Professional Documents
Culture Documents
the Basics
Angela S. Dubis-Bohn M.A.,
CCC/SLP, BRS-S
Objectives
• Identify anatomy and physiology as
pertaining to the swallowing mechanism
• Describe the basic components of a
clinical examination for swallowing
• Identify appropriate compensatory and
rehabilitation techniques based on
swallowing dysfunction
Stages of Swallowing
• Anticipatory Stage
• Oral Stage
– Oral Preparation
– Oral Transit
• Pharyngeal Stage
• Esophageal Stage
Anatomy of Oral Cavity
Muscles of Mastication
• Temporalis- contraction
elevates and retracts the mandible
(closing of the jaw). Innervated by
c.n. V
• Masseter-contraction
elevates the jaw (closes the
jaw). Innervated by c.n. V
• Buccinator-Contraction
tenses the cheek, thus
maintaining food between the
molars. Also active during
sucking. Innervated by c.n. VII
Muscles of Mastication
• Medial Pterygoid-
Contraction closes the jaw by
raising mandible against maxilla,
Innervated by c.n. V
• Lateral Pterygoid-
Contraction assists in opening
mouth and rotary movement of the
jaw. Innervated by c.n. V
Floor of the Mouth
• Geniohyoid
Floor of the Mouth
• Mylohyoid
Floor of the Mouth
• Transversus- contraction
narrows and elongates the
tongue Innervated by c.n. XII.
Extrinsic Muscles of the Tongue
• Genioglossus-
contraction protracts and
depresses the tongue.
Innervated by c.n. XII
• Hyoglossus- contraction
depresses the tongue and
pulls it backwards towards the
hyoid bone. Innervated by c.n.
XII
Extrinsic Muscles of the Tongue
• Palatoglossus-
contraction elevates the floor
of the tongue and
approximates the tongue to the
palatoglossal arch thus closing
off the oral cavity from the
oropharynx. Innervated by c.n
IX
Extrinsic Muscles of the Tongue
• Styloglossus-
• Retracts and elevates the
tongue.
• Innervated by c.n. XII and by
pharyngeal plexus (c.n. IX & X)
Tongue Base
• Active during the
pharyngeal swallow
• Under involuntary
control coordinated in
the brainstem
• Motor- c.n. XII
Salivary Glands
• Three main salivary
glands
Parotid
Submandibular
Sublingual
Parotid Gland
• Produces serous (thin and watery)
saliva, which makes up 25% of our saliva
production.
• Excreted through Swenson’s ducts near
the second maxillary molar.
• Particularly important when eating and
drinking
Submandibular Gland
• Produces both serous and mucoidal
saliva (mostly serous) which makes up
60% of our saliva production
• The buccinator flattens the cheek and holds the bolus in contact
with the teeth
• The tongue will tilt its dorsal plane toward the working side, while
the jaw opens and closes to keep food between the teeth.
Branches of Vagus
• Superior Laryngeal
Nerve (SLN)
• Recurrent Laryngeal
Nerve (RLN)
Divisions of the Pharynx
• Nasopharynx
• Oropharynx
• Hypopharynx
Musculature of the Pharynx
• Pharyngeal Constrictors
• Middle (c.n. X)
• Valleculae
• Laryngeal Vestibule
• Laryngeal Ventricle
(space between the false
and true vocal folds)
Cartilages of the Larynx
• Epiglottis
• Cuniform cartilages
(support and stiffen the
aryepiglottic folds to maintain
opening to larynx)
• Hyoid Bone
• Thyroid Cartilage
• Cricoid Cartilage
Intrinsic Muscles of the Larynx
• Aryepiglottic Muscle-
– Sometimes credited with depressing epiglottis in initial
stages of swallowing
• Interarytenoids- Approximates arytenoid cartilages
• Sternothyroid
• Omohyoid
Physiology of the Pharyngeal
Swallow
• Bolus division at the level of the vallecula
-1/2 flowing down either side of the
pharynx (lateral channels)
• Swallow reflex is triggered at anterior
facial arches or at the level of vallecula
• Brief period of apnea
• Arytenoids medialize and tilt towards
epiglottis, TVC are still open
Physiology of the Pharyngeal
Swallow
• Tongue base retracts towards the
posterior pharyngeal wall
• Velopharyngeal port closes
• Hyolaryngeal elevation with simultaneous
pharyngeal squeezing and shortening
occurs
Physiology of the Pharyngeal
Swallow
• Epiglottis retroflexes during laryngeal
elevation
• TVC contract .63 seconds AFTER the
arytenoids begin medialization
• Airway closure is not complete at the level
of the glottis until midway through the
swallow
Physiology of the Pharyngeal
Swallow
• Relaxation of the cricopharyngeus to allow
passage of the bolus into the esophagus.
