Swallowing Guide PDF

SWALLOWING: Week 12 1. Identify phases of swallowing and events that correspond to each of the phases - These phases describe the movements of the bolus through the oral, pharyngeal, and esophageal segments of swallowing The Oral Preparatory Phase of swallowing is the initial...

SWALLOWING: Week 12 1. Identify phases of swallowing and events that correspond to each of the phases - These phases describe the movements of the bolus through the oral, pharyngeal, and esophageal segments of swallowing The Oral Preparatory Phase of swallowing is the initial stage of the swallowing process, which involves preparing food or liquid in the mouth for safe and efficient swallowing. This phase is entirely voluntary and requires coordinated actions of the lips, tongue, cheeks, and jaw. Key steps and features of this phase include: 1. Food or Liquid Intake: The lips close tightly to prevent food or liquid from escaping the mouth (lip seal), and the cheeks contract to keep the bolus (the mass of food or liquid) centralized on the tongue. 2. Mastication (Chewing): For solid food, the teeth and jaw work to break it into smaller pieces, while saliva is secreted to moisten it, forming a cohesive bolus that is easier to swallow. 3. Bolus Formation: The tongue manipulates and mixes the food with saliva, shaping it into a bolus. This ensures the bolus is of an appropriate size and consistency for swallowing. 4. Sensory Processing: During this phase, sensory receptors in the oral cavity assess the texture, size, and temperature of the bolus, which helps coordinate the subsequent swallowing stages. 5. Bolus Positioning: Once the bolus is ready, the tongue positions it on the center of the tongue, typically just behind the front teeth, in preparation for the next phase (the Oral Phase). - This phase is critical for ensuring the bolus is safe and properly prepared for swallowing, reducing the risk of aspiration (entry of food or liquid into the airway) or choking. Impairments in this phase, often due to neurological or structural issues, can lead to difficulties in swallowing, known as dysphagia. The Oral Transport Phase is the second stage of swallowing, following the Oral Preparatory Phase. It is a voluntary phase that involves moving the prepared bolus (a cohesive mass of food or liquid) from the oral cavity to the pharynx, initiating the swallowing reflex. - Voluntary phase that transitions into the involuntary phase 1. Tongue Action: ○ The tongue plays a central role by pressing against the hard palate (roof of the mouth) in a wave-like motion, propelling the bolus posteriorly (toward the back of the mouth). ○ The sides of the tongue maintain contact with the teeth or alveolar ridge to prevent the bolus from escaping laterally. 2. Lips and Cheeks: ○ The lips remain sealed to maintain pressure and prevent any bolus escape. ○ The cheeks stay contracted to assist in guiding the bolus centrally. 3. Velum Elevation: ○ The soft palate (velum) begins to rise and close off the nasopharynx to prevent the bolus from entering the nasal cavity. 4. Transition to the Pharyngeal Phase:  ○ The bolus reaches the anterior faucial pillars (near the back of the oral cavity), triggering the involuntary Pharyngeal Phase of swallowing. 5. Timeframe: ○ This phase is typically rapid, lasting approximately 1 second. - Efficient movement of the bolus during this phase ensures that it reaches the pharynx smoothly and safely, without residue in the oral cavity. Any dysfunction in this phase, such as weak tongue muscles or poor coordination, can result in difficulty propelling the bolus (oral dysphagia), leading to residue, delayed swallowing, or aspiration risk. The Pharyngeal Phase is the third stage of swallowing and is involuntary. It begins when the bolus passes the anterior faucial pillars and triggers the swallowing reflex. This phase is rapid and involves complex, coordinated actions to safely transport the bolus from the pharynx into the esophagus while protecting the airway. 1. Soft Palate Elevation: ○ The soft palate (velum) elevates and seals off the nasopharynx, preventing the bolus from entering the nasal cavity. 2. Pharyngeal Constriction: ○ The pharyngeal muscles contract in a wave-like motion (pharyngeal peristalsis) to propel the bolus downward toward the esophagus. 3. Laryngeal Elevation and Closure: ○ The larynx elevates and moves anteriorly, positioning it away from the path of the bolus. ○ The vocal folds close, and the epiglottis folds down to cover the laryngeal inlet, protecting the airway from aspiration. 4. Cricopharyngeal Relaxation: ○ The upper esophageal sphincter (UES), also called the cricopharyngeus muscle, relaxes and opens to allow the bolus to enter the esophagus. 5. Respiratory Pause: ○ Breathing temporarily stops (deglutition apnea) to further protect the airway during this phase. - This phase occurs quickly, typically lasting about 1 second. - The Pharyngeal Phase ensures that the bolus moves safely into the esophagus without entering the airway. Dysfunction in this phase can result in pharyngeal dysphagia, leading to risks of aspiration (food or liquid entering the airway), choking, or residue in the pharynx, which may cause further swallowing complications. More notes on the pharyngeal phase - Triggered when bolus passes a certain point, it’s under automatic control - Velopharynx closes forcefully - Hyoid bone and larynx (hyolaryngeal complex) move upward and forward to move out of the path of the bolus - Larynx closes at 3 levels - Vocal folds adduct - Ventricular folds adduct - Epiglottis folds down over the larynx - The tongue pushes bolus into pharynx and it constricts to squeeze the bolus toward the esophagus (aided by pressure differentials)  - Bolus divides to pass through the left and right epiglottic valleculae to the left and right pyriform sinuses (or flows down midline) - Upper Esophageal sphincter opens The esophageal phase is the fourth and final stage of swallowing. It is involuntary and involves the transportation of the bolus from the esophagus to the stomach through a series of coordinated muscular contractions called peristalsis. 