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DYSPHAGIA
Dysphagia Assessment and Treatment Planning: A Team Approach, Fifth Edition integrates the
Kendall
Leonard
fundamentals of aerodigestive tract anatomy and physiology with objective assessment techniques and
multidisciplinary treatment approaches. Contributors from speech-language pathology, otolaryngology, and
gastroenterology present a variety of perspectives across domains of the professionals who serve patients with
swallowing disorders. The in-depth, evidence-based assessment techniques and treatment models represent
the most current dysphagia research and best practices.
New to the Fifth Edition:

• A new chapter focuses on the impact of dysphagia on the
airway and how artificial airways may affect swallowing
Assessment and Treatment Planning
function
• A new online-only bonus chapter on telehealth and dysphagia
is available on the companion website A TEAM APPROACH
• Treatment approaches have been updated to include new
material on neuroplasticity, chin tuck against resistance
FIFTH
(CTAR), and prophylactic strategies
EDITION FIFTH EDITION
• The chapter on endoscopy has been enhanced and expanded
• The chapters on fluoroscopy have been streamlined
and condensed
• The most recent nutrition guidelines have been updated, with
DYSPHAGIA
a special focus on integration of texture modifications and
dietary preferences with optimal nutrition
STUDENT
• The pediatrics chapter now provides a detailed discussion
of thickeners and adequate nutrition
WORKBOOK
AVAILABLE!
• Updated and expanded references, perspectives on
recently published literature reviews, and additional Includes practical
figures, tables, and end-of-chapter reflection questions exercises aligned
• Effective and well-documented examples of specific with each chapter
treatments have been included as supplementary boxes of the text.
Rebecca Leonard, PhD, is a Professor Emerita in the Department of Otolaryngology-Head

and Neck Surgery at the University of California, Davis. Her interest in dysphagia began with
the development of prosthetic appliances to improve speech and swallowing in head and neck
cancer patients. Subsequently, she and her colleagues developed techniques for extracting
quantitative measures of swallow mechanics from fluoroscopic swallow studies. These strategies
led to an improved understanding of normal and disordered swallowing, and have aided
significantly in both treatment selection and monitoring of treatment effects. Dr. Leonard has
frequently extolled the virtues of a team approach to dysphagia management. Team details
may vary depending on setting, but given the complexity of dysphagia, specialists with unique
skills coming together to assess and treat patients represent an extremely valuable resource.
Katherine Kendall, MD, has spent her career as a head and neck oncological surgeon and
laryngologist with clinical and research expertise in the evaluation and treatment of dysphagia.
Her interest in swallowing function began with a desire to improve swallowing outcomes
Rebecca Leonard
in head and neck cancer patients after tumor resection and reconstruction, which evolved
into her research program focusing on the application of objective measures of swallowing
Katherine Kendall
evaluation to the assessment of swallowing disorders in multiple patient populations. As an
academic otolaryngologist, she has been involved in the education of surgeons and speech-
language pathologists alike and has been an advocate of the team approach to dysphagia
assessment and treatment throughout her career.
www.pluralpublishing.com
DYSPHAGIA
A TEAM APPROACH
FIFTH EDITION
DYSPHAGIA
A TEAM APPROACH
FIFTH EDITION
Rebecca Leonard, PhD

Katherine A. Kendall, MD
9177 Aero Drive, Suite B
San Diego, CA 92123
email: information@pluralpublishing.com
website: https://www.pluralpublishing.com
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Library of Congress Cataloging-in-Publication Data:

Names: Leonard, Rebecca, editor. | Kendall, Katherine (Staff physician)
editor.
Title: Dysphagia assessment and treatment planning : a team approach /
[edited by] Rebecca Leonard, Katherine Kendall.
Description: Fifth edition. | San Diego, CA : Plural Publishing, Inc.,
[2025] | Includes bibliographical references and index.
Identifiers: LCCN 2023022305 (print) | LCCN 2023022306 (ebook) | ISBN
9781635504736 (hardcover) | ISBN 1635504732 (hardcover) | ISBN
9781635504736 (ebook)
Subjects: MESH: Deglutition Disorders--diagnosis | Deglutition
Disorders--therapy | Patient Care Planning | Patient Care Team
Classification: LCC RC815.2 (print) | LCC RC815.2 (ebook) | NLM WI 258 |
DDC 616.3/23--dc23/eng/20230718
LC record available at https://lccn.loc.gov/2023022305
LC ebook record available at https://lccn.loc.gov/2023022306
NOTICE TO THE USER

Care has been taken to confirm the accuracy of the indications, procedures, drug dosages, and
diagnosis and remediation protocols presented in this book and to ensure that they conform to
the practices of the general medical and health services communities. However, the authors,
editors, and publisher are not responsible for errors or omissions or for any consequences from
application of the information in this book and make no warranty, expressed or implied, with
respect to the currency, completeness, or accuracy of the contents of the publication. The diag-
nostic and remediation protocols and the medications described do not necessarily have specific
approval by the Food and Drug administration for use in the disorders and/or diseases and
dosages for which they are recommended. Application of this information in a particular situ-
ation remains the professional responsibility of the practitioner. Because standards of practice
and usage change, it is the responsibility of the practitioner to keep abreast of revised recom-
mendations, dosages, and procedures.
Contents
Introduction vii
Multimedia List xi
Acknowledgments xii
Contributors xiii
1 Anatomy and Physiology of Deglutition 1

Katherine A. Kendall
2 History and Physical Examination in Dysphagia 33

3 Clinical Swallow Evaluation 49

Susan J. Goodrich and Alice I. Walker
4 Endoscopy in Assessing and Treating Dysphagia 65

Rebecca Leonard
5 Barium Radiographic Evaluation of the Pharynx and Esophagus 87

Jacqui E. Allen
6 Dynamic Fluoroscopic Swallow Study: Swallow Evaluation 101

With Videofluoroscopy
Rebecca Leonard and Susan McKenzie
7 DSS: A Systematic Approach to Analysis and Interpretation 121

Rebecca Leonard and Susan McKenzie
8 Dynamic Swallow Study: Objective Measures and Normative 141

Data in Adults
Rebecca Leonard
9 Other Technologies in Dysphagia Assessment 175

Maggie A. Kuhn
10 The Treatment Plan: Behavioral Approaches 187

Rebecca Leonard and Deirdre Larsen (With Addenda by James Curtis,
Madeline Mills, Maggie-Lee Huckabee, Ivy Cheng, and Shaheen Hamdy)
v
vi DYSPHAGIA ASSESSMENT AND TREATMENT PLANNING: A TEAM APPROACH
11 The Treatment Plan: Medical and Surgical Therapies 263

12 Airway Considerations in Dysphagia 273

Katherine A. Kendall and Anne F. Sievers
13 Nutritional Considerations in Dysphagia 287

Katherine A. Kendall and Beverly Lorens
14 Pediatric Clinical Feeding Assessment 325

Anna Miles
15 Esophageal Phase Dysphagia 349

James H. Clark, Catherine J. Rees Lintzenich, and Peter C. Belafsky
16 Neurogenic Dysphagia 365

Jacqui E. Allen
17 Dysphagia in Head and Neck Cancer Patients 393

18 Laryngopharyngeal Reflux 425

James H. Clark, Catherine J. Rees Lintzenich, and Peter C. Belafsky
19 Spinal Abnormalities in Dysphagia 439

Derrick R. Randall
Bonus Online-Only Chapter. Telehealth www

Georgia A. Malandraki
Index 455
Introduction
The initial publication of Dysphagia As- well-established academic speech-lan-

sessment and Treatment Planning: A Team guage pathologists and physicians with
Approach took place over 25 years ago! expertise in dysphagia. We also hope to
At that time, the text illustrated how the develop in readers an appreciation for
development of a “Dysphagia Team” the incredible power of objective mea-
optimized assessment and treatment surement tools available for dysphagia
for our patients with dysphagia. It also assessment. By embracing a standard-
introduced the concept of objective ized, objective method of swallowing
measures made from videofluoroscopy assessment as presented in this text,
to improve accuracy, detect subtle swal- even experienced clinicians will im-
lowing abnormalities, and evaluate the prove their abilities to define both
impact of interventions. That original subtle and obvious swallowing abnor-
text contained the collective clinical malities while enhancing communica-
experience of a number of phenomenal tion between clinicians and objectively
contributors on our Dysphagia Team. monitoring patient improvements.
Since that time, four editions of the This book is organized so that con-
text have been published. The number cepts central to the understanding of
of contributors to the text has grown, dysphagia assessment are presented
along with the vast amount of clinical first, followed by chapters covering the
experience contained within it. What development and implementation of
has not changed are the foundational treatment recommendations. Informa-
concepts of the dysphagia team and the tion on specialized dysphagia popula-
use of objective measures. tions is presented in the latter part of
This current edition of Dysphagia As- the book. At the end of each chapter,
sessment and Treatment Planning: A Team a series of questions allow the reader
Approach covers topics of interest to the to evaluate their understanding of the
graduate student as well as the practic- chapter material. In addition, there
ing clinician. We hope that it will serve are numerous clinical video examples
as a text for students of swallowing available on the companion website to
function and as a reference for expe- illustrate the concepts presented in the
rienced clinicians by including infor- text. The companion workbook con-
mation on fundamental swallowing tains further opportunities for readers
physiology through advanced medi- to test their knowledge of subjects pre-
cal dysphagia topics. We would like sented in the book.
to share with our readers the impres- To enable readers to learn and prac-
sive collective clinical and research tice how to make objective measures of
experience of the authors who are all swallowing function, this book includes
vii
viii DYSPHAGIA ASSESSMENT AND TREATMENT PLANNING: A TEAM APPROACH
access to Swallowtail™, a software appli- normal function and the impairments

cation designed to increase the ease of created by cranial nerve deficits are
making measures from dynamic fluo- included for easy reference.
roscopic swallow studies, comparing The subsequent chapters cover clini-
those measures to normative data and cal swallowing evaluation, the use of
creating a database for patient tracking endoscopy in swallowing assessment
and documentation purposes. Readers and therapy, and the radiographic eval-
will discover how little extra time is uation of the pharynx and esophagus.
required to make measures using this These updated chapters form the fun-
technology. We encourage all those who damental knowledge required of the
are involved in the care of dysphagic clinician to function well in a medical
patients to adapt the use of objective setting.
measures as part of fluoroscopic assess- Three chapters are devoted to the
ment. We hope to provide the tools dynamic swallow study analysis and
for them to do so and the knowledge interpretation with a detailed expla-
required to advocate for themselves nation of making objective measures.
and their patients when negotiating the These chapters provide not only knowl-
purchase of such technology, regardless edge about dynamic swallow study
of their clinical setting. analysis but also a wealth of clinical
There have been numerous advances information regarding methods of op-
in our understanding of dysphagia timal swallow study performance. An
over the past 25 years, through the additional chapter devoted to other
development of new technologies in technologies in dysphagia assessment
both assessment and treatment. Every provides an updated discussion of the
chapter of this latest edition has been latest technological advances.
updated to reflect the most current The treatment section has been di-
information on the topic presented. In vided into two chapters: One addresses
addition, a new chapter on the role of the medical and surgical treatment of
telehealth in the evaluation and treat- dysphagia, and the other addresses the
ment of dysphagia has been added. application of exercises, positioning,
Further, as editors and authors, we other external therapeutic maneuvers,
have done our best to respond to com- and interventions to the treatment of
ments and suggestions from our read- dysphagia. Within the chapter, indi-
ers for improvements and additional viduals with particular expertise in the
information in each chapter. latest innovations for dysphagia treat-
The first chapters cover swallowing ment have contributed information on
anatomy and physiology along with the role, indications, outcomes, and
the history and physical examination limitations of new technologies.
of the dysphagic patient. The concept Subsequent chapters focus on two
of the upper aerodigestive tract as a ancillary but critically important top-
series of chambers and valves that act ics: airway and nutritional concerns.
together to propel the bolus from the Both subjects impact the management
lips to the stomach is introduced here of dysphagia and must be considered
and is reinforced throughout the book. in every patient with dysphagia. These
Two cranial nerve charts focusing on chapters provide updated basic, yet
INTRODUCTION ix
indispensable, information for the dys- Each person on the team brings their
phagia clinician and underscore the individual insights, expertise, train-
value of a team approach to dysphagia ing, and experience to the assessment
management. and treatment recommendations for
The later chapters focus on special every patient. Team makeup and par-
patient populations, including pediat- ticipation should be customized to the
rics, esophageal dysphagia, neurogenic individual institution. Our team has
dysphagia, head and neck cancer, spi- included speech pathologists, otolaryn-
nal abnormalities, and the impact of gologists, nurses, nutritionists, radiolo-
laryngopharyngeal reflux on swallow- gists, gastroenterologists, neurologists,
ing. These chapters present information and pediatricians. Fellow and resident
of an advanced nature and should serve trainees have also attended team meet-
as a reference for clinicians throughout ings. Whatever the makeup of the
their career. team has been, the experience has been
Lastly, throughout this book, we immensely instructive and gratifying.
focus attention on the advantages of We would like to thank the contribu-
working together as a team in the man- tors to this book whose work creates the
agement of patients with dysphagia. synergy that illustrates A Team Approach.
Multimedia List
Chapter 1 Video 8–2. YngEldNormalSwallow

