Incoordination of pharyngeal swallow 2. Effects: Prolongs/increases hyolaryngeal excursion, Improves LVC (Decreases aspiration), Increases duration and width of UES opening 3. Considerations: Cognitive abilities, Best when taught with biofeedback 2. Match physiologic deficits with compensatory techniques. ii. Rehabilitation techniques: techniques, indications, and potential effects (contraindications). 1. Labial strengthening and ROM a. ROM - Pucker lips and smile or /u/ /i/, Send a kiss, Inflate the cheeks and hold, b. Resistive exercises (strength), Straw drinking, Different liquid consistencies and straw diameter, Hold tongue depressor between lips, Blowing exercises, Iowa Oral Performance Instrument (IOPI)  c. Use when impaired lip seal, difficulty removing food from utensils d. Effects: improve ROM and strength, decrease anterior loss of food and maintain intraoral pressure 2. Lingual exercises a. ROM - side to side, tongue tip elevation, stick tongue out, tongue up and down b. Resistive exercises - Press tip of tongue against tongue depressor (hold for 5 seconds), Press tip of tongue against alveolar ridge (hold for 5 seconds), IOPI tongue press at max level or swallow pressing tongue at different pressure levels, IOPI endurance (set to 50-80% max) c. Use when impaired bolus control (premature spillage), Impaired bolus preparation, Impaired bolus transport/lingual motion (Oral residue) d. Effects: improve muscle mass, tongue control during bolus hold, bolus preparation, bolus transport/lingual motion 3. Mandibular strengthening and ROM a. ROM & strengthening - open and close mouth, move jaw side to side, mastication tasks, mouth stretching b. Use when trismus, resection mastication muscles, fibrosis c. Effects: improve bolus preparation/mastication 4. Masako maneuver (tongue hold) a. Stick out tongue and swallow while holding tongue between teeth b. Use when Reduced PPW contraction (Vallecular and PPW residue), BOT resection c. Effects: Improves contact between BOT and PPW (PPW bulging and BOT anterior position), Improves pharyngeal stripping wave (Pharyngeal clearance) 5. Shaker exercise (head lift) a. Isokinetic - Lie down in supine position, Raise head and look at toes without raising shoulders, Repetitions: 30 head raisings at constant speed b. Isometric - lie down in supine position, raise head and look at toes, Hold head for 3x60 seconds with 1-minute rest between trials c. Use when reduced UES opening (residue PS and UES), reduced hyolaryngeal excursion  d. Effects: improves magnitude of UES opening, improves hyoid movement (and larynx), strengthened suprahyoid muscles 6. Chin tuck against resistance (CTAR) a. ISOKINETIC - Put the CTAR ball (or device) between chin and chest, Squeeze the ball (device) with your chin b. ISOMETRIC - Put the CTAR ball (or device) between chin and chest, Squeeze the ball (device) with your chin and hold it for 60 seconds c. Use when reduced UES opening (residue PS and UES), reduced hyolaryngeal excursion d. Effects: improved magnitude of UES opening, improves hyoid movement (and larynx), strengthened suprahyoid muscles 7. Jaw opening against resistance (JOAR) a. ISOKINETIC - Put the CTAR device between chin and chest, Open the mouth while holding the CTAR device in place b. ISOMETRIC - Put the CTAR device between chin and chest, Open the mouth keeping the CTAR device in place and hold it for 3-5 seconds c. Use when reduced UES opening (residue PS and UES), reduced hyolaryngeal excursion, impaired jaw opening/mastication d. Effects: improves magnitude of UES opening, improved hyoid movement, improves jaw-opening (facilitates chewing) 8. Effortful pitch glide a. Produce /i/ starting in your comfortable pitch, Glide up to your highest pitch, Once you reach the highest pitch, exert effort to produce a forceful /i/ b. Use when impaired pharyngeal stripping wave and pharyngeal contraction, impaired laryngeal elevation c. Effects: Improves pharyngeal contraction and constriction, Effortful production, Improves laryngeal elevation, Pitch glide production 9. Effortful swallow (see above) 10. Mendelsohn effect (see above) 11. Expiratory muscle strength training (EMST) a. 5 sets of 5 breaths, 5 days a week, 5 weeks  b. Use when Inadequate respiratory driving forces c. Effects: Improves expiratory