1. Entry of the Bolus: ○ The bolus enters the esophagus as the upper esophageal sphincter (UES), or cricopharyngeus muscle, relaxes and then closes to prevent backflow into the pharynx. 2. Peristalsis: ○ The esophageal muscles contract in a wave-like manner (peristalsis) to propel the bolus downward toward the stomach. ○ The smooth and striated muscles of the esophagus work in a coordinated sequence to ensure efficient movement. 3. Lower Esophageal Sphincter (LES) Relaxation: ○ As the bolus approaches the stomach, the lower esophageal sphincter (LES) relaxes to allow the bolus to pass into the stomach. ○ After the bolus enters the stomach, the LES closes to prevent stomach contents from refluxing back into the esophagus - The esophageal phase lasts about 8–20 seconds, depending on the consistency of the bolus (liquids typically move faster than solids). - This phase ensures the safe delivery of food or liquid to the stomach for digestion, completing the swallowing process. - Disorders of the esophageal phase can result in esophageal dysphagia, characterized by symptoms like difficulty swallowing, chest discomfort, regurgitation of food, or acid reflux. Conditions such as achalasia, gastroesophageal reflux disease (GERD), or esophageal motility disorders can impair this phase. Esophageal Phase - Bolus enters the upper esophageal sphincter - Bolus is propelled through the esophagus by peristaltic actions of the esophageal walls that create pressure differentials - Primary peristalsis may be followed by a secondary peristalsis 2. Define aspiration - Invasion of substances below the vocal folds - Aspiration refers to the accidental entry of food, liquid, saliva, or other substances into the airway (trachea and lungs) instead of the esophagus. - This occurs when the protective mechanisms during swallowing, such as vocal fold closure or the proper positioning of the epiglottis, fail to function correctly, allowing material to bypass the normal route to the stomach - Can happen at any phase of swallowing but typically happens during the pharyngeal phase - Can lead to choking, coughing or pneumonia 3. Describe the role of SLP and other team members in assessment and treatment of swallowing - The Speech-Language Pathologist (SLP) plays a central role in assessing and treating swallowing disorders (dysphagia), conducting both clinical and instrumental evaluations to diagnose the type and severity of the disorder. - The SLP develops individualized treatment plans that may include swallowing exercises, diet modifications, and compensatory strategies to improve swallowing safety and efficiency. - They also provide education to patients and families on safe swallowing techniques. - The SLP works closely with other healthcare professionals, including physicians, dietitians, occupational therapists, respiratory therapists, and nurses, to address the underlying causes of dysphagia, ensure proper nutrition, and prevent complications such as aspiration or pneumonia. - This interdisciplinary collaboration ensures comprehensive care for individuals with swallowing difficulties 4. Understand imaging techniques for swallowing - Videofluoroscopy: X-rays with barium to image swallowing movements (modified barium swallow (MBS) study - GOLD STANDARD) - SLP presents liquids and foods of different consistencies, textures, and volumes - Analysis include spatial and temporal measures and ratings - In these procedures, a barium compound (usually barium sulfate) is ingested or introduced into the body. The barium is radio-opaque, meaning it does not allow X-rays to pass through, so it appears white on X-ray images, helping to highlight the structure of organs and detect abnormalities - In a barium swallow test, the patient drinks a liquid containing barium sulfate, which coats the inside of the esophagus and allows the physician to view the esophagus, stomach, and upper intestines during an X-ray to check for conditions like reflux, ulcers, or blockages. This is commonly used in diagnosing swallowing disorders and gastrointestinal issues. - Surface Electromyography - Surface electrodes put on the skin under the chin (pick up activity of mylohyoid, geniohyoid, and anterior belly of the digastric - Called Submental sEMG - Peak amplitude is used to mark the onset of the swallow and may also be interpreted to reflect relative force - Non-invasive - Small sensors (electrodes) are placed on the skin, usually under the chin or on the throat. - These sensors detect the electrical signals produced by the muscles when you try to swallow. - It helps doctors see how well your swallowing muscles are working.  - Ultrasonography - a non-invasive imaging technique that uses sound waves to assess the function and structure of the muscles involved in swallowing. It can be particularly useful in evaluating the oral and pharyngeal phases of swallowing - can visualize the movement and coordination of the tongue, lips, and pharyngeal muscles during swallowing. It provides real-time images of how these muscles work together to propel the bolus (food or liquid) toward the esophagus. - Transducer generates signal that reflects back when it encounters air and is picked up by a sensor - Used to image tongue and pharyngeal movements during swallowing - Client Self -Report - Client may describe symptoms related to swallowing in an unstructured interview - Clients may select and/or rate symptoms of dysphagia (disordered swallowing) using a symptom-specific tool 5. Describe how swallowing change with development and aging - Anatomical changes - Tongue goes from filling entire oral cavity to just its floor - Teeth emerge - Fatty pads in cheeks eventually disappear (sucking pads) - Oropharynx enlarges as larynx descends - Larynx descends and relative size of structures changes - Swallowing undergoes significant changes throughout development and aging, influenced by anatomical and physiological factors. In infants, the high position of the larynx and a smaller oral cavity facilitate simultaneous breathing and feeding, with swallowing becoming more coordinated as the tongue, jaw, and teeth develop. By age 5, children can manage more complex textures and demonstrate fully coordinated swallowing. - In aging, anatomical changes such as decreased muscle tone, reduced elasticity in the pharyngeal and esophageal muscles, and a lower larynx can impair swallowing efficiency and increase the risk of aspiration. Loss of teeth and decreased sensory awareness in the oral and pharyngeal cavities further complicate the process. Neurological changes in older adults can lead to delayed swallow initiation and decreased coordination between swallowing phases, making it harder to swallow safely and efficiently. Muscles/Bones and Diagrams What are the anatomical structures of Respiration, Phonation, Articulation, Resonance and Swallowing? Vocal ligaments and membrane What speech processes do these muscles impact: - Respiration - Phonation - Articulation - Resonance ACOUSTIC REGIONS 1. Where does phonation occur? 2. Where does articulation occur? 3. Where does resonance occur? 4. Which area moves the most during speech production? 5. What are the lower boundaries of each pharyngeal cavity? Place of articulation: - Front is alveolar process of the maxilla - Central is hard palate - Back is velum/posterior pharyngeal wall Degree of major oral constriction: This is the degree of cross sectional size of vocal tract and influenced by the height of the jaw. - High constriction has a small cross sectional space - Lip rounding leads to reduction in area between lips - Refers to the extent to which the oral cavity is constricted (or narrowed) during the production of certain speech sounds, specifically consonants. This constriction plays a critical role in shaping the airflow and acoustic properties of the sound produced. - In speech, different phonemes (sounds) are classified based on the degree and location of constriction in the vocal tract. For example: - Plosives (like /p/, /b/, /t/, /d/, /k/, and /g/) involve a complete closure or very tight constriction at a certain point in the oral cavity, which is released suddenly to produce the sound - Fricatives (like /f/, /s/, /z/, /sh/) involve a partial constriction that allows air to pass through with friction, creating a hissing or buzzing sound. - Approximants (like /l/, /r/, /w/, /j/) have a more open constriction, where the airflow is not completely blocked but is still shaped by the positioning of the articulators. - The degree of constriction affects both the articulatory features (how the sound is produced) and the acoustic characteristics (how the sound is heard), influencing factors like loudness, tone, and quality of the phoneme. 1. What facial muscles might be responsible for retracting the lip? The facial muscles responsible for retracting the lip (pulling the lip backward) include: 1. Risorius: This muscle is primarily responsible for pulling the corners of the mouth laterally (outward) and can contribute to retracting the lip. It plays a key role in movements like smiling or grimacing. 2. Zygomaticus Major: Although its primary function is to elevate the corners of the mouth (as in smiling), the zygomaticus major can also assist in retracting the upper lip slightly when it contracts. 3. Buccinator: This muscle helps in pulling the lips backward, as it contributes to pressing the cheeks inward and against the teeth. It is essential in activities like blowing, sucking, and chewing. - These muscles work together, often in coordination with other facial muscles, to control lip movements, including retraction. 2. What tongue muscle connected to the velum influences the degree of opening for back vowel? - The palatoglossus muscle, an extrinsic tongue muscle, is connected to the velum and plays a significant role in influencing the degree of opening for back vowels. - The palatoglossus originates from the soft palate (velum) and inserts into the side of the tongue. When it contracts, it can pull the back of the tongue upward toward the soft palate, which influences the pharyngeal cavity's size, helping to shape the resonance and articulation of back vowels (such as /ɑ/, /o/, /u/). - In the context of back vowels, the degree of opening refers to the position of the tongue in relation to the roof of the mouth and the velum. The palatoglossus helps control this by adjusting the tongue's height and the oral cavity’s resonance space, which is crucial for producing clear and accurate back vowels.