Video 1–1. Straw Drinking Video 8–3. BP1AEcl
Video 8–4. Hmax
Chapter 4
Video 8–5. HL
Video 4–1. VPPORT
Video 8–6. PCR
Video 4–2. OROPHX
Video 8–7. PESmax
Video 4–3. HYPOPHX
Video 8–8. BCR
Video 4–4. FEESPT1
Video 8–9. BulletPharynx
Video 4–5. FEESPT2
Video 8–10.
Chapter 6 Pharyngeal Shortening Measure
Video 6–1. ZDtwoviews
Chapter 9
Video 6–2. AP Aspiration
Video 9–1. GOOSE
Chapter 7
Video 7–1. NrmPhPeristalsis Chapter 10
Video 7–2. AbsInc-PhPeristalsis Video 10–1. Strategy 1
Video 7–3. ExcPhPeristalsis Video 10–2. Strategy 2A
Video 7–4. AbsIncEpigInv Video 10–3. Strategy 2B
Video 7–5. BolusRedirect Video 10–4. Strategy 3
Video 7–6. Video 10–5. Strategy 4
ImpairedPharyngealShortening Video 10–6. Strategy 5
Video 7–7. ASPBefore Video 10–7. Strategy 6
Video 7–8. ASPDuring
Video 7–9. ASPAfter Chapter 19
Video 7–10. DiffuseEsophSpasm Video 19–1.
Video 7–11. Stasis CSpineBolusConsistManipulation
Video 19–2.
Chapter 8 CSpineBolusVolManipulation
Video 8–1. BTSGTiming Video 19–3. CSpineBolusRedirect
xi
Acknowledgments
The authors extend a sincere “thank backgrounds and skill sets represents
you” to the members of the UC Davis an excellent approach to dysphagia
Dysphagia Team, past and present, management, as well as a perpetual
as well as to our colleagues at other source of continuing education for
institutions, for their generosity and individual members. We are hopeful
expertise in the preparation of this text. that the text will inspire other profes-
Many of our authors have contributed sionals to develop similar resources in
to previous editions; others, including their own settings. We also thank those
James Clark, MD, Assistant Professor at patients and volunteer subjects who
Johns Hopkins School of Medicine, and have played a role in materials used
Deirdre Larsen, PhD, Assistant Profes- in the book, as well as in our collection
sor at Eastern Carolina University, are of normative and other data. These
first-time contributors. Our “team” individuals have graciously shared
experience at UCD has convinced us their time and experiences with us,
that a highly interactive, interdisciplin- and we gratefully acknowledge their
ary group of individuals with unique contributions.
xii
Contributors
Jacqui E. Allen, MD, FRACS, Department of Otolaryngology-Head

ORL-HNS & Neck Surgery
Laryngologist Weill Cornell Medical College
Department of Surgery New York, New York
University of Auckland Chapter 10 Addendum
Takapuna, Auckland
New Zealand Susan J. Goodrich, MS
Chapters 5, 16 Ret. Senior Speech-Language
Pathologist
Peter C. Belafsky, MD, MPH, PhD Voice-Speech-Swallowing Center
Professor and Director, Center for Department of Otolaryngology
Voice and Swallowing University of California, Davis
Department of Otolaryngology Sacramento, California
University of California, Davis Chapter 3
Sacramento, California
Chapters 15, 18 Shaheen Hamdy, MB ChB, PhD,
FRCP
Ivy Cheng, PhD Professor and Honorary Consultant
Postdoctoral Research Associate Gastroenterologist/Physician
Division of Diabetes, Endocrinology Department of GI Sciences, School of
and Gastroenterology Medical Sciences
University of Manchester University of Manchester
Manchester, United Kingdom Manchester, United Kingdom
Chapter 10 Addendum Chapter 10 Addendum
James H. Clark, MD Maggie-Lee Huckabee, PhD

Assistant Professor Director and Distinguished Professor
Department of Otolaryngology-Head The Rose Centre for Stroke Recovery
and Neck Surgery and Research
John Hopkins University, School of School of Psychology Speech and
Medicine Hearing, College of Science
Baltimore, Maryland University of Canterbury
Chapters 15, 18 Christchurch, New Zealand
Chapter 10 Addendum
James A. Curtis, PhD, CCC-SLP,
BCS-S Katherine A. Kendall, MD, FACS
Assistant Professor of Speech- Professor
Language Pathology Division of Otolaryngology
xiii
xiv DYSPHAGIA ASSESSMENT AND TREATMENT PLANNING: A TEAM APPROACH
University of Utah Susan McKenzie, MS

Salt Lake City, Utah Ret. Senior Speech-Language
Chapters 1, 2, 11, 12, 13, 17 Pathologist
Voice-Speech-Swallowing Center
Maggie A. Kuhn, MD, MAS Department of Otolaryngology
Associate Professor University of California, Davis
Department of Otolaryngology-Head Sacramento, California
and Neck Surgery Chapters 6, 7
University of California, Davis
Anna Miles, PhD
Chapter 9
Senior Lecturer, Speech Science
Deirdre Larsen, PhD, CCC-SLP The University of Auckland
Assistant Professor Auckland, New Zealand
Department of Communication Chapter 14
Sciences and Disorders
East Carolina University Madeline Mills, BSLP(Hons)
Greenville, North Carolina The Rose Centre for Stroke Recovery
Chapter 10 and Research
School of Psychology, Speech and
Rebecca Leonard, PhD Hearing, College of Science
Professor, Emeritus University of Canterbury
Department of Otolaryngology-Head Christchurch, New Zealand
and Neck Surgery Chapter 10 Addendum
University of California, Davis
Sacramento, California Derrick R. Randall, MD, MSc,
Chapters 4, 6, 7, 8, 10 FRCSC
Clinical Assistant Professor and
Beverly Lorens, MS, RD
Residency Program Director
Senior Clinical Dietitian, retired
Section of Otolaryngology-Head and
Food and Nutrition Services
Neck Surgery
University of California Davis Medical
University of Calgary
Center
Calgary, Alberta, Canada
Chapter 19
Academy of Nutrition and Dietics
Chapter 13
Catherine J. Rees Lintzenich, MD
Georgia A. Malandraki, PhD, Associate Professor Otolaryngology
CCC-SLP, BCS-S, ASHA Fellow Head and Neck Surgery
Professor Center for Voice and Swallowing
Department of Speech, Language, and Disorders
Hearing Sciences Wake Forest University School of
Purdue University Medicine
West Lafayette, Indiana Winston-Salem, North Carolina
Bonus Online Chapter Chapters 15, 18
2. HISTORY AND PHYSICAL EXAMINATION IN DYSPHAGIA xv
Ann E. F. Sievers, RN, MA, CORLN Alice I. Walker, MS

ENT Nurse Expert Ret. Senior Speech-Language Pathologist
Department of Patient Care Services Voice-Speech-Swallowing Center
and Otolaryngology Department of Otolaryngology
University of California, Davis University of California, Davis
Sacramento, California Sacramento, California
Chapter 12 Chapter 3
1
Anatomy and Physiology
of Deglutition
Familiarity with the anatomy and phys- PHYSIOLOGY: SERIES OF

iology of normal deglutition enables a CHAMBERS AND VALVES
focused approach to the evaluation of
patients with disordered swallowing. The oral cavity, oropharynx, and esoph-
An understanding of how head and agus can be thought of as a series of
neck structures interact to accomplish expanding and contracting chambers,
swallowing allows the clinician to com- divided by muscular sphincters or
prehend how various types of pathol- valves. Propulsion of a bolus through
ogy are likely to negatively impact this part of the alimentary tract is the
swallowing function. Once specific result of forces or positive pressure
aspects of swallowing dysfunction are developed behind the bolus, as well as
identified, therapy can be tailored to a vacuum or negative pressure devel-
focus on those dysfunctional aspects oped in front of the bolus. The positive
with the goal of achieving safe and pressure behind the bolus pushes it
effective swallowing, even in the face forward through the alimentary tract
of ongoing pathology. This chapter dis- while negative pressure in front of the
cusses the anatomy and interaction of bolus acts to suck or pull the bolus for-
head and neck structures involved in ward into the next alimentary chamber.
swallowing and reviews the sequence The creation of propulsion pressures
of events resulting in a successful depends on the sequential contraction
swallow. and expansion of the chambers of the
1
2 DYSPHAGIA ASSESSMENT AND TREATMENT PLANNING: A TEAM APPROACH
upper aerodigestive tract and the com- and can be considered the first sphincter
petency of the sphincters dividing the of the swallowing system (Figure 1–1).
chambers. Any disturbance in the func- Weakness or incompetence of the orbi-
tional elements or coordination of this cularis oris muscle results in difficulty
system is likely to cause a less efficient maintaining a bolus inside the oral
transfer of a bolus from the oral cavity cavity during bolus preparation with
to the stomach, resulting in dysphagia. spillage of the bolus from the mouth.
Swallowing involves coordination of Weakness or incompetence of the orbi-
the sequence of activation and inhibi- cularis oris muscle will also result in
tion for more than 25 pairs of muscles spillage of saliva, or drooling, between
in the mouth, pharynx, larynx, and meals.
esophagus. An understanding of how The buccinator muscle of the cheek
the structures of the head and neck contracts to keep the bolus from pool-
interact and coordinate to bring about ing in the pockets formed by the gingi-
the propulsion pressures required for val buccal sulci lateral to the mandible.
normal swallowing is vital for the cli- Buccinator muscle fibers run between
nician involved in the evaluation and the lateral aspect of the orbicularis oris
treatment of patients with swallowing muscle and the pterygoid plates of the
complaints. skull base (see Figure 1–1).
For simplicity, the act of deglutition These facial muscles receive neu-
is traditionally divided into four parts: ral input from the facial nerve, also
the preparatory phase, the oral phase, the known as cranial nerve VII (Figure 1–2).
pharyngeal phase, and the esophageal Patients suffering from paralysis of the
phase (Dodds et al., 1990; Miller, 1982). facial nerve, such as in Bell’s palsy, will
experience problems during the prepa-
ratory phase of swallowing, character-
PREPARATORY PHASE ized by difficulty maintaining a bolus
in the oral cavity and lateral pooling of
The preparatory phase of swallow- the bolus between the mandible and the
ing includes mastication of the bolus, cheek on the side of the palsy.
mixing it with saliva, and dividing the Most of the movement and position-
food for transport through the pharynx ing of the bolus during preparation
and esophagus. The preparatory phase for swallowing is carried out by the
takes place in the oral cavity, the first tongue muscles. In addition to four
chamber in the swallowing system. intrinsic muscles, the tongue has four
This oral preparatory phase of swal- paired extrinsic muscles: the genio-
lowing is almost entirely voluntary and glossus, palatoglossus, styloglossus,
can be interrupted at any time. and hyoglossus muscles (Figure 1–3).
During bolus preparation, facial Along with the genioglossus muscle,
muscles play a role in maintaining the the intrinsic muscles act primarily to
bolus on the tongue and between the alter the shape and tone of the tongue
teeth for chewing. Specifically, the orbi- while the other three extrinsic muscles
cularis oris muscle, the circular muscle aid in the positioning of the tongue
of the lips, maintains oral competence relative to other oral cavity and pha-
1. ANATOMY AND PHYSIOLOGY OF DEGLUTITION 3
Levator anguli
Zygomatic oris
minor
Levator labii
Incisivus labii superioris
superioris
Levator labii
superioris
alaeque
nasi
Zygomatic
major
Buccinator
Risorius Orbicularis
oris
Incisivus
labii inferioris
Depressor
labii inferioris
Mentalis
Depressor anguli
oris Platysma
Figure 1–1. Facial musculature shown in relationship to the oral cavity. Note
the orbicularis oris muscle encircling the mouth and the fibers of the bucci-
nator muscle running anteriorly to insert in the lateral orbicularis oris muscle.
Note the attachment of the buccinator muscles to the lateral pterygoid plate
of the skull base. From Foundations of Speech and Hearing: Anatomy and
Physiology, 2nd ed. (p. 173), by Jeannette D. Hoit, Gary Weismer, and Brad
Story, 2022, Plural Publishing. © 2022 by Plural Publishing.
ryngeal structures. The genioglossus of the hyoglossus muscles results in