• Cricopharyngeal dysfunction
Compensatory Strategies
Goals of Compensatory Strategies
• Immediate but transient effect on
efficiency or safety of swallowing.
• Changes the flow and gravitational
direction of a bolus to allow safe passage
into the stomach.
• Reimbursement for long-term
intervention is typically not supported.
Postural Strategies
• Chin Tuck
– Also called “chin flexion” or “chin down”
– First introduced by Logemann (1983) to treat observed delays
in triggering the pharyngeal swallow, poor tongue control,
reduced tongue base retraction, and/or reduced closure of the
laryngeal vestibule and vocal cords as assessed by MBS
– Symptoms observed on MBS include pre-swallow vallecular
pooling (secondary to a swallow delay) and/or aspiration
during a swallow
– Contraindicated for patients with poor lip closure or poor oral
control
– Patient is asked to place the chin to the chest during
swallowing.
Postural Strategies
• Head Rotation
– Rotation, or turning, the head toward the weaker,
hemiparetic side can direct the flow of the bolus
toward the stronger more sensate side of the
pharynx
– Size of the pharyngeal cavities on impaired side will
be reduced, and thus the bolus will be directed
toward the more functional side
– May benefit the patient who has diffuse weakness
and residual
– Patient must be able to rotate head 90 degrees
Postural Strategies
• Head Tilt
– Tilting the head toward the stronger side may help
to direct the bolus to the stronger, potentially more
sensate oral and pharyngeal side
– Increased sensation and motor
strength/coordination on the unaffected side may
facilitate improved oral control, bolus formation and
propulsion with a stronger pharyngeal swallow.
– Pt. is instructed to tilt head toward the stronger non-
impaired side during PO intake.
Postural Strategies
• Side lying
– Described by Logemann (1996) as an effective
posture to compensate for reduced pharyngeal
contraction that results in diffuse residue in the
pharynx
– Rationale is that a lateral head/trunk position will
reduce the gravitational force on any residue that is
left in the pharynx after the swallow.
– Pt. is placed laterally in a bed or in a semi-reclined
or fully reclined chair
Postural Strategies
• Neck extension
– The posture of leaning the head back utilizes gravity to propel
a bolus into the pharynx and is primarily used when oral motor
deficits inhibit efficient anterior to posterior transit of a bolus
into the pharynx.
– Pt must have prompt, efficient swallow response
– Pts. are instructed to take a breath, hold it, then bring chin up
and allow gravity to move the bolus back towards the pharynx.
– Contraindications – can decrease the patient’s ability to close
laryngeal vestibule effectively. Also, decreases UES’s ability
to relax – directly related to the degree of extension. May
increase aspiration risk in neurogenic dysphagia pt’s who may
be forced into this position unintentionally.
Bolus Control Strategies
• Lingual sweep
– Most practical and “normalized technique”
– Goal is to actively use the tongue to clear residue
from oral cavity and redirect to the tongue blade for
bolus development
– Patient is cued to use the tongue purposefully to
sweep the entire oral cavity with special focus to the
area of weakness.