pressure and cough pressure, Improves hyolaryngeal excursion (Strengthens submental muscles) d. Neuromuscular electrical stimulation (NMES) i. Electrodes placed on face or neck, low voltage electrical currents cause contraction of muscle fibers ii. voluntary contraction + electrical stimulation = increased movement e. McNeal Dysphagia therapy program (MDTP) i. Intensive swallowing practice program (Food hierarchy: Ice chips – thick liquids – thin liquids –pudding – soft solids – hard solids), Starts with safest liquid ii. “Swallow as fast and hard as you can” iii. Improvements: MASA and FOIS scores but needs instrumental swallowing evidence f. Lee Silverman Voice Treatment (LSVT) i. Systematic hierarchy of voice/speech exercises 1. Loudness 2. High-effort vocalizations ii. System-wide effects 1. Improvements in breath support for respiratory drive 2. Improves recruitment and strength of pharyngeal and laryngeal muscles c. Understand how Principles of Neuroplasticity and Motor Learning can be applied to dysphagia management. i. Neuroplasticity 1. Use It or Lose It: Encourage active swallowing practice. Inactivity can lead to further decline in neural networks related to swallowing. Example: Practicing swallowing with safe consistencies to maintain or regain function 2. Use It and Improve It: Target swallowing exercises designed to strengthen and refine specific swallow functions. Example: Shaker exercises or effortful swallows to improve suprahyoid muscle strength  3. Specificity: Therapy tasks should closely mimic actual swallowing to facilitate neural connections specific to the act. Example: Using bolus swallows instead of non-swallow exercises when safe. 4. Repetition Matters: Repeated practice is crucial for reinforcing neural pathways. Example: High-frequency repetition of swallowing exercises during sessions and at home. 5. Intensity Matters: Higher-intensity interventions can promote better neuroplastic adaptation. Example: Intense programs like the McNeill Dysphagia Therapy Program (MDTP). 6. Time Matters: Earlier intervention may lead to better outcomes due to greater neural plasticity post-injury. Example: Initiating swallowing exercises as soon as it's safe after a stroke. 7. Salience Matters: Activities must be meaningful to the patient to engage neural mechanisms effectively. Example: Incorporating food or drink the patient enjoys when appropriate. 8. Age Matters: Neuroplastic changes can occur at any age but may be slower in older adults. Example: Adjusting the therapy pace for older adults while maintaining consistent practice. 9. Transference: Training in one swallowing activity can facilitate improvements in similar tasks. Example: Practicing effortful swallows to generalize strength across different bolus sizes. 10. Interference: Avoid competing neural adaptations that may interfere with progress. Example: Discouraging compensatory strategies that reduce swallowing effort, like chin tuck, if not needed. ii. Motor Learning 1. Practice Variability: Use varied tasks and conditions to promote generalization. Example: Practicing with different bolus sizes, textures, and temperatures. 2. Feedback: Provide immediate, specific feedback during the early learning phase, transitioning to less frequent feedback to foster independent motor learning. Example: "That was a strong effortful swallow—keep activating those muscles!" transitioning to "How did that feel?" 3. Distribution of Practice: Spaced practice (distributed over time) is more effective than massed practice. Example: Practicing swallowing exercises several times a day instead of all at once. 4. Task Complexity: Begin with simpler tasks and gradually increase difficulty as the patient improves. Example: Starting with dry swallows before progressing to food or liquid swallows.  5. Active Engagement: Active participation in exercises improves learning and outcomes. Example: Incorporating patient-led goal setting and self-monitoring. 