muscles attach to the interior surface depression and posterior movement of
of the mandible and then fan out into the tongue (see Figure 1–3).
the tongue so that contraction of the The palatoglossus muscles originate
genioglossus muscles results in move- in the soft palate and insert into the
ment of the tongue forward in the oral lateral aspects of the posterior tongue,
cavity. The styloglossus muscles run along with the styloglossus muscles
inferiorly from the medial aspect of the (Figure 1–4). Contraction of the pala-
styloid processes at the skull base to toglossus muscles elevates the tongue
insert into the side and inferior aspects base and approximates it to the soft
of the lateral tongue. Contraction of palate. During the bolus preparatory
these muscles elevates the tongue base. phase of deglutition, the posterior part
The hyoglossus muscles arise from the of the tongue elevates against the soft
hyoid bone and insert into the side and palate, which simultaneously is pulled
inferior part of the tongue. Contraction downward against the tongue base.
Figure 1–2. Extracranial course of the facial nerve.

Figure 1–3. Extrinsic musculature of the tongue and course of hypoglossal nerve (XII).
Note the tongue muscles: styloglossus, genioglossus, and hyoglossus and their attach-
ments. Note how the fibers of the genioglossus muscle attach to the inner surface of
the mandible and the anterior surface of the hyoid bone. Note nerve fibers from cervi-
cal nerve rootlets that travel with the hypoglossal nerve and travel to the strap muscles
in the neck.
6
Figure 1–4. Muscles of the soft palate. Note the fibers of the palatoglossus muscle between the palate and the tongue base. Contraction of
this muscle approximates the soft palate and the tongue base, effectively closing off the back of the oral cavity from the pharynx during oral
bolus preparation and prevents early entrance of the bolus into the pharynx.
This action of the soft palate against ficulty with the oral preparatory phase
the tongue base effectively closes off the of swallowing due to the requirement
back of the oral cavity and prevents the for nasal breathing during this phase
bolus from escaping prematurely into (Figure 1–5).
the pharynx. The palate and tongue Cranial nerve XII, the hypoglossal
base constitute the second sphincter in nerve, carries the motor nerve fibers
the swallowing system. With the soft that innervate both the intrinsic and
palate approximating the tongue base, extrinsic tongue muscles, except for the
the nasopharyngeal airway remains palatoglossus muscles (see Figure 1–3).
open during the oral preparatory Injury to cranial nerve XII (hypoglossal)
phase of swallowing and nasal respi- can be detected clinically by asking the
ration is uninterrupted. Obstruction patient to protrude the tongue. The side
of the nose and nasopharynx due to of injury will not be able to protrude
any cause such as a mass, severe sep- due to weakness of the musculature
tal deviation, enlarged nasopharyngeal on that side and the tip of the tongue
adenoid tissue, and so on results in dif- will point toward the side of injury.
Figure 1–5. Lateral view from videofluoroscopic swallow-

ing study: Preparatory phase. Note bolus in the oral cav-
ity on the superior surface of the tongue. Palate closes
against the tongue base to close posterior oral cavity from
the oropharynx. Respiration is via nasal cavity as the velo-
pharyngeal valve closes off the oral cavity and opens the
posterior nasopharynx.
Tongue weakness results in difficulty ogy at the skull base or intracranially.

with bolus positioning during the pre- Weakness of the palatoglossus muscle
paratory phase of swallowing as well impairs the activity of the posterior oral
as early spillage of the bolus into the cavity sphincter and results in early
pharynx due to incompetence of the escape of the bolus from the oral cavity
posterior oral cavity sphincter. into the pharynx before the onset of the
A branch of the pharyngeal plexus pharyngeal phase of swallowing.
from the vagus nerve (X) sends motor A high density of mechanoreceptors
fibers to innervate the palatoglos- within and on the surface of the tongue
sus muscles (Figure 1–6). These fibers indicates that the tongue is an impor-
branch from the vagus soon after the tant sensory region for determining
nerve exits the skull base. Injury to the size of the bolus. Sensory informa-
these nerve fibers results from pathol- tion from the anterior two-thirds of the
Figure 1–6. Pharyngeal plexus and vagus nerve branches. Note fibers to the palato-
glossus muscle and to the pharyngeal constrictor muscles.
tongue is carried back to central swal- Mastication, or chewing, of the bolus

lowing control centers via the lingual involves the masseter muscles, the tem-
nerve, a branch of the trigeminal nerve poralis muscles, and the medial and
or cranial nerve V (Figure 1–7). Sensory lateral pterygoid muscles to move the
information from the tongue is critical mandible relative to the maxilla. This
to modulation of bolus preparation and muscle group is known collectively as
in the coordination of subsequent swal- the muscles of mastication (Figure 1–8).
lowing of the bolus. Motor nerve fibers controlling the con-
Sensory information from the poste- traction of these muscles are carried in
rior one third of the tongue is carried branches of the trigeminal nerve (V)
centrally by the glossopharyngeal nerve, (see Figure 1–7). Unilateral weakness
or cranial nerve IX (see Figure 1–6). of the muscles of mastication results in
Stimulation of the sensory portion of the asymmetry of jaw opening with swing
glossopharyngeal nerve in the tongue of the mandible toward the normal
base elicits the pharyngeal protection side. Information regarding the “hard-
reflex known as the gag reflex. ness” of the bolus material is sensed
Figure 1–7. Trigeminal nerve. Note branches that enter the

tongue and carry sensory information from the tongue (lin-
gual nerve). Note branches to muscles of mastication.
Side view Side view
External
pterygoid
Internal
pterygoid
Temporalis
Masseter
Geniohyoid
Figure 1–8. Muscles of mastication. From Foundations of Speech and Hearing:

Anatomy and Physiology (p. 167), by Jeannette D. Hoit, Gary Weismer, and Brad Story,
2018, Plural Publishing. © 2018 by Plural Publishing.
via muscle spindles in the muscles of oral cavity that are largely responsible
mastication during chewing. This infor- for dental caries. The secretion of saliva
mation is relayed to the cerebral central is controlled by the salivatory nucleus
control mechanisms via the trigeminal in the brainstem. The nerve fibers of the
nerve (V). parasympathetic nervous system carry
signals from the salivatory nucleus to
the salivary glands. The parasympa-
Salivation thetic nerve fibers arrive in the oral cav-
ity as part of the lingual nerve, a branch
Successful transfer of a food bolus of the trigeminal nerve (Guyton, 1981)
from the oral cavity into the esophagus (Figure 1–7).
requires the mixing of the bolus with
saliva. Saliva lubricates and dilutes
the bolus to an optimal consistency for ORAL PHASE
swallowing. Saliva contains two major
types of protein secretion: an enzyme The bolus is propelled from the oral
for digesting starches and mucus for cavity into the pharynx during the
lubricating purposes. Normal salivary oral phase of swallowing. The top of
secretion ranges from 1.0 to 1.5 liters per the tongue is placed on the superior
day. Saliva also plays an important role alveolar ridge behind the maxillary
in maintaining healthy oral tissues. It central incisors. Voluntary opening of
is bacteriostatic and controls the patho- the pharynx then begins with elevation
genic bacteria normally present in the of the soft palate and depression of the
Superior
constrictor
Middle
constrictor
Inferior
constrictor
Figure 1–9. Posterior view of the pharyngeal constric-

tor muscles. The superior pharyngeal constrictor is sus-
pended from the skull base via the pharyngobasilar
fascia. Note the paired muscles meet in the midline.
From Foundations of Speech and Hearing: Anatomy
and Physiology, 2nd ed. (p. 133), by Jeannette D. Hoit,
Gary Weismer, and Brad Story, 2022, Plural Publishing. ©
2022 by Plural Publishing.
www posterior tongue (see Video 1–1, Straw pressed against the maxillary alveo-
Drinking on the companion website). In lar ridge and the anterior half of the
this way, there is expansion of the pos- hard palate in rapid sequence, moving
terior oral cavity and a chute forms in the bolus posteriorly on the dorsum
the tongue base guiding the movement of the tongue. Coordinated and effec-
of the bolus into the pharynx. Eleva- tive tongue movement, full range of
tion of the palate occurs as a result of tongue motion, and tongue strength are
contraction of the levator veli palatini imperative for the efficient transfer of
muscle (see Figure 1–4). The levator veli the bolus from the oral cavity into the
palatini muscle receives motor innerva- pharynx. Tongue muscle weakness, cra-
tion from the vagus nerve (X) via the nial nerve XII injury, or tethering of the
pharyngeal plexus (see Figure 1–6). The tongue secondary to injury or surgery
hyoglossus muscle (innervated by XII) can prevent adequate tongue function
and, to a lesser extent, the styloglos- and can impair bolus movement into
sus muscle (also innervated by XII) are the pharynx.
active in posterior tongue depression. Contraction of the orbicularis oris and
The anterior half of the tongue is then buccinator muscles prevents pressure
escape forward, out of the mouth, or more forceful closure of the nasophar-
laterally during bolus movement into ynx. The superior pharyngeal constric-
the pharynx. Patients with facial muscle tor is suspended from the skull base
weakness have difficulty with the oral via the pharyngobasilar fascia and the
phase of swallowing due to the incom- paired muscles meet and attach to one
petence of the first valve, the lips. Try another in the posterior midline (see
a “dry” swallow of saliva with the lips Figure 1–9). The anterior attachments
open for a firsthand experience of the of the superior pharyngeal constrictor
difficulty created by a failure of the include the inferior aspect of the pter-
anterior oral sphincter! ygoid plates, the buccinator muscle,
During the oral phase of swallowing, and the inner surface of the mandible
soft palate elevation allows the bolus (Figure 1–10).
to pass through the tonsillar pillars The effective closing of the naso-
and into the oropharynx. Once the soft pharynx, along with the cessation of
palate is fully elevated, it contacts the nasal respiration, is required to pre-
adjacent pharyngeal walls in a valving vent pressure or bolus escape into
action that acts to prevent penetration the nasopharynx and weakening the
of the bolus or escape of air pressure forces that drive the bolus inferiorly
into the nasopharynx. The side walls into the pharynx. In this way, the soft
of the nasopharynx, consisting of the palate has a dual sphincteric function
superior pharyngeal constrictor mus- with respect to swallowing. Along with
cles, oppose the soft palate to make a the tongue base, the soft palate is part
Figure 1–10. Lateral view of the