Bolus Control Strategies
• Cyclic ingestion (alternating
solids/liquids)
– Indicated for patients with bolus
manipulation deficits, especially those who
exhibit post swallow residue
– Patient is instructed to alternate solids and
fluids to clear the oral cavity of residue
unable to be managed with lingual sweeping
Bolus Control Strategies
• Dry swallows (multiple swallow)
– Can be used with a patient who exhibits post
swallow residue somewhere within the digestive
tract (oral residue, vallecular residue, pyriform sinus
residue)
– Pt. is instructed to dry swallow after every bolus
swallow – as many times as indicated by
instrumental assessment
Bolus Control Strategies
• Bolus placement
– Position the bolus in the more sensate,
unimpaired side of the oral cavity for
preparation
– Patient is instructed to angle utensil toward
the unimpaired side.
Bolus Control Strategies
• Modification of bolus size
– Smaller boluses may allow for greater
control and less scatter of the bolus to oral
recesses
– In some patients with decreased sensitivity,
larger bolus can provide increased sensory
input – especially with heavier bolus with
variable texture – allows for better oral
awareness (dementia)
Bolus Control Strategies
• Adaptations in the rate of intake
– Slower rate may give pt. with neurologic deficits
more time to manage the bolus
– External controls may need to be employed may be
required to slow rate of TBI or right CVA pt.
(Impulsivity)
Volitional Airway Protection
Strategies
• Supraglottic Swallow
– Provides volitional airway protection when patient is a silent
aspirator or has delayed reflexive airway protection
– Pt. is instructed to take a deep breath and hold it firmly while
swallowing the bolus. On completion of the swallow, patient is
instructed to cough prior to inhalation. The patient swallows
and coughs for a second time.
– Caution: Cardiac patients- Chaudhuri et al. (2002) – fitted
stroke patients with holster monitors to measure the
cardiovascular impact of supraglottic and super-supraglottic
swallow. 86.6% (13/15 patients) showed abnormal cardiac
readings (arrhythmias) during the maneuvers.
Volitional Airway Protection
Strategies
• Super-supraglottic swallow
– Patient is instructed to take a deep breath and
tightly hold, then swallow “hard” or with greater
effort than usual. Following swallow. Pt. should
follow with a cough prior to inhalation
• These exercises may help with bolus control, decreased anterior loss of
bolus
• If hypertonic – slow, progressive stretching in effort to relieve spasm.
Provide firm directed pressure to lips and move laterally and
superior/inferior positions
• Mendelson Maneuver
• Shaker exercises
• Expiratory Muscle Strength Training
Rehabilitation- Tongue Base
• Masako Maneuver
• Valsalva Maneuver (Effortful Swallow)
• DPNS
Rehabilitation- Laryngeal Valving
• Vocal adduction exercises
• Shaker exercises
Correspondence
• Angela S. Dubis-Bohn M.A., CCC/SLP, BRS-S
• Dodd Rehabilitation Hospital
• 480 Medical Center Dr. Room 1145
• Columbus, Ohio 43210
• (614) 293-5275
• angie.dubis-bohn@osumc.edu
References
• References- Anatomy & Physiology
• Bartoshuk, L.M., Duffy, V.B, Leder, S.B., &Snyder, D.J. (2003). “Oral Sensation: genetic and
pathological sources of variation”. Perspectives on swallowing and swallowing disorders. 12:4.
3-9.
• Berkovitz, B, Kirsch, C., et. Al. (2003). Interactive head and neck CD-ROM. London: Primal
Pictures.
• Butler, S.G., Psstima, G.N., Fischer, E. (2004). “Effects of viscosity, taste, and bolus volume on
swallowing apnea duration of normal adults”. Otolaryngology- Head and neck surgery. 131:6,
860-863.
• Corbin-Lewis, K., Liss, J.M., Sciortino, K.L. (2004). Clinical anatomy and physiology of the
swallow mechanism. Clifton Park: Thompson/Delmar Learning.
• Crary, M. (2003). Old and new strategies for assessing and treating adult dysphagia.
• Cathy Chester Memorial Seminar: Columbus.
• Crary, M.A., & Groher, M.E. (2003). Introduction to adult swallowing disorders.
• St. Louis, MO: Butterworth-Heinemann.