6. Error-Based Learning: Allow safe errors to facilitate learning through correction. Example: Letting the patient attempt a challenging swallow task and guiding them to adjust technique. d. What are the differences between strength training vs. skill training? i. Skill training 1. Exercises to target accurate swallowing performance (timing, movement, strength, coordination), relearning sequencing movement (repetition and refinement, visual biofeedback) ii. Strength training 1. Exercises to strengthen the peripheral swallowing muscles, practice and training lead to improvement in performance, assumptions of muscle weakness 7. Plan of Care a. Goal writing (S.M.A.R.T.) i. Specific, measurable, attainable, relevant, timely ii. b. Short-term goals i. Smaller, hierarchical steps designed to reach the long-term goals ii. Examples: iii. Patient will decrease pharyngeal residue by improving pharyngeal stripping while performing the Masako Maneuver in 3 sets of 8 out of 10 trials without evidence of fatigue using visual biofeedback.. iv. Patient will increase the duration and extent of UES opening and improve pharyngeal clearance by performing the Mendelsohn Maneuver and holding for 5 seconds during 8 out of 10 trials to minimize clinical signs of penetration/aspiration (e.g., coughing, throat clearing, wet vocal quality).  c. Long-term goals i. Cover the period of time the patient is in the current level of care (Acute care vs. outpatient) ii. Consider patient-reported outcomes iii. Example: Patient will meet nutritional need by mouth, with a regular diet and nectar thick liquids, without use of strategies within 6 weeks with no radiographic evidence of pharyngeal residue. iv. Patient will maintain adequate nutrition/hydration in session and at home with safety and efficiency of swallowing function intake without overt signs and symptoms of aspiration for the highest appropriate diet level. v. Patient will utilize compensatory strategies in session and at home with safety and efficiency of swallowing function without overt signs and symptoms of aspiration for the highest appropriate diet level. 8. Ethics and Cultural Competence a. Understand how the Principles of Healthcare Ethics are applied to dysphagia management. i. Autonomy: right of patients to make decisions about their medical car (e.g., patient not following diet recommendations, refusing tube feeding) ii. Beneficence: acting in patient’s best interest to promote well being (e.g., optimize quality of life, optimizing swallow function) iii. Nonmaleficence: do no harm (e.g., safe recommendation, regular monitoring) iv. Justice: healthcare access & disparities, barriers that impact health outcomes b. What are the steps of the decision-making process for patient care? i. Clinical indication 1. Medical history, accurate diagnosis treatment options ii. Patient preferences 1. Personal history, religious and personal values, preferences, capacity to express decisions iii. Contextual factor 1. Economic, family preferences, legal issues c. Understand how cultural differences may impact dysphagia management. i. Communication - degree to which patients understand and use the information given to them ii. Food choices - food preferences, meal times/meal expectations, eating rules iii. Cultural beliefs & values - family roles, perspectives in death, gender/age roles etc. d. How to be culturally responsive in dysphagia management?  i. Acknowledge cultural differences ii. Understand your own culture iii. Engage in self-assessment iv. Acquire cultural knowledge & skills v. View behavior within a cultural conext Functional Name Innervation Action Swallowing physiology Swallowing deficit Group Lip m. Orbicularis oris CN VII (facial) Open/close mouth, Lip seal Impaired lip seal invert/ twist/ pucker lips Anterior bolus loss Difficulty taking food from utensils Reduced oral pressure Pocketing food anterior/lateral sulci Cheek m. Buccinator CN VII (facial) Compresses lips and cheeks Helps transport bolus Bolus pocketing against teeth, draws mouth corner through oral cavity Difficulty sucking from straw laterally Soft palate m. Palatoglossus CN X (pharyngeal Lowers soft palate, elevates Prevents premature Pocketing of food in anterior plexus vagus) posterior tongue, creates spillage before the sulcus and lateral sulci posterior boundary of oral cavity swallow Difficulty holding/collecting food on midline tongue Palatopharyngeus CN X (pharyngeal Lowers soft palate, closes Closes velopharynx to Increased oral transit time plexus vagus) velopharynx by moving lateral make sure bolus Difficulty propelling bolus to walls in doesn’t enter back of