pharyngeal constrictor muscles.
Note the anterior attachment of
the superior pharyngeal constric-
tor to the mandible and posterior
fascia of the buccinator muscle.
The middle constrictor attaches
to the hyoid bone and the infe-
rior constrictor to the thyroid and
cricoid cartilages. From Founda-
tions of Speech and Hearing:
Middle Anatomy and Physiology, 2nd ed.
constrictor
(p. 133), by Jeannette D. Hoit, Gary
Weismer, and Brad Story, 2022,
Plural Publishing. © 2022 by Plural
Superior Publishing.
constrictor Inferior
constrictor
of the sphincter at the posterior part of pathology, forces needed for effective
the oral cavity that prevents premature bolus movement are impaired by pres-
movement of the bolus into the pharynx sure escape from the active swallowing
during the preparatory phase of swal- chamber (the oropharynx) through the
lowing and the soft palate also forms incompetent sphincter (palate to naso-
a sphincter with the superior pharyn- pharyngeal walls) (Figure 1–11).
geal constrictor muscles between the Toward the end of the preparatory
nasopharynx and the oropharynx dur- phase of swallowing, the hyoid bone is
ing the oral and pharyngeal phases of moderately elevated in preparation for
swallowing. Motor nerve fibers from the pharyngeal phase of swallowing.
the vagus nerve (X) via the pharyngeal The anterior displacement of the hyoid
plexus innervate the superior pharyn- bone pulls open the anterior-posterior
geal constrictor and palatal muscula- dimension of the pharynx. This expan-
ture (see Figure 1–6). Palatal defects sion of the pharyngeal chamber creates
or weakness result in early spillage of a vacuum within the oropharynx that
the bolus into the pharynx during the aids in movement of the bolus into the
preparatory phase of swallowing and pharynx. Early hyoid bone elevation
reflux of bolus into the nasopharynx occurs primarily as a result of mylohy-
during the oral and pharyngeal phases oid muscle contraction. The mylohyoid
of swallowing. Even if bolus movement muscle attaches to the lateral interior
is not significantly impacted by palatal of the mandible and joins the opposite
Figure 1–11. Lateral view from videofluoroscopic swallowing study:

pharyngeal phase. Note elevation of the palate and contact with
the posterior pharyngeal wall.
mylohyoid muscle in the midline. Pos- onstrating their maximal activity later.
teriorly, the mylohyoid muscle attaches The mylohyoid and the anterior and
to the hyoid bone. Motor innervation posterior bellies of the digastric muscle
of the mylohyoid muscle comes from participate in the subsequent elevation
a branch of the trigeminal nerve (V) of the hyoid and larynx.
(Figure 1–12).
The muscles involved in the oropha-
ryngeal phase of swallowing represent PHARYNGEAL PHASE
three anatomical regions: the suprahy-
oid suspensory muscles (which affect Passage of food through the pharynx
the position of the posterior tongue and and into the esophagus occurs during
the hyoid bone), the muscles surround- the pharyngeal phase of swallowing.
ing the tonsillar pillars, and the muscles Respiration and swallowing must be
involved in the closure of the nasophar- coordinated during this portion of the
ynx. Muscles that discharge during swallow, since both functions occur
the preparatory phase of swallowing through the common portal of the phar-
include the muscles of the face (specifi- ynx but not simultaneously. Respira-
cally those within the lips and cheeks), tion must cease during the pharyngeal
the tongue muscles, the superior pha- phase of deglutition with closure of the
ryngeal constrictor, the styloglossus, soft palate against the superior pharyn-
and stylohyoid, geniohyoid, and mylo- geal constrictor muscle. Central control
hyoid muscles, with the palatoglossus of pharyngeal swallowing involves an
and palatopharyngeus muscles dem- efficient, automatic mechanism, so that
respiration can resume in a timely man-
ner. The pharyngeal phase of swallow-
ing is also involuntary, and once initi-
Front View ated, it is an irreversible motor event.
At the onset of the pharyngeal phase
of swallowing, the tongue carries the
bolus into the oropharynx, as the entire
posterior mass of the tongue is rolled
backward on the hyoid bone while main-
taining the bolus on the tongue surface.
Digastric
The mandibular muscles (medial and
(anterior) Mylohyoid lateral pterygoid muscles, masseter and
temporalis muscles [innervated by V])
Figure 1–12. Mylohyoid muscle. The mus-
contribute to stabilization of the tongue
cle attaches to the interior surface of the base during the development of the
mandible anteriorly and the hyoid poste- tongue’s piston-like movements, and this
riorly. Contraction results in anterior move- stabilization of the tongue is more critical
ment and elevation of the hyoid bone. with boluses of thicker consistency. The
From Foundations of Speech and Hear-
mandible is held in a closed position dur-
ing: Anatomy and Physiology, 2nd ed.
(p. 168), by Jeannette D. Hoit, Gary Weis- ing swallowing (see Figure 1–8).
mer, and Brad Story, 2022, Plural Publish- As the bolus is propelled posteri-
ing. © 2022 by Plural Publishing. orly by the piston-like movement of
the tongue, the pharynx, as a whole, constrictor attaches to the hyoid bone
elevates and then contracts to create a anteriorly, and the inferior constric-
descending peristaltic wave behind the tor attaches to the thyroid and cricoid
bolus. Elevation of the pharynx occurs cartilage anteriorly (see Figures 1–9
when the paired palatopharyngeus and and 1–10).
stylopharyngeus muscles contract. The As the oropharynx is a closed cav-
walls of the pharyngeal chamber stiffen ity at the time of bolus passage (the soft
because of the sequential contraction palate has closed off the nasopharynx,
of its three constrictors. The palatopha- and the pharyngo-esophageal segment
ryngeus muscles and the pharyngeal is closed inferiorly), the pressure gener-
constrictors are innervated by branches ated by the tongue base contacting the
of cranial nerve X and the stylopharyn- pharyngeal walls provides a force that
geus by cranial nerve IX, both via the drives the bolus inferiorly. In normal
pharyngeal plexus (see Figure 1–6). swallowing, the pharyngeal chamber
Just like the superior pharyngeal con- constricts behind the bolus to the point
strictor muscles, the paired middle of complete obliteration of the pharyn-
and inferior constrictor muscles meet geal cavity, effectively clearing all the
in the posterior midline. The middle bolus from the pharynx (Figure 1–13).
Figure 1–13. Lateral view from videofluoroscopic swallow-

ing study: pharyngeal phase. Note anterior displacement
of hyoid and larynx with expansion of the hypopharynx.
The tongue base contacts the posterior pharyngeal wall.
Subject has a cricopharyngeal bar at cervical vertebra 5.
Weakness or defects of the tongue base ynx and into the upper esophagus (see
and weakness of the pharyngeal con- Figure 1–13).
strictors prevent complete contact of As the bolus is driven inferiorly and
the tongue base with the constrictors the larynx begins to move forward, the
and impair development of adequate epiglottis folds down over the laryngeal
driving forces behind the bolus. Weak opening. The epiglottis moves from an
pharyngeal constriction or incom- upright to a horizontal position and
plete posterior tongue base movement then tips downward. This positional
therefore results in pharyngeal residue change of the epiglottis is caused mainly
remaining in the pharynx after the pha- by elevation of the hyoid and larynx
ryngeal phase of swallowing and cre- as well as by contraction of the paired
ates a significant risk for aspiration of thyrohyoid muscles (C1) followed by
residual bolus after the swallow. contraction of the intrinsic laryngeal
While the tongue base and pharyn- muscles to close the vocal folds (X,
geal constrictors are creating a piston- via the recurrent laryngeal nerve). The
like constriction behind the bolus in abductors of the vocal folds, the poste-
the pharynx, the hyoid and larynx rise rior cricoarytenoid muscles, are inhib-
and are pulled forward under the root ited during this phase, ensuring closure
of the tongue by the contraction of the of the vocal folds and protection of the
suprahyoid muscles. The mylohyoid airway from the bolus. The true and
muscle and anterior belly of the digas- ventricular vocal folds play a major role
tric muscle are innervated by a branch in protecting the laryngeal vestibule by
of the trigeminal nerve (V) (see Figures constricting the laryngeal aperture. The
1–7 and 1–12), and the geniohyoid mus- larynx closes anatomically from below
cle is innervated by a branch of cervical upward: first, the vocal folds, then the
root 1 (C1) that travels with the hypo- vestibular folds, then the lower ves-
glossal nerve (XII) (see Figure 1–3). tibule (approximation and forward
Contraction of these muscles moves the movement of the arytenoids), and then
hyoid superiorly and anteriorly toward the upper vestibule (horizontal position
the anterior arch of the mandible. of the epiglottis that contacts the closed
The larynx moves superiorly with arytenoids). Opening of the larynx pro-
the hyoid bone because it is attached to ceeds from above downward. Many of
the hyoid bone by the thyrohyoid mem- the mechanisms that contribute to air-
brane and paired thyrohyoid muscles way protection also contribute to bolus
(innervated by C1). This superior-ante- transportation as closure of the larynx
rior movement of the larynx simulta- creates pressures that promote move-
neously protects the larynx from pen- ment of the bolus away from the lar-
etration by the bolus and expands the ynx and into the upper esophagus (Fig-
hypopharyngeal chamber, causing a ure 1–14) (Doty & Bosma, 1956; Kidder,
decrease of pressure in the pharyngo- 1995).
esophageal (PE) segment. This decrease Closure of the larynx during swal-
in pressure in front of the bolus, along lowing is carried out by the adductor
with the piston action of the tongue muscles of the vocal folds. These mus-
base against the pharyngeal constric- cles are innervated by a branch of the
tors, drives the bolus through the phar- vagus nerve, the recurrent laryngeal
paralysis (Schiedermayer et al., 2020;

Stevens et al., 2022).
The upper esophageal sphincter,
also known as the PE segment, is the
third and final sphincter involved in the
oropharyngeal phase of deglutition. At
rest, the sphincter is closed by the tonic
contraction of the cricopharyngeus
muscle, located at the inferior aspect
of the inferior pharyngeal constrictor.
Inhibition of the tonic cricopharyngeal
muscle contraction, which results in
relaxation and allows for opening of the
sphincter, starts at the onset of the oro-
pharyngeal phase of swallowing and
lasts until the cricopharyngeus muscle
becomes active and propels the bolus
into the esophagus. Both laryngeal ele-
vation (which pulls the cricoid lamina
away from the posterior pharyngeal
wall) and cricopharyngeal relaxation
are essential for normal opening of the
PE segment for bolus passage. Mano-
metric studies have shown that a suc-
cessful swallow depends on the tongue
Figure 1–14. Innervation of the muscles driving pressure and the negative pres-
of the larynx by the recurrent and superior
laryngeal nerves.
sure developed in the PE segment more
than the peristaltic-like pressure of the
constrictors (McConnel, 1988a, 1988b).
nerve (see Figure 1–14). Vocal fold paral- Failure of complete relaxation of the
ysis, most commonly due to injury to the cricopharyngeus muscle results in nar-
recurrent laryngeal nerve, impairs com- rowing of the opening to the esopha-
plete closure of the laryngeal sphincter gus. A “cricopharyngeal bar” may be
during swallowing. Although complete seen on the videofluoroscopic swallow-
closure of the vocal folds is considered ing study as the bolus passes through
important for airway protection during the PE segment and into the esophagus
swallowing, only approximately 20% of (see Figure 1–13).
individuals with vocal fold paralysis Once the bolus passes into the PE
have been shown to aspirate. Aspira- segment, the force of the pharyngeal
tion is much more common in patients contraction eliminates the bolus from
with proximal injury to the vagus and the pharynx. If pharyngeal contractions
thus the pharyngeal plexus as well as do not fully clear the bolus from the
the recurrent laryngeal nerve. Proximal pharynx while the laryngeal aperture
vagal injuries cause both pharyngeal is closed, then a portion of the residual
constrictor weakness and vocal fold bolus may be aspirated upon reopening
the airway and inhalation. The pharyn- Neural Control of the