• Easterling, C.S. (2003). “Getting acquainted with the esophagus”. Perspectives on bean
• swallowing and swallowing disorders. 12:2. 3-7.
• Kaplan, M.D. & Baum, B.J. (1993). “The functions of saliva.” Dysphagia. 8:225-229.
• Langmore, S. (2004). FEES and fluoroscopy. ASHA Health Care Convention 2004: Orlando.
References
• References- Anatomy and Physiology (Cont)
• Leopold, N.A., Kagel, M.C. (1997). “Dysphagia- ingestion or deglutition? A proposed paradigm”.
Dysphagia. 12: 202-206.
• Logemann: J.A. (1998). Evaluation and Treatment of Swallowing Disorders (2nd Ed.).
• Austin, TX:Pro-Ed.
• Miller, R.M. & Groher, M.E. (1993). “Speech-language pathology and dysphagia: a brief
• historical perspective.” Dysphagia. 8:3, 180.
• Morgan, A. et. Al. (2004). “Clinical characteristics of acute dysphagia in pediatric patients
following traumatic brain injury”. Journal of Head Trauma and Rehabilitation. 19:3, 226-240.
• Simmons, Mary. MBS: The Clear Picture. CIAO Seminars. Accessed 03/04/08.
• VanDaele, DJ, McColloch, TM, Palmer, PM, Langmore, SE. (2005). “Timing of glottic closure
during swallowing:A combined electromyographic and endoscopic analysis.” Ann Otol Rhinol
Laryngol. 114, 478-87.
• Ylvisaker, m. & Logemann, J.A. (1985). “Therapy for feeding and swallowing disorders following
head injury.” In Ylvisaker, M. (Ed). Head injury rehabilitation- Children and adolescents. Boston:
College Hill Press. 195-215.
• Yorick, W. & M. Freed (2008). Vital Stim Certification Seminar. Columbus, Ohio. April, 2008.
• Zemlin, W. (1988). Speech and hearing science anatomy and physiology.
• New Jersey:Prentice-Hall.
References
• References- Disorders of Swallowing
• Rosenbeck, J.C., Robbins, J.A., Roecker, E.B., Coyle, J.L., & J.L. Wood.
(1996). A penetration-aspiration scale. Dysphagia. 11:93-98.
References
Compensatory Strategies
• Bulow, M., Olsson, R., & Ekberg, O. (2003). Videoradiographic analysis of how
carbonated thin liquids and thickened liquids affect the physiology of swallowing in
subjects with aspiration on thin liquids. Acta Radiologica. 44: 366-372.
• Chaudhuri, G., Hildner, C.D., Brady, S., Hutchins, B., Aliga, N., & Abadilla, E. (2002).
• Cardiovascular effects of the supraglottic and super-supraglottic swallowing
• maneuvers in stroke patients with dysphagia. Dysphagia. 17: 19-23.
• Huckabee, M.L., & Pelletier, C.A. (1999). Management of adult neurogenic
dysphagia.
• San Diego, CA: Singular Publishing Group.
• Logemann, J.A., Pauloski, B.R., Colangelo, L., Lazarus, C., Fujiu, M., & Kahrilas, P.J.
(1995). Effects of a sour bolus on oropharyngeal swallowing measures in patients
with neurogenic dysphagia. Journal of Speech and Hearing Research. 556-563.
• Pelletier, C.A., & Lawless, H.T. (2003). Effect of citric acid and citric-acid sucrose
mixtures on swallowing in neurogenic oropharyngeal dysphagia. Dysphagia. 18:
231-214.
References
• References- Clinical Evaluation of Swallowing
• Addington, W.R., Stephens, R.E., Gilliand, K., Rodriguez, M. (1999).
Assessing the laryngeal cough reflex and the risk of developing pneumonia
after stroke. Archives of Physical Medicine and Rehabilitation. 80:150-154.
• Aviv, J. (2002). The bedside swallowing evaluation when endoscopy is an
option: what would you choose? Dysphagia. 17:219.
• Corbin-Lewis, K., Liss, J.M., Sciortino, K.L. (2004). Clinical anatomy and
physiology of the swallow mechanism. Clifton Park, NY: Thompson/Delmar
Learning.