tongue nasopharynx Levator Veli CN X (pharyngeal Elevates soft palate to Prevents bolus from Nasal Regurgitation Palatini plexus vagus) velopharyngeal closure entering nasopharynx Musculus uvulae CN X (pharyngeal Forms uvula, elevates soft palate, Shortening uvula allows Nasal Regurgitation plexus vagus) shortens/elevates uvula for closure of nasopharynx Tensor Veli Palatini CN V (trigeminal) Tenses soft palate, helps Tensing the soft palate Nasal Regurgitation  velopharyngeal closure during prevents food from swallowing entering nasopharynx Intrinsic tongue Superior CN XII (hypoglossal) Shortens tongue and elevates tip Moves bolus to back of Impaired bolus transport, m. longitudinal tongue difficulty propelling bolus back into oropharynx, tongue pumping, slow or disorganized lingual motion (oral residue), increased oral transit time Inferior CN XII (hypoglossal) Shortens tongue and depresses Helps with bolus Impaired bolus transport, longitudinal tongue tip transport to molars for difficulty propelling bolus back mastication and back of into oropharynx, tongue tongue pumping, slow or disorganized lingual motion (oral residue), increased oral transit time Transverse CN XII (hypoglossal) Narrows tongue and elongates Helps with bolus Impaired bolus transport, tongue transport to molars for difficulty propelling bolus back mastication and back of into oropharynx, tongue tongue pumping, slow or disorganized lingual motion (oral residue), increased oral transit time Vertical CN XII (hypoglossal) Flattens tongue Helps with bolus Impaired bolus transport, transport to molars for difficulty propelling bolus back mastication and back of into oropharynx, tongue tongue pumping, slow or disorganized lingual motion (oral residue), increased oral transit time Extrinsic tongue Genioglossus CN XII (hypoglossal) Posterior fibers: draw tongue Helps with bolus Impaired bolus transport, m. forward from tongue tip transport to molars for difficulty propelling bolus back  protrusion. Anterior fibers: retract mastication and back of into oropharynx, tongue tongue tip into oral cavity. tongue pumping, slow or disorganized Contraction of whole muscle: lingual motion (oral residue), depresses tongue. increased oral transit time Hyoglossus CN XII (hypoglossal) Elevates and closes mandible Mastication of bolus Impaired bolus preparation, ineffective and prolonged mastication Styloglossus CN XII (hypoglossal) Pulls tongue upward and retracts Bolus transport Increased oral transit time, oral tongue residue Palatoglossus CN X (pharyngeal Elevates tongue and lowers soft Bolus transport Increased oral transit time, oral plexus vagus) palate residue Mastication m. Masseter CN V (trigeminal) Elevates and closes mandible Mastication of bolus Impaired bolus preparation, ineffective and prolonged mastication Temporalis CN V (trigeminal) Elevates and retracts mandible Mastication of bolus Impaired bolus preparation, ineffective and prolonged mastication Medial pterygoid CN V (trigeminal) Elevates and closes mandible Mastication of bolus Impaired bolus preparation, ineffective and prolonged mastication Lateral Pterygoid CN V (trigeminal) opens/closes mandible, side to Mastication of bolus Impaired bolus preparation, side motion of mandible and ineffective and prolonged protrudes mandible mastication FOM m. Anterior belly CN V (trigeminal) Depresses mandible Contributes to hyoid Impaired bolus preparation, Digastric elevation, mastication ineffective and prolonged mastication  Reduced epiglottic inversion, reside in valleculae, decreased airway protection Mylohyoid CN V (trigeminal) Depresses mandible Contributes to hyoid Impaired bolus preparation, elevation, mastication ineffective and prolonged mastication Reduced epiglottic inversion, reside in valleculae, decreased airway protection Geniohyoid CN XII (hypoglossal) Depresses mandible Contributes to hyoid Impaired bolus preparation, elevation, mastication ineffective and prolonged mastication Reduced epiglottic inversion, reside in valleculae, decreased airway protection Pharyngeal Superior CN X (pharyngeal Assists with VP closure and tongue Moves bolus from Decreased pharyngeal stripping constrictors constrictor plexus vagus) base retraction pharynx into esophagus wave, decreased pharygneal (pharyngeal stripping driving