geal phase of swallowing is completed Pharyngeal Phase
when the soft palate returns to its origi- of Swallowing
nal position and the larynx is reopened
for respiration. The complex oropharyngeal muscle
The oropharyngeal phase of swal- contraction and relaxation sequence
lowing is a complex sequence of not that results in a successful swallow is
only excitatory but also inhibitory triggered and controlled by a group
events that take place generally in less of neurons within the reticular forma-
than 1 second. It involves a set of stri- tion of the brainstem. These neurons
ated muscles that always participate in are collectively referred to as a central
the fundamental motor pattern. Elec- pattern generator because they drive
tromyographic studies of the muscles a sequence of complex but repetitive
involved in the pharyngeal phase of movements. The neurons of the central
swallowing have delineated that the pattern generator directly stimulate
onset of swallowing begins with a con- several pools of motoneurons located
traction of the mylohyoid muscle ele- in various brainstem cranial motor
vating the hyoid bone. At the same time nuclei responsible for excitatory and
or very shortly thereafter, the anterior inhibitory signals to the muscles of the
digastric and the pterygoid muscles oropharynx involved in swallowing
begin to contract (innervation from (Doty, 1968; Jean, 1984b, 2001; Yama-
the trigeminal nerve V), followed by mura et al., 2010).
the geniohyoid (XII), stylohyoid (VII), Peripheral feedback from sensory
styloglossus (XII), posterior tongue, receptors in the muscles and mucosa of
superior constrictor (X), palatoglossus the pharynx is thought to modify the
(X), and palatopharyngeus muscles swallow sequence via direct input to
(innervation from pharyngeal plexus: the neurons of the central pattern gen-
X). This group of muscles is called the erator. During the preparatory phase of
“leading complex.” The middle and swallowing, sensory information from
inferior constrictor muscles then con- the oral cavity structures is sent to the
tract in an overlapping sequence. The brainstem regarding the size, hardness,
oropharyngeal sequence ends when the consistency, and readiness for swallow-
wave of contraction reaches the upper ing of the bolus (V). This information
esophageal sphincter. Electrophysi- is applied to the programming of the
ologic studies have shown that any pharyngeal phase of the swallowing
background electrical activity in the sequence for that bolus. Once the swal-
swallowing muscles is inhibited with lowing reflex is triggered, pharyngeal
the onset of electrical activity in the and laryngeal sensory feedback to the
leading complex and that inhibition is brainstem confirms a successful swal-
also found in the muscles of the lead- low sequence (Humbert & German,
ing complex just before they contract 2013; Humbert et al., 2012; Shadmehr
during swallowing (Doty, 1968; Doty & et al., 2010; Steele & Miller, 2010).
Bosma, 1956; Hrycyshyn & Basmajian, The central pattern generator can
1972; Miller, 1982). therefore be subdivided into three sys-
tems: an afferent input system from swallowing with a short latency, and
peripheral sensory mechanisms to the this finding has led to the belief that
center, an efferent system correspond- the fibers of the SLN constitute the
ing to the motor outputs from the cen- main afferent pathway involved in the
ter to the muscles of the pharynx, and initiation of swallowing. Stimulation of
an organizing system corresponding the glossopharyngeal nerve facilitates
to the interneuronal network within swallowing but alone does not trigger
the brainstem that programs the motor the pure motor pattern of oropharyn-
pattern. Within the central pattern gen- geal swallowing. Stimuli eliciting the
erator, some neurons may participate swallow reflex are mechanical, chemi-
in activities other than swallowing, cal, and thermal. Water can stimulate
such as respiration, mastication, and the reflex in the region of the SLN (Doty
vocalization. Respiration is also likely & Bosma, 1956; Humbert & German,
controlled via a central pattern gen- 2013; Humbert et al., 2012; Jafari et al.,
erator that coordinates with the swal- 2003; Jean, 1990, 2001; Kajii et al., 2002;
lowing pattern generator to integrate Kessler & Jean, 1985; Kitagawa et al.,
swallowing and respiratory functions 2002; Miller, 1982; Ootani et al., 1995;
(Altschuler et al., 1989; Broussard & Shadmehr et al., 2010; Shingai et al.,
Altschuler, 2000; Doty & Bosma, 1956; 1989; Steele & Miller, 2010).
Dutschmann & Dick, 2012; Jean, 1990; Both the glossopharyngeal and the
Jean et al., 1975). superior laryngeal nerves send fibers to
the nucleus tractus solitarius (NTS) in
the brainstem. The nucleus tractus soli-
Afferent Input to the Central tarius is the principal sensory nucleus
Pattern Generator of the pharynx and esophagus, and all
the afferent fibers involved in initiating
Branches from three cranial nerves — or facilitating swallowing converge in
the trigeminal (V), the glossopharyn- the NTS, mainly in the interstitial sub-
geal (IX), and the vagus (X) — provide division. Almost all of the NTS neurons
peripheral sensory feedback to the cen- that are involved in swallowing are
tral pattern generator. Swallow initia- activated with stimulation of the SLN.
tion is modulated by sensory input from Most of the same NTS neurons can be
the teeth, tongue, and muscles of masti- activated by stimulation of the glosso-
cation (V) as well as taste receptors (VII pharyngeal nerve. During swallowing,
and IX). The most sensitive oropharyn- stimulation of sensory receptors in the
geal mucosal receptor regions for the pharynx by the posterior movement of
stimulation of the oro- and pharyngeal the bolus is thought to initiate the invol-
phase of the swallowing sequence are untary pharyngeal phase of swallowing
innervated by fibers of the pharyngeal coordinated by the central pattern gen-
branch of the glossopharyngeal nerve erator via the superior laryngeal nerve
(IX) via the pharyngeal plexus and by (Altschuler, 2001; Jean, 2001).
the superior laryngeal nerve (SLN) via Although the oropharyngeal swal-
the vagus nerve (X). Stimulation of the lowing motor sequence is centrally
superior laryngeal nerve induces pure organized, it can change in response
to peripheral afferent information. The erator. Many of the neurological dis-

same irreversible muscle sequence is orders that result in dysphagia do not
exhibited during swallowing of food, involve the brainstem but rather affect
liquids, or saliva, but sensory informa- a wide range of supramedullary central
tion received from peripheral recep- neural regions. In addition, the fact that
tors during the preparatory phase of swallowing can be initiated voluntarily
swallowing can modulate the central without stimulation of the pharynx by
network activity to adapt the swal- a bolus, such as in a “dry” swallow,
lowing motor sequence according to indicates that input from the cerebral
bolus consistency and size. Oropharyn- cortex can trigger swallowing. Recent
geal muscle contraction timing, dura- advances in brain imaging such as
tion, and likely intensity change with positron emission tomography (PET),
changes in bolus size and consistency. functional magnetic resonance imaging
Sensory feedback likely modifies the (fMRI), transcranial magnetic stimula-
central program by adjusting the motor tion (TMS), and magnetoencephalog-
outputs depending on the contents raphy (MEG) have confirmed that the
of the oropharyngeal tract. In other cortex and multiple subcortical brain
words, continuous sensory feedback regions are active during swallowing
from the oral cavity and pharynx may (Hamdy, Mikulis, et al., 1999; Hamdy,
influence the neurons of the central pat- Rothwell, et al., 1999; Hasimoto et al.,
tern generator and thus modulate the 2021; Martin et al., 1997, 2001; Michou
central program. Considerable vari- & Hamdy, 2009; Mosier & Bereznaya,
ability in the sequence of events that 2001; Suzuki et al., 2003).
occurs during the pharyngeal phase The mechanism by which higher
of swallowing can be appreciated on cortical centers impact swallowing
videofluoroscopic studies of swallow- function is poorly understood, but it
ing in normal individuals. Ablation of appears that a widespread network of
sensory feedback does not, however, brain regions participates in the con-
disrupt sequential discharge of the trol of swallowing. It is hypothesized
cranial motor nerve fibers that occurs that the preparatory phase and the oral
during swallowing (Hamdy et al., 1997; phase of swallowing (voluntary con-
Hamdy, Mikulis, et al., 1999; Hamdy, trol) rely on the lateral regions of the
Rothwell, et al., 1999; Humbert et al., primary motor cortex and the premotor
2012; Jean, 2001; Kendall, 2002; Kendall areas that are mapped somato-topically
et al., 2000, 2003; Shadmehr et al., 2010; to the anterior vocal tract. In addition,
Steele & Miller, 2010). there are a number of subcortical sites,
including the corticofugal swallowing
pathway, which can trigger or modify
Higher Cortical Input to the swallowing, in particular the internal
Central Pattern Generator capsule, subthalamus, basal ganglia,
amygdala, hypothalamus, substantia
Higher cortical input has been found to nigra, mesencephalic reticular forma-
initiate and influence coordination of tion, and monoaminergic brainstem
swallowing by the central pattern gen- nuclei. Many studies of central swal-
lowing control emphasize the impor- ized in the rostral compact formation
tance of the inferior precentral gyrus. of the nucleus, the pharyngeal and soft
The anterior insula/claustrum and palate motoneurons are in the interme-
the cerebellum are also likely active diate semicompact formation, and most
in the initiation of voluntary swallow- of the laryngeal motoneurons are in the
ing. Once swallowing is initiated by caudal loose formation of the nucleus.
the cortex or stimulation of the SLN, The organization scheme results in
control moves to the central pattern sequential firing of the motoneurons
generator in the brainstem (Barlow & within the nucleus ambiguus during
Burton, 1990; Hamdy, Mikulis, et al., swallowing. Because the neurons in
1999; Hamdy, Rothwell, et al., 1999; the nucleus fire sequentially during
Kendall et al., 2003; Mistry & Hamdy, swallowing, each group of neurons in
2008; Mosier & Bereznaya, 2001; Palmer this chain may control more and more
et al., 2007; Zald & Pardo, 1999). distal regions of the swallowing chain
Stimulation of either cortical hemi- and be responsible for the successive
sphere is capable of eliciting a swal- firing behavior. In addition to excit-
lowing response, and swallowing atory drive, these motoneurons may
musculature is represented in both also receive inhibitory inputs or have
hemispheres, but there is evidence that complex intrinsic properties that are
one hemisphere may be dominant over activated by the swallowing sequence.
the other one. This finding is of inter- The motoneurons also exhibit exten-
est as stimulation of the noninjured sive dendritic extensions into the adja-
hemisphere in stroke patients may be cent reticular formation with a distinct
an important avenue for swallowing pattern for each muscle group. Because
rehabilitation (Hamdy et al., 1996, 2001; the reticular formation is the location of
Jean, 2001; Martin et al., 1999). the neuronal network that is the central
pattern generator, these dendrites pro-
vide an anatomical basis for the inter-
Motor Output From the action of the swallowing motoneurons
Central Pattern Generator and the neurons of the central pattern
generator (Bieger & Hopkins, 1987;
The main motor nuclei of the brain- Doty & Bosma, 1956; Gestreau et al.,
stem involved in deglutition are the 2005; Lawn, 1966, 1988; Tomomune &
hypoglossal (XII) motor nucleus and Takata, 1988; Zoungrana et al., 1997).
the nucleus ambiguus (X) (Figure 1–15). It has been reported that when the
The cell bodies of the hypoglossal motoneurons responsible for the begin-
nucleus are organized myotopically, ning of the swallowing sequence fire,
related to the different tongue muscles the neurons controlling the more dis-
innervated by the hypoglossal moto- tal parts of the tract are inhibited and
neurons. The nucleus ambiguus is orga- their activity is delayed. In some cases,
nized in a rostrocaudal pattern with the activity of distal neurons is inhib-
respect to the motoneurons innervating ited before the motor activity of proxi-
the esophagus, pharynx, and larynx. mal muscle groups is initiated. These
The esophageal motoneurons are local- inhibitory mechanisms may contribute
Motor nuclei Sensory nuclei
Edinger-Westphal nucleus (CN III)
Oculomotor nucleus (CN III) Mesencephalic nucleus of CN V

Figure 1–15. Sensory and
motor nuclei in the brain-
Trochlear nucleus (CN IV)
stem. From Foundations of
Speech and Hearing: Anat-
Chief sensory nucleus of CN V omy and Physiology, 2nd
22
Trigeminal motor nucleus (CN V) Spinal trigeminal nucleus ed. (p. 297), by Jeannette D.
Superior salivatory nucleus (CN VII) Vestibular nuclei (CN VIII) Hoit, Gary Weismer, and Brad
Dorsal and ventral cochlear nuclei Story, 2022, Plural Publishing.
Facial nucleus (CN VII)
(CN VIII) © 2022 by Plural Publishing.
Abducens nucleus (CN VI)
Inferior salivatory nucleus (CN IX)
Nucleus solitarius (CN VII, IX, X)
Nucleus ambiguus (CN IX, X)
Hypoglossal nucleus (CN XII)

