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TYPICAL SWALLOWING
PHYSIOLOGY IN ADULTS
Rik Lemoncello, PhD, CCC/SLP

Associate Professor

School of CSD, Pacific University, Forest Grove, OR

Disclosures
■ Financial:
– Dr. Lemoncello receives salary from Pacific University.
– Dr. Lemoncello receives royalties from Video Continuing Education for this
presentation.

■ Non-Financial:
– Dr. Lemoncello is a member of the ASHA SIG 13 (Swallowing & Swallowing
Disorders), including the ASHA Community forum.
– Dr. Lemoncello serves on the Video Continuing Education Advisory Board.

Agenda/Overview
■ Part One: Overview
– Overview of eating, digestion, swallowing, & neurology

■ Part Two: Details of the phases of swallowing

– Oral preparation phase
– Oral transit phase
– Pharyngeal transit phase
– Esophageal transit phase

■ Part Three: Additional Topics

– Basic dysphagia terminology
– Typical swallowing changes associated with aging
– Next steps for learning about dysphagia management
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 Eating: The Whole Thing!

■ Cognitive

■ Social-Emotional

■ Sensory

■ Motor

Overview of Digestion
■ Purpose:
– Absorb nutrition & hydration
– Eliminate body waste

■ Mechanical digestion

■ Chemical digestion

■ Absorption

■ Overview video
– (AP Revealed; McGraw-Hill, 2007)
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Stop & Reflect

■ G-tube (gastric = stomach)

■ J-tube (jejunum = small intestine)

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 Phases of Oropharyngeal Swallowing
■ (Eating, Feeding/Intake)

■ Oral Preparation
■ Oral Transit

■ Pharyngeal Transit
■ Esophageal Transit

Neurology of Swallowing
Voluntary Control Involuntary Control
■ Oral prep & oral transit phases ■ Pharyngeal & Esophageal transit phases

■ Brain motor areas (recall MSDs) ■ Brainstem centers in medulla

– Motor planning cortex (apraxia) – Nucleus of the solitary tract
– Motor programming (dysarthrias) – Nucleus ambiguus
■ Basal ganglia
■ Cerebellum
– Motor execution (dysarthrias)
■ Upper motor (cortex, subcortex)
■ Lower motor (CN, SN)

Brainstem Nuclei
■ Sensory nuclei/centers
– Sensory CN
■ Somatosensation: CN V, IX, X
■ Taste: CN I, VII, IX, X
– Nucleus of the solitary tract

■ Motor nuclei/centers
– Motor CN
■ CN V, VII, IX, X, XII
– Nucleus ambiguus

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 Stop & Reflect
■ What might be the consequences of a brainstem stroke in the
medulla?
(aka “medullary stroke”)

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1. Oral Preparation Phase

■ Voluntary/volitional control!
– Timing: “as little or as long as you want”

■ Begins when food/liquid enters oral cavity

■ Ends with “bolus formation” on anterior “tongue bowl”

■ Airway remains open (breathing)

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1. Oral Preparation Phase

■ Sensory Components:
– Vision (CN II); occipital lobes
– Hearing (CN VIII); temporal lobes
– Taste/Smell (CN I, VII, IX, X); temporal lobes, insula
– Proprioception (CN V, IX, X); parietal lobes

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 1. Oral Preparation Phase
■ Motor Components:
– Bolus “manipulation” with tongue

– Solid Foods: Chewing

■ munch v. rotary
■ Jaw, lips, tongue & cheeks

– (Thin) Liquids
■ Labial seal anteriorly
■ Lingual-velar seal posteriorly

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Stop & Reflect

■ What would be some observable signs of difficulty in the
oral preparation phase of swallowing?

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2. Oral Transit Phase

■ Voluntary/volitional control!
– Timing ≅ 1 - 1.5 sec

■ Rapid, coordinated transit

– Anterior to posterior (“AP” transit)
■ Wave-like motion of tongue
■ Ends when bolus reaches pharynx

■ Airway starts to close

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 2. Oral Transit Phase
■ Motor Components:
– Jaw stabilized (mouth closed)
– Lingual contractions to roof of mouth

– Release lingual-velar seal as bolus

approaches pharynx
■ Start to drop base of tongue
■ Start to raise velum

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Stop & Reflect

■ What would be some observable signs of difficulty in the
oral transit phase of swallowing?