pressures, increased wave) pharygneal transit time Middle constrictor CN X (pharyngeal Narrows diameter of pharynx Moves bolus from Decreased pharyngeal stripping plexus vagus) pharynx into esophagus wave, decreased pharygneal (pharyngeal stripping driving pressures, increased wave) pharygneal transit time Inferior constrictor CN X (pharyngeal contracts/narrows pharynx Moves bolus from Decreased pharyngeal stripping plexus vagus) pharynx into esophagus wave, decreased pharygneal (pharyngeal stripping driving pressures, increased wave) pharygneal transit time Long Stylopharyngeus CN IX Elevates pharynx Elevating pharynx helps increased pharygneal transit pharyngeal m. (glossopharyngeal) move bolus down the time, impaired opening of UES esophagus Salpingopharyngeu CN X (pharyngeal Elevates pharynx Elevating pharynx helps increased pharygneal transit s plexus vagus) move bolus down the time, impaired opening of UES esophagus Palatopharyngeus (pharyngeal plexus Elevates pharynx Elevating pharynx helps increased pharygneal transit vagus) move bolus down the time, impaired opening of UES esophagus Suprahyoid m. mylohyoid CN V (trigeminal) Depresses mandible, lifts hyoid Elevating hyoid Aspiration/penetration after the (Extrinsic bone, elevates FOM provides airway swallow or during laryngeal m.) protection, elevating floor of mouth helps propel bolus into oropharynx Digastric Anterior: CN V Anterior: depresses mandible Elevating hyoid Aspiration/penetration after the Posterior: CN VII Posterior: elevates and retracts provides airway swallow or during hyoid protection stylohyoid CN VII (facial) Elevates and retracts hyoid Elevating hyoid Aspiration/penetration after the provides airway swallow or during protection,  geniohyoid CN XII Hyoid fixed: depresses mandible Mandible fixed: elevates and protrudes hyoid Infrahyoid m. thyrohyoid CN XII Decreases distance Elevates larynx, Decreased Laryngeal Elevation = Reduced airway (Extrinsic (hypoglossa between hyoid facilitates opening of protection (aspiration or penetration), impaired UES laryngeal m.) l) bone and thyroid UES opening = penetration/aspiration AFTER swallow, residue cartilage pyriform sinuses omohyoid CN XII Depresses hyoid Depressing hyoid Decreased anterior hyoid excursion (reduced epiglottic (hypoglossa bone bone protects the inversion, decreased airway protection) impaired UES l) airway, helps open opening = penetration/aspiration AFTER swallow, residue UES pyriform sinuses sternohyoid CN XII Depresses hyoid Depressing hyoid Decreased anterior hyoid excursion (reduced epiglottic (hypoglossa bone bone protects the inversion, decreased airway protection) impaired UES l) airway, helps open opening = penetration/aspiration AFTER swallow, residue UES pyriform sinuses sternothyroid CN XII Depresses thyroid Reopens airway by Delayed airway reopening (hypoglossa cartilage depressing larynx l) after swallowing has occured Intrinsic laryngeal thyroarytenoi CN X - RLN Relaxes vocal Closes vocal folds for Incomplete VF adduction (decreased airway protection) m. d ligament airway protection causes penetration/aspiration BEFORE or DURING the swallow Lateral CN X - RLN Adduction of vocal Closes vocal folds for Incomplete VF adduction (decreased airway protection)  cricoarytenoi folds airway protection causes penetration/aspiration BEFORE or DURING the d swallow Interarytenoi CN X - RLN Close glottis and Closes vocal folds for Incomplete VF adduction (decreased airway protection) d & SLN vocal folds airway protection causes penetration/aspiration BEFORE or DURING the swallow Cricothyroid CN X -SLN Stretches and Closes vocal folds for Incomplete VF adduction (decreased airway protection) tenses vocal airway protection causes penetration/aspiration BEFORE or DURING the ligament swallow Posterior CN X - RLN Abduction of vocal Repoens the airway Delayed airway reopening cricoarytenoi folds and rotates after swallowing has d the cartilage occured Oblique CN X - RLN Adduction of Closes vocal folds for Incomplete VF adduction (decreased airway protection) arytenoids arytenoid cartilages airway protection causes penetration/aspiration BEFORE or DURING the swallow Esophagus Esophagus CN X Contracts to move Esophageal peristalic Esophageal dysmotility, GERD muscle bolus through wave esophagus to stomach