Nucleus solitarius (CN IX, X)
Dorsal motor nucleus of CN X (CN X)
Spinal accessory nucleus (CN XI)

directly to the sequential excitation rali et al., 2001; Chiao et al., 1994; Ezure
of the motoneurons. Via mechanisms et al., 1993; Gestreau et al., 2005; Kessler
such as disinhibition or postinhibitory & Jean, 1985; Larson et al., 1994).
rebounds, the inhibitory connections Dorsal swallowing group interneu-
may be at least partly responsible for rons are thought to be involved in trig-
the progression of the contraction wave gering, shaping, and timing the sequen-
(Jean, 2001). tial swallowing motor pattern. These
interneurons exhibit a sequential firing
pattern that parallels the sequential
Brainstem Interneurons motor pattern typical of deglutition,
Responsible for the with considerable overlap between the
Programming and Coordination sequential firing of the various neurons.
of the Swallowing Sequence The neurons in this part of the reticu-
lar formation have been shown to have
The network of brainstem neurons direct connections with the motoneu-
thought to be responsible for the coor- rons that drive the musculature of the
dination of the pharyngeal swallowing pharynx involved in swallowing. Each
motor sequence is made up of interneu- dorsal swallowing group neuron may
rons or pre-motoneurons. In general, be directly activated by signals from
central nervous system interneurons peripheral afferent fibers originating in
are identified by their connectivity the corresponding part of the orophar-
with multiple areas of the brainstem ynx under its control.
and other areas of the central nervous Stimulation of the superior laryn-
system. Specifically, the physical con- geal nerve results in initial activity,
nections of the central swallowing pat- producing a single spike, in all of the
tern generator interneurons provide an dorsal swallowing group interneurons
anatomic substrate for the integration (see Figure 1–15). Some of the neu-
of swallowing-related activities with rons in the dorsal swallowing group
airway-protective reflexes. The inter- exhibit activity before the onset of the
neurons of the central swallowing pat- swallowing motor sequence, which is
tern generator are thought to be located continuous and called “preswallow-
in two main brainstem areas, although ing activity.” Those dorsal swallowing
some controversy exists regarding group interneurons that display pre-
their exact locations. The dorsal swal- swallowing activity can be activated
lowing group (DSG) of interneurons by stimulation of both the superior
is located in the dorsal medulla within laryngeal nerve and the glossopha-
the nucleus tractus solitarius (NTS) and ryngeal nerve. This pattern of activ-
adjacent reticular formation. The neu- ity observed in the dorsal swallowing
rons of the NTS receive and integrate group interneurons suggests that these
sensory information. The ventral swal- neurons are involved in the initiation
lowing group (VSG) of interneurons of swallowing. Cortical input into the
is located in the ventrolateral medulla swallowing central pattern generator
just above the nucleus ambiguus. The has been found to involve the neu-
motor nuclei of the nucleus ambiguus rons of the dorsal swallowing group.
control the pharyngeal muscles (Ami- The dorsal swallowing group neurons,
therefore, receive convergent informa- swallowing interneurons have been

tion from both cortical and peripheral identified within the trigeminal and
inputs that trigger swallowing. Finally, hypoglossal motor nuclei, or in close
the two hemicentral pattern generators proximity. They may play the role of
located in each half of the medulla are premotor neurons or be involved in the
tightly synchronized, and it is thought organization of the swallowing drive
that this connection occurs within the to the various motoneurons involved
dorsal swallowing group of interneu- in swallowing within a single motor
rons (Cunningham & Sawchenko, 2000; nucleus. They might also be involved in
Jean, 2001; Kessler & Jean, 1985). the bilateral coordination of the moto-
The interneurons of the ventral neuron pools (Car & Amri, 1987; Jean,
swallowing group are thought to be 2001; Kessler & Jean, 1985; Ono et al.,
“switching” neurons that distribute and 1998).
coordinate the swallowing drive to the There is also a population of inter-
various pools of motoneurons involved neurons, identified more rostrally in the
in swallowing. The firing behavior of pons, that fire during the oropharyn-
these neurons also exhibits a sequen- geal phase of swallowing. These inter-
tial pattern, but with more overlap, neurons have been classified as sensory
longer latency, greater duration vari- relay neurons and are thought to pro-
ability, and lower frequency than the vide information from the oropharyn-
interneurons of the dorsal swallowing geal receptors to the higher nervous
group. This type of firing behavior indi- centers and may help coordinate swal-
cates that the connections between the lowing and respiration (Dutschmann &
ventral swallowing group interneurons Dick, 2012; Jean et al., 1994).
and their afferent fibers are likely to be In conclusion, the dorsal swallow-
polysynaptic. The ventral swallowing ing group interneurons are involved
group interneurons are probably acti- in initiating the swallowing sequence.
vated by the interneurons of the dor- They stimulate the interneurons of the
sal swallowing group. They, in turn, ventral swallowing group, which then
are connected to all the various groups modulate and coordinate the stimu-
of motoneurons involved in swallow- lation of the various motoneurons
ing, and within the ventral swallowing involved in the swallowing sequence
group interneurons, each neuron can (Bieger, 2001; Roda et al., 2002).
project to more than one motor nucleus.
The trigeminal and hypoglossal motor
nuclei are connected only to the ventral ESOPHAGEAL PHASE
swallowing group interneurons and
not to the dorsal swallowing group. The bolus is transported down the
Swallowing motoneurons only receive esophagus into the stomach. The
input from the ipsilateral efferent fibers esophageal phase is quite simple and
of the ventral swallowing interneurons consists of a peristaltic wave of contrac-
(Amri et al., 1990; Jean, 2001; Kessler & tion that propagates down the esopha-
Jean, 1985; Larson et al., 1994). gus. There is considerable variability in
In addition to the interneurons of the the speed and strength of the esopha-
ventral and dorsal swallowing groups, geal contractile wave. Once initiated,
it is not an all-or-none phenomenon traction of esophageal striated muscle

but may dissipate before reaching the is controlled by the motor nuclei of the
lower esophageal sphincter. Sensory brainstem (nucleus ambiguus) while
feedback likely plays a role in regu- smooth muscle contraction is con-
lating the speed and intensity of the trolled by the autonomic nervous sys-
esophageal peristaltic wave, depend- tem. Smooth muscle of the esophagus
ing on the characteristics of the bolus. is innervated by preganglionic fibers
The lower esophageal sphincter is a site originating in the vagal motor nucleus.
of high pressure, resulting from tonic Similar to the muscles of the orophar-
contraction of the smooth muscle mak- ynx, the muscles of the esophagus are
ing up the sphincter. Increased pressure inhibited and stimulated by motoneu-
within the sphincter prevents reflux of rons under the control of interneurons
stomach contents into the esophagus. associated with the swallowing central
During swallowing, the lower esopha- pattern generator. They regulate the
geal sphincter tone is inhibited, relax- esophagus and coordinate the oropha-
ing the sphincter for bolus passage into ryngeal and esophageal phases of swal-
the stomach (Jean, 2001). lowing. It is believed that fewer inter-
Secondary esophageal peristalsis is neurons are involved in regulating the
defined as peristalsis without a pre- esophageal phase of deglutition and
ceding oropharyngeal phase of swal- that central control may be more depen-
lowing. Secondary peristalsis occurs dent on afferent input than during oro-
in response to stimulation of esopha- pharyngeal swallowing (Jean, 2001).
geal sensory receptors by distension
of the esophageal lumen and is other-
wise similar in character, with regard STUDY QUESTIONS
to strength and speed of contraction,
to primary esophageal peristalsis. Ter- 1. What are the four phases of deglu-
tiary peristalsis of the esophagus refers tition? Which are under voluntary
to peristalsis of the smooth muscle control, and which are primar-
portion of the esophagus, unrelated to ily involuntary or “reflexive” in
extrinsic innervation (Jean, 2001). nature?
The esophageal phase of swallowing 2. What are the three sphincters in the
requires both excitatory and inhibitory upper aerodigestive tract? Which
input to the muscles of the esophagus. chambers do they divide? How do
At rest, the esophagus is electromyo- they open and close?
graphically silent. All of the esopha- 3. What muscles are involved in bolus
geal motoneurons are strongly inhib- propulsion through the pharynx?
ited during the oropharyngeal phase 4. What sensory nerves are important
of swallowing, and the contractile wave in triggering the pharyngeal phase
of the esophagus during the esophageal of swallowing and what areas of
phase is preceded by inhibitory input. the mucosa do they supply?
Once the bolus enters the esophagus, 5. Describe in general terms what is
bolus movement involves the coordi- known about the central control
nated contraction of the smooth and of pharyngeal swallowing. What
striated muscles of the esophagus. Con- is the central pattern generator?
What are the inputs to the central way-protective reflexes. American Journal
pattern generator? How does the of Medicine, 108, 62S–67S.
central pattern generator control Car, A., & Amri, M. (1987). Activity of neu-
swallowing? rons located in the region of the hypo-
glossal motor nucleus during swallow-
ing in sheep. Experimental Brain Research,
69, 175–182.
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Divided Cranial Nerve Chart for Chapter 1
Cranial Nerve Branch Muscle Group Muscles Role During Swallowing Other
Temporalis Bolus preparation (mastication)

Medial Pterygoid and stabilization of tongue
Muscles of
base during transition from the
Mastication Lateral Pterygoid preparatory phase to the oral
Masseter phase of swallowing
Elevation of the hyoid bone

Mylohyoid during the pharyngeal phase of
Suprahyoid
Anterior Belly of swallowing. Pull the larynx under
V, Trigeminal Muscles
V3 the Digastric the tongue base, opening the
Nerve pharyngeal chamber
Tenses the soft palate during

Tensor Veli
Palatal Muscle elevation against the superior
30
Palatini
constrictor
Sensation from the anterior

2/3 of the tongue and
parasympathetic fibers to
the salivatory nucleus
Orbicularis Oris Anterior oral sphincter

VII, Facial Nerve Facial Muscles Maintain bolus between teeth
Buccinator
during preparatory phase
Pharyngeal Pharyngeal
Stylopharyngeus Shorten the pharynx
IX, Plexus Muscles
Glossopharyngeal Sensation to posterior
Nerve 1/3 of the tongue and
pharyngeal mucosa
Cranial Nerve Branch Muscle Group Muscles Role During Swallowing
Depresses the palate and elevates the tongue base

Palatoglossus during the preparatory phase of swallowing: posterior oral
Palatal cavity sphincter
Muscles Elevates the palate against the nasopharyngeal walls during
Levator Veli
the pharyngeal phase of swallowing: sphincter between
Palatini
oropharynx and nasopharynx
Pharyngeal Shorten the pharynx during the pharyngeal phase

Palatopharyngeus
Muscles of swallowing
Pharyngeal
31
X, Vagus Nerve Superior
Plexus Contracts against the soft palate to close off
Pharyngeal
the nasopharynx
Constrictor
Middle Contracts against the tongue base during the pharyngeal

Pharyngeal
Pharyngeal phase of swallowing and is required for clearance of the
Constrictor
Constrictor bolus from the pharynx
Muscles
Inferior Contracts against the tongue base to clear bolus from
Pharyngeal the pharynx during the pharyngeal phase of swallowing.
Constrictor/ Confluent with the cricopharyngeus muscle that forms the
Cricopharyngeus pharyngo-esophageal sphincter.
continues
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the House all the data available for a judgment and decision,
understating, as is his wont, the case for such a solution as he
himself might be apt to favour.
It now appears (he said) from the news I have received to-
day, which has come quite recently—and I am not yet quite sure
how far it has reached me in an accurate form—that an
ultimatum has been given to Belgium by Germany, the object of
which was to offer Belgium friendly relations with Germany on
condition that she would facilitate the passage of German troops
through Belgium. Well, until one has these things absolutely
definitely up to the last moment, I do not wish to say all that one
would say if one was in a position to give the House full,
complete, and absolute information upon the point. We were
sounded once in the course of last week as to whether if a
guarantee was given that after the war Belgian integrity would be
preserved that would content us. We replied that we could not
bargain away whatever interests or obligations we had in
Belgian neutrality. Shortly before I reached the House I was
informed that the following telegram had been received from the
King of the Belgians by King George:
“Remembering the numerous proofs of your Majesty’s friendship and

that of your predecessor, and the friendly attitude of England in 1870,
and the proof of friendship you have just given us again, I make a
supreme appeal to the diplomatic intervention of your Majesty’s
Government to safeguard the integrity of Belgium.”
Diplomatic intervention took place last week on our part.