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3. Pharyngeal Transit Phase

■ Involuntary/automatic control!
– Timing ≅ 1 sec (or less)

■ Begins when bolus reaches faucial pillars

■ Bolus passes laterally around larynx
■ Ends when bolus enters esophagus

■ Airway closed (“swallow apnea”)

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 3. Pharyngeal Transit Phase
■ Sensory Components:
– Nucleus of the solitary tract
■ Taste/Smell (CN I, VII, IX, X)
■ Proprioception (CN V, IX, X)

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3. Pharyngeal Transit Phase

■ Motor Components:
– Nucleus ambiguus
■ Motor CN (V, VII, IX, X, XII)

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3. Pharyngeal Transit Phase

■ Seal the system:
– velopharyngeal closure
– laryngeal closure

■ Muscular contractions:
– hyolaryngeal excursion (up & forward)
– pharyngeal constriction (BOT – PPW)

■ Opening of the esophagus:

– relax & pull open UES

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 3. Pharyngeal Transit Phase
Laryngeal Closure
– “bottom to top”
– complete closure of laryngeal vestibule

– hyolaryngeal elevation
– aryepiglottic folds inward
– arytenoids rock forward
– FVF closure
– TVF closure

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Stop & Reflect

■ What would be some observable signs of difficulty in the
pharyngeal transit phase of swallowing?

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4. Esophageal Transit Phase

■ Involuntary/automatic control!
– Timing ≅ 5-20 sec

■ Begins when bolus enters UES

■ Ends when bolus leaves LES

■ Airway open again

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 4. Esophageal Transit Phase
■ Esophagus composed of circular smooth
muscle fibers (and vertical fibers)
■ Esophagus passes thru thorax
– behind trachea, past heart, thru diaphragm

■ Esophageal peristalsis
– Series of muscular relaxations &
contractions
– One-way passage from top to bottom of
esophagus
• UES
• LES
• stomach
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Stop & Reflect

■ What would be some observable signs of difficulty in the
esophageal transit phase of swallowing?

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Breathing & Swallowing Coordination

■ Swallow apnea for about 1 sec
– Begins with oral transit phrase
– Continues through pharyngeal transit phase

■ Typical sequence:
Inhale
Begin Exhale
Initiate Swallow
(Swallow Apnea)
Exhale

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 Some Basic Dysphagia Terminology
■ Laryngeal Penetration = bolus enters laryngeal vestibule (above TVF)

■ Aspiration = bolus touches/falls below TVF into trachea

■ Silent Aspiration = no response

■ Aspiration Pneumonia = lung infection

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Some Basic Dysphagia Terminology

■ Residue = leftovers after the swallow
– oral (labial, lingual, buccal)
– pharyngeal (BOT, PPW, valleculae, pyriform sinuses)

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A Helpful App
■ “Dysphagia” App for iDevices
– Northern Speech Services ($9.99)
– http://www.northernspeech.com/applications/swallowphysiology.php

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 Typical Swallowing Changes with Aging
■ Older Adults (>65 yo)
– (e.g., Daggett et al., 2006; Leonard, 2010; Logemann et al., 2000; Robbins
et al., 1996; Shaker et al., 1994)
■ Social/emotional changes can affect “eating”
■ Sensory losses in vision, hearing, taste, smell, somatosensation
– [also consider effects of medications]
– Reduced laryngeal sensation
■ Dentition changes
■ Stiffening/hardening of structures (cartilages, bones, lungs)

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Typical Swallowing Changes with Aging

■ Loss of muscular “reserves” (atrophy, stiffening)
– jaw, lips, tongue, pharynx, larynx
– Reduced hyolaryngeal excursion / reduced UES opening

– More vulnerable to losses (less to lose) – “decompensation”

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Typical Swallowing Changes with Aging

■ Slight slowing of movements ! slight increases in phase durations
– Slight increases but still WNL:
■ oral transit (1-1.5 sec)
■ pharyngeal transit (< 1 sec)
■ esophageal transit (5-20 sec)

– Pharyngeal transit may initiate slightly later (valleculae rather

than faucial pillars), but no aspiration

■ Slight increase in laryngeal penetration, but not aspiration

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 Next Steps
…Once you know about typical swallowing anatomy & physiology

– Disorders that can affect eating, feeding, & swallowing

– Assessment of oropharyngeal swallowing
■ Clinical evaluation of swallowing
■ MBS: Modified Barium Swallow Study
– (VFSS: Video-Fluorographic Swallow Study)
■ FEES: (Fiberoptic Endoscopic Evaluation of Swallowing)

– Management / Treatment ! ! !

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Thank You!

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