• Felt, P. (1999). The national dysphagia diet project: the science and
practice. Nutrition in clinical practice. 14:S60-S63.
• Hendrix, T.R. (1993). Art and science of history taking in the patient with
difficulty swallowing. Dysphagia. 8:69-73.
• Logemann, J. (1998). Evaluation and treatment of swallowing disorders.
(2nd Ed). Austin, TX: Pro-Ed.
References
• References- Clinical Evaluation of Swallowing
• Logemann, J., Veis, S., & Colangelo. (1999). A screening procedure for
oropharyngeal dysphagia. Dysphagia. 14:44-51.
• Mann, G. (2002). The mann assessment of swallowing ability. San Diego,
CA: Singular Publishing.
• Murray, J. (1999). Manual of dysphagia assessment in adults. San Diego,
CA: Singular Publishing.
• O’Neil, K.H., Purdy, M., Falk, J., & L. Gallo. (1999). The dysphagia
outcome and severity scale. Dysphagia. 14:139-145.
• Pearlman, A.L., Ettema, S.L., & J. Barkmeier. (2000). Respiratory and
acoustic signals associated with bolus passage during swallowing.
Dysphagia. 15:89-94.
• Swigert, N. (2000). The source for dysphagia updated and expanded. East
Moline, IL: Linguisystems.
• Tohara, H., Eiichi, S., Mays, K.A., Kuhlemeier, K., & J.B. Palmer. (2003).
Three tests for predicting aspiration without videofluroscopy. Dysphagia.
18: 126-134.
References
• References- Rehabilitation
• Clark, H.M. (2003). Neuromuscular treatments for speech and swallowing:
A tutorial. American Journal of Speech-Language Pathology. 12:400-415.
• Corbin-Lewis, K., Liss, J.M., & K.L. Sciortino. (2004). Clinical anatomy and
physiology of the swallow mechanism. Clifton Park, NY: Thompson/Delmar
Learning.
• Dworkin, J.P. (2002). Differential diagnosis and treatment of motor speech
disorders. Short-course presentation. OSLHA Convention. Dayton, Ohio.
• Fink, B.R. & R.J. Demarest. Laryngeal Biomechanics. Cambridge, MA:
Harvard University; 1978.
• Freed, M.L., Freed, L., Chatburn, R.L., & M. Christian. (2001). Electrical
stimulation for swallowing disorders caused by stroke. Respiratory Care.
46:5, 466-474.
• Hagg, M., & B. Larsson. (2004). Effects of motor and sensory stimulation
in stroke patientrs with long lasting dysphagia. Dysphagia. 19:219-230.
References
• References- Rehabilitation
• Huckabee, M.L., & Pelletier, C.A. (1999). Management of adult neurogenic dysphagia. San
Diego, CA: Singular Publishing Group.
• Kim, J. & C. Sapienza. (2005). Implications of expiratory muscle strength training for rehabilitation
of the elderly:Tutorial. Journal of Rehabilitation Research and Development. 42:2, 211-224.
• Robbins, J. Et. Al . (2005). The effects of lingual exercise on swallowing in older adults. J Amer
Geriatrics Soc. 53:1483-1489.
• Robbins, J. et. Al (2005- in press). The effects of lingual exercise in stroke patients with
dysphagia.
• Saleem, A.F. et. Al. (2005). Respiratory muscle strength training: Treatment and response
duration in a patient with early idiopathic parkinson’s disease. NeuroRehabilitation. 20: 323-333.
• Sapienza, C. (2005). Respiratory Muscle Strength Training. Presentation- Charleston Swallowing
Conference.
• Shaker, R., Kern, M., Bardan, E., Taylor, A., ET.Al (1997). Augmentation of deglutitive upper
esophageal sphincter opening in the elderly by exercise. American Journal of Physiology. 272:
G1518-G1522.
• Stephanakos, K. (1997). Deep pharyngeal neuromuscular stimulation. Seminar. Lexington, Ky.