What can diplomatic intervention do now? We have great and
vital interests in the independence of Belgium, and integrity is
the least part. If Belgium is compelled to allow her neutrality to
be violated, of course the situation is clear. Even if by agreement
she admitted the violation of her neutrality, it is clear she could
only do so under duress. The smaller States in that region of
Europe ask but one thing: their one desire is that they should be
left alone and independent. The one thing they fear is, I think,
not so much that their integrity should be interfered with, but
their independence. If in this war which is before Europe one of
the combatants should violate its neutrality and no action should
be taken to resent it, at the end of the war, whatever the integrity
may be, the independence will be gone. I have one further
quotation from Mr. Gladstone as to what he thought about the
independence of Belgium. He said:
“We have an interest in the independence of Belgium which is wider

than that we have in the literal operation of the guarantee. It is found in
the answer to the question whether under the circumstances of the case
this country, endowed as it is with influence and power, would quietly
stand by and witness the perpetration of the direst crime that ever
stained the pages of history, and thus become participators in the sin.”
Now if it be the case that there has been anything in the

nature of an ultimatum to Belgium, asking her to compromise or
violate her neutrality, whatever may have been offered to her in
return, her independence is gone if that holds, and if her
independence goes, the independence of Holland will follow.
As yet, however, there was nothing solid in the way either of a

declaration of Germany’s policy or of an ascertained breach of
Belgium’s neutrality to go upon. And the Foreign Secretary was
careful to make this clear:
Now (he said) I have put the question of Belgium somewhat

hypothetically, because I am not yet sure of all the facts, but if
the facts turn out to be as they have reached us at present, it is
quite clear that there is an obligation on this country to do its
utmost to prevent the consequences to which those facts will
lead if they are undisputed.
Meanwhile, the British Ambassador in Berlin had kept on

pressing for an answer to what was indeed a Sphinx question—the
scrap of paper—for the Kaiser, whose diagnosis of the British
character, fitfully tested and modified by the official despatches daily
pouring in upon him, played a material part in swaying his
appreciation of the situation, and together with it his decision. The
bearings of this decision were twofold—political and military.
Germany might dispense with the strategic advantages which the
route through Belgium offered her army under one of two conditions:
either if the odds against France were sufficient to enable her to
count upon an easy victory, or if the political disadvantages that
would accrue to her from a violation of the Treaty of 1839
outweighed the military facilities it would secure her. And it was for
the purpose of settling this preliminary point and allowing her to
choose whichever course offered her the greatest inducements that
Prince Lichnowsky put the question whether the British Government
would engage to remain neutral if Germany promised to observe the
terms of the Treaty. And when, this attempt having failed to elicit a
definite assurance, he pressed Sir Edward Grey to formulate
conditions which would buy our neutrality, the British Secretary of
State virtually told him that it was not for sale.
This straightforward way of meeting the stratagem by which our
hands were to be fettered, while Germany was to be free to choose
whichever alternative best suited her, clinched the matter in the
Kaiser’s mind, if we may judge by the closing conversations between
his Ministers in Berlin and our Ambassador.
Sir Edward Goschen describes these final scenes of the historic
game of “hedging” in words which will be remembered as long as the
British Empire stands:
In accordance with the instructions contained in your

telegram of the 4th inst. (he writes) I called upon the Secretary of
State that afternoon and inquired, in the name of his Majesty’s
Government, whether the Imperial Government would refrain
from violating Belgian neutrality. Herr von Jagow at once replied
that he was sorry to say that his answer must be “No,” as, in
consequence of the German troops having crossed the frontier
that morning, Belgian neutrality had been already violated. Herr
von Jagow again went into the reasons why the Imperial
Government had been obliged to take this step, namely, that
they had to advance into France by the quickest and easiest
way, so as to be able to get well ahead with their operations and
endeavour to strike some decisive blow as early as possible.
It was a matter of life and death for them, as if they had gone
by the more southern route they could not have hoped, in view
of the paucity of roads and the strength of the fortresses, to have
got through without formidable opposition entailing great loss of
time. This loss of time would have meant time gained by the
Russians for bringing up their troops to the German frontier.
Rapidity of action was the great German asset, while that of
Russia was an inexhaustible supply of troops. I pointed out to
Herr von Jagow that this fait accompli of the violation of the
Belgian frontier rendered, as he would readily understand, the
situation exceedingly grave, and I asked him whether there was
not still time to draw back and avoid possible consequences,
which both he and I would deplore. He replied that, for the
reasons he had given me, it was now impossible for them to
draw back.
Thus the die was cast. An accomplished fact was created which
could not, it was urged, be undone. It was now unhappily too late,
just as it had been too late to stay Austria’s invasion of Servia. But at
least reasons could still be offered in explanation of the stroke, and it
was hoped that Great Britain might own that they were forcible. The
Germans “had to advance into France by the quickest and easiest
way, and they could not have got through by the other route without
formidable opposition entailing great loss of time.” And the German
army was in a hurry.
During the afternoon (continues the British Ambassador) I

received your further telegram of the same date, and, in
compliance with the instructions therein contained, I again
proceeded to the Imperial Foreign Office, and informed the
Secretary of State that unless the Imperial Government could
give the assurance by twelve o’clock that night that they would
proceed no further with their violation of the Belgian frontier and
stop their advance, I had been instructed to demand my
passports and inform the Imperial Government that his Majesty’s
Government would have to take all steps in their power to
uphold the neutrality of Belgium and the observance of a treaty
to which Germany was as much a party as themselves.
Herr von Jagow replied that to his great regret he could give
no other answer than that which he had given me earlier in the
day, namely, that the safety of the Empire rendered it absolutely
necessary that the Imperial troops should advance through
Belgium. I gave his Excellency a written summary of your
telegram, and, pointing out that you had mentioned twelve
o’clock as the time when his Majesty’s Government would
expect an answer, asked him whether, in view of the terrible
consequences which would necessarily ensue, it were not
possible even at the last moment that their answer should be
reconsidered. He replied that if the time given were even twenty-
four hours or more, his answer must be the same.
I said that in that case I should have to demand my
passports. This interview took place at about seven o’clock. In a
short conversation which ensued Herr von Jagow expressed his
poignant regret at the crumbling of his entire policy and that of
the Chancellor, which had been to make friends with Great
Britain, and then, through Great Britain, to get closer to France. I
said that this sudden end to my work in Berlin was to me also a
matter of deep regret and disappointment, but that he must
understand that under the circumstances and in view of our
engagements, his Majesty’s Government could not possibly
have acted otherwise than they had done.
I then said that I should like to go and see the Chancellor, as
it might be, perhaps, the last time I should have an opportunity of
seeing him. He begged me to do so. I found the Chancellor very
agitated. His Excellency at once began a harangue, which lasted
for about twenty minutes. He said that the step taken by his
Majesty’s Government was terrible to a degree; just for a word
—“neutrality,” a word which in war-time had so often been
disregarded—just for a scrap of paper Great Britain was going to
make war on a kindred nation who desired nothing better than to
be friends with her. All his efforts in that direction had been
rendered useless by this last terrible step, and the policy to
which, as I knew, he had devoted himself since his accession to
office had tumbled down like a house of cards. What we had
done was unthinkable; it was like striking a man from behind
while he was fighting for his life against two assailants. He held
Great Britain responsible for all the terrible events that might
happen.
I protested strongly against that statement, and said that, in
the same way as he and Herr von Jagow wished me to
understand that for strategical reasons it was a matter of life and
death to Germany to advance through Belgium and violate the
latter’s neutrality, so I would wish him to understand that it was,
so to speak, a matter of “life and death” for the honour of Great
Britain that she should keep her solemn engagement to do her
utmost to defend Belgium’s neutrality if attacked. That solemn
compact simply had to be kept, or what confidence could anyone
have in engagements given by Great Britain in the future? The
Chancellor said, “But at what price will that compact have been
kept? Has the British Government thought of that?” I hinted to
his Excellency as plainly as I could that fear of consequences
could hardly be regarded as an excuse for breaking solemn
engagements, but his Excellency was so excited, so evidently
overcome by the news of our action, and so little disposed to
hear reason, that I refrained from adding fuel to the flame by
further argument.
As I was leaving he said that the blow of Great Britain joining
Germany’s enemies was all the greater that almost up to the last
moment he and his Government had been working with us and
supporting our efforts to maintain peace between Austria and
Russia. I said that this was part of the tragedy which saw the two
nations fall apart just at the moment when the relations between
them had been more friendly and cordial than they had been for
years. Unfortunately, notwithstanding our efforts to maintain
peace between Russia and Austria, the war had spread, and
had brought us face to face with a situation which, if we held to
our engagements, we could not possibly avoid, and which
unfortunately entailed our separation from our late fellow-
workers. He would readily understand that no one regretted this
more than I.
After this somewhat painful interview I returned to the
Embassy, and drew up a telegraphic report of what had passed.
This telegram was handed in at the Central Telegraph Office a
little before nine p.m. It was accepted by that office, but
apparently never despatched.
At about 9.30 p.m. Herr von Zimmermann, the Under-
Secretary of State, came to see me. After expressing his deep
regret that the very friendly official and personal relations
between us were about to cease, he asked me casually whether
a demand for passports was equivalent to a declaration of war. I
said that such an authority on international law as he was known
to be must know as well or better than I what was usual in such
cases. I added that there were many cases where diplomatic
relations had been broken off, and, nevertheless, war had not
ensued; but that in this case he would have seen from my
instructions, of which I had given Herr von Jagow a written
summary, that his Majesty’s Government expected an answer to
a definite question by twelve o’clock that night, and that in
default of a satisfactory answer they would be forced to take
such steps as their engagements required. Herr Zimmermann
said that that was, in fact, a declaration of war, as the Imperial
Government could not possibly give the assurance required
either that night or any other night.
CHAPTER XI
JUST FOR “A SCRAP OF PAPER”
“Just for neutrality—a word which in war-time had so often been

disregarded—just for a scrap of paper, Great Britain was going to
make war on a kindred nation.”
The frame of mind which generated this supreme unconcern for
the feelings of the Belgians, this matter-of-fact contempt for the
inviolability of a country’s plighted word, gives us the measure of the
abyss which sunders the old-world civilization, based on all that is
loftiest in Christianity, from modern German culture. From this
revolutionary principle, the right to apply which, however, is reserved to
Germany alone, radiate wholly new conceptions of right and wrong,
truth and falsehood, plain and double dealing, which are destructive of
the very groundwork of all organized society. Some forty or fifty years
ago it was a doctrine confined to Prussia of the Hohenzollerns: to-day
it is the creed of the Prussianized German Empire.
Frederic the Great practised it without scruple or shame. It was he
who, having given Maria Theresa profuse assurances of help should
her title to the Habsburg throne ever be questioned by any other State,
got together a powerful army as secretly as he could, invaded her
territory, and precipitated a sanguinary European war. Yet he had
guaranteed the integrity of the Austrian Empire. What were his
motives? He himself has avowed them openly: “ambition, interest, and
a yearning to move people to talk about me were the mainsprings of
my action.” And this wanton war was made without any formal
declaration, without any quarrel, without any grievance. He was soon
joined by other Powers, with whom he entered into binding
engagements. But as soon as he was able to conclude an
advantageous peace with the Austrian Empress, he abandoned his
allies and signed a treaty. This document, like the former one, he soon
afterwards treated as a mere scrap of paper, and again attacked the
Austrian Empire. And this was the man who wrote a laboured
refutation of the pernicious teachings of Machiavelli, under the title of
“Anti-Machiavel”!
Now, Frederic the Great is the latter-day Germans’ ideal of a
monarch. His infamous practices were the concrete nucleus around
which the subversive Pan-Germanic doctrines of to-day gathered and
hardened into the political creed of a race. What the Hohenzollerns did
for Prussia, Prussia under the same Hohenzollerns has effected for
Germany, where not merely the Kaiser and his Government, or the
officials, or the officers of the army and navy, or the professors and the
journalists, but the clergy, the socialists, nay, all thinking classes of the
population, are infected with the virus of the fell Prussian disease
which threatens the old-world civilization with decomposition.
To this danger humanity cannot afford to be either indifferent or
lenient. It may and will be extremely difficult to extirpate the malady,
but the Powers now arrayed against aggressive and subversive
Teutonism should see to it that the nations affected shall be made
powerless to spread it.
The sheet-anchor of new Germany’s faith is her own exclusive
right to tear up treaties, violate agreements, and trample the laws of
humanity underfoot. To no other Power, however great its temptation,
however pressing its needs, is this privilege to be extended. Belgian
neutrality is but a word to be disregarded—by Germany; a solemn
treaty is but a scrap of paper to be flung into the basket—by Germany;
but woe betide any other Power who should venture to turn Germany’s
methods against herself! Now that Japan has begun operations
against German Tsingtao, the Kaiser’s Minister in Pekin promptly
protested against the alleged violation of Chinese neutrality which it
involved. Sacred are all those engagements by which Germany stands
to gain some advantage, and it is the duty of the civilized world to
enforce them. All others which are inconvenient to the Teuton he may
toss aside as scraps of paper.
To the threats that China would be held responsible for injury to
German property following on the Japanese operations, unless she
withstood the Japanese by force, the Pekin Government administered
a neatly worded lesson. If the Pekin Government, the Foreign Minister
replied, were to oppose the landing of the Japanese on the ground that
the territory in question belongs to China, it would likewise be her duty
to drive out the Germans for the same reason, Tsingtao also being
Chinese. Moreover, Tsingtao had only been leased to Germany for a
term of years, and, according to the scrap of paper, ought never to
have been fortified, seeing that this constituted a flagrant violation of
China’s neutrality. These arguments are unanswerable, even from
Germany’s point of view. But the Kaiser still maintains that he has right
on his side! Deutschland über Alles!
With a people whose reasoning powers show as little respect for
the laws of logic as their armies evince for the laws of humanity or their
press for truth, it would be idle to argue. Psychologically, however, it is
curious to observe the attitude of the body of German theologians
towards the scrap of paper. Psychologically, but also for a more direct
reason: because of the unwarranted faith which the British people are
so apt to place in the German people’s sense of truth and justice, and
more particularly in the fairmindedness of their clergy. Well, this clergy,
in its most eminent representatives, does indeed expend strong
adjectives in its condemnation—not of the Kaiser’s crime, but of
Belgian atrocities!
This is how German divines propound the rights and wrongs of the
Belgian episode to Evangelical Christians abroad:
Unnameable horrors have been committed against Germans

living peaceably abroad—against women and children, against
wounded and physicians—cruelties and shamelessness such as
many a heathen and Mohammedan war has not revealed. Are
these the fruits, by which the non-Christian peoples are to
recognize whose disciples the Christian nations are? Even the not
unnatural excitement of a people, whose neutrality—already
violated by our adversaries—could under the pressure of
implacable necessity not be respected, affords no excuse for
inhumanities, nor does it lessen the shame that such could take
place in a land long ago christianized.
If Ministers of the Gospel thus tamper with truth and ignore elementary
justice and humanity, can one affect surprise at the mischievous
inventions of professional journalists?
This strange blending of religion with mendacity, of culture with
humanity, of scientific truth with political subterfuge, reads like a
chapter in cerebral pathology. The savage military organism against
which a veritable crusade is now being carried on by the peace-loving,
law-abiding nations of Europe has been aptly characterized as “the
thing which all free civilization has learned to loathe like a vampire: the
conscienceless, ruthless, godless might of a self-centred militarism, to
which honour is a word, chivalry a weakness, and bullying aggression
37
the breath of life.”
* * * * *
It is a relief to turn from the quibbles, subterfuges, and downright
falsehoods that characterize the campaign of German diplomacy to the
dignified message which the King-Emperor recently addressed to the
Princes and Peoples of that India which our enemies hoped would rise
up in arms against British rule.
To the Princes and Peoples of my Indian

Empire:
During the past few weeks the peoples of my whole Empire at
home and overseas have moved with one mind and purpose to
confront and overthrow an unparalleled assault upon the continuity
of civilization and the peace of mankind.
The calamitous conflict is not of my seeking. My voice has
been cast throughout on the side of peace. My Ministers earnestly
strove to allay the causes of strife and to appease differences with
which my Empire was not concerned.
Had I stood aside when in defiance of pledges to which my
Kingdom was a party the soil of Belgium was violated, and her
cities laid desolate, when the very life of the French nation was
threatened with extinction, I should have sacrificed my honour and
given to destruction the liberties of my Empire and of mankind. I
rejoice that every part of the Empire is with me in this decision.
Paramount regard for treaty faith and the pledged word of
rulers and peoples is the common heritage of England and of
India.
Among the many incidents that have marked the unanimous
uprising of the populations of my Empire in defence of its unity and
integrity, nothing has moved me more than the passionate
devotion to my Throne expressed both by my Indian subjects and
by the Feudatory Princes and the Ruling Chiefs of India, and their
prodigal offers of their lives and their resources in the cause of the
Realm.
Their one-voiced demand to be foremost in the conflict has
touched my heart, and has inspired to the highest issues the love
and devotion which, as I well know, have ever linked my Indian
subjects and myself.
I recall to mind India’s gracious message to the British nation
of goodwill and fellowship, which greeted my return in February,
1912, after the solemn ceremony of my Coronation Durbar at
Delhi, and I find in this hour of trial a full harvest and a noble
fulfilment of the assurance given by you that the destinies of Great
Britain and India are indissolubly linked.
The history of the Kaiser’s dealings with Belgium is but a single

episode in the long series of lessons taught us by German militarism,
with its two sets of weights and measures and its Asiatic maxims of
foreign policy. The paramount interest of this incident is to be ascribed
to the circumstance that it marks the central moment of the collision
between Germany and Britain. It also struck a keynote of difference
between the new Pan-Germanic code of morals and the old one still
common to the remainder of the human race. Lastly, it opened the
eyes of the purblind in this country and made them see at last.
Belgium and Luxemburg are neutral States, and all Europe is
bound to respect their neutrality. But this obligation in the case of
Prussia is made more sacred and more stringent still by the
circumstance that she herself is one of the guarantors of that neutrality.
Not only is she obliged to refrain from violating Belgian territory, but it
is her duty to hinder, with force if necessary, a breach by other nations.
This twofold obligation Germany set at naught, and then affected
wonder at the surprise of her neighbours. “By necessity we have
occupied Luxemburg, and perhaps have already entered Belgian
territory,” the Chancellor said calmly. “This is an infraction of
international law.... We are ... compelled to overrule the legitimate
protest of the Luxemburg and Belgian Governments. We shall repair
the wrong we are doing as soon as our military aims have been
achieved.” Military aims annul treaties, military necessities know no
law, and the slaughter of tens of thousands of peaceable citizens and
the destruction of their mediæval monuments constitute a wrong which
“we Germans shall repair as soon as our military aims are achieved.”
In such matter-of-fact way this German Bayard, as he once was
called by his English admirers, undertakes, if he be allowed to break
two promises, that he will make a third by way of compensation.
Not content with having brought six Powers into line against her
destructive doctrines and savage practices, Germany would fain throw
the blame for the war now on Great Britain, now on Russia. Here,
again, it is the Imperial Chancellor who propounds the thesis. On
September 12th he sent the following curious statement to the Danish
Press Bureau for publication:—
The English Prime Minister, in his Guildhall speech, reserved

to England the rôle of protector of the smaller and weaker States,
and spoke about the neutrality of Holland, Belgium, and
Switzerland as being exposed to danger from the side of
Germany. It is true that we have broken Belgium’s neutrality
because bitter necessity compelled us to do so, but we promised
Belgium full indemnity and integrity if she would take account of
this state of necessity. If so, she would not have suffered any
damage, as, for example, Luxemburg. If England, as protector of
the weaker States, had wished to spare Belgium infinite suffering
she should have advised Belgium to accept our offer. England has
not “protected” Belgium, so far as we know; I wonder, therefore,
whether it can really be said that England is such a disinterested
protector.
We knew perfectly well that the French plan of campaign
involved a march through Belgium to attack the unprotected
Rhineland. Does anyone believe England would have interfered to
protect Belgian freedom against France?
We have firmly respected the neutrality of Holland and
Switzerland; we have also avoided the slightest violation of the
frontier of the Dutch province of Limburg.
It is strange that Mr. Asquith only mentioned the neutrality of
Belgium, Holland, and Switzerland, but not that of the
Scandinavian countries. He might have mentioned Switzerland
with reference to France, but Holland and Belgium are situated
close to England on the opposite side of the Channel, and that is
why England is so concerned for the neutrality of these countries.
Why is Mr. Asquith silent about the Scandinavian countries?
Perhaps because he knows that it does not enter our head to
touch these countries’ neutrality; or would England possibly not
consider Denmark’s neutrality as a noli me tangere for an advance
in the Baltic or for Russia’s warlike operations?
Mr. Asquith wishes people to believe that England’s fight
against us is a fight of freedom against might. The world is
accustomed to this manner of expression. In the name of freedom
England, with might and with the most recklessly egotistic policy,
has founded her mighty Colonial Empire, in the name of freedom
she has destroyed for a century the independence of the Boer
Republics, in the name of freedom she now treats Egypt as an
English colony and thereby violates international treaties and
solemn promises, in the name of freedom one after another of the
Malay States is losing its independence for England’s benefit, in
the name of freedom she tries, by cutting German cables, to
prevent the truth being spread in the world.
The English Prime Minister is mistaken. When England joined
with Russia and Japan against Germany she, with a blindness
unique in the history of the world, betrayed civilization and handed
over to the German sword the care of freedom for European
peoples and States.
The Germanistic conceptions of veracity and common honesty

which this plea reveals makes one feel the new air that breathes over
every department of the national cult—the air blowing from the
borderland between the sphere of high scientific achievement and
primeval barbarism. One is puzzled and amused by the solemn
statement that if Germany has ridden rough shod over the rights of
Belgium, she has committed no such breach of law against Holland,
Denmark, and other small states. “We have firmly respected the
neutrality of Holland and Switzerland.” It is as though an assassin
should say: “True, I killed Brown, whose money I needed sorely. But at
least give me credit for not having murdered Jones and Smith, who
possess nothing that I could carry away at present, and whose
goodwill was essential to the success of my stroke”!
The violation of Belgium’s neutrality was part of Germany’s plan of
campaign against France. This fact was known long ago. It was
implicitly confessed in the official answer given to Sir Edward
Goschen’s question on the subject. Yet on Sunday, August 2nd, the
German military Attaché in Brussels, in conversation with the Belgian
War Minister, exclaimed: “I cannot, for the life of me, understand what
you mean by mobilizing. Have you anything to fear? Is not your
neutrality guaranteed?” It was, but only by a scrap of paper. For a few
38
hours later the Belgian Government received the German ultimatum.
On the following day Germany had begun to “hack her way” through
treaty rights and the laws of humanity. The document published by the
Chancellor is the mirror of German moral teaching and practice.
The reply to it, issued by the British Press Bureau, with the
authority of the Secretary of State for Foreign Affairs, is worth
reproducing:
“Does anyone believe,” asks the German Chancellor, “that

England would have interfered to protect Belgian freedom against
France?”
The answer is that she would unquestionably have done so.
Sir Edward Grey, as recorded in the White Paper, asked the
French Government “whether it was prepared to engage to
respect the neutrality of Belgium so long as no other Power
violates it.” The French Government replied that they were
resolved to respect it. The assurance, it was added, had been
given several times, and formed the subject of conversation
between President Poincaré and the King of the Belgians.
The German Chancellor entirely ignores the fact that England
took the same line about Belgian neutrality in 1870 that she has
taken now. In 1870 Prince Bismarck, when approached by
England on the subject, admitted and respected the treaty
obligations in relation to Belgium. The British Government stands
in 1914 as it stood in 1870; it is Herr von Bethmann-Hollweg who
refused to meet us in 1914 as Prince Bismarck met us in 1870.
“Not Very Tactful.”

The Imperial Chancellor finds it strange that Mr. Asquith in his
Guildhall speech did not mention the neutrality of the
Scandinavian countries, and suggests that the reason for the
omission was some sinister design on England’s part. It is
impossible for any public speaker to cover the whole ground in
each speech.
The German Chancellor’s reference to Denmark and other
Scandinavian countries can hardly be considered very tactful. With
regard to Denmark, the Danes are not likely to have forgotten the
parts played by Prussia and England respectively in 1863–4, when
the Kingdom of Denmark was dismembered. And the integrity of
Norway and Sweden was guaranteed by England and France in
the Treaty of Stockholm in 1855.
The Imperial Chancellor refers to the dealings of Great Britain
with the Boer Republics, and suggests that she has been false
therein to the cause of freedom.
Without going into controversies now happily past, we may
recall what General Botha said in the South African Parliament a
few days ago, when expressing his conviction of the righteousness
of Britain’s cause and explaining the firm resolve of the South
African Union to aid her in every possible way: “Great Britain had
given them a Constitution under which they could create a great
nationality, and had ever since regarded them as a free people
and as a sister State. Although there might be many who in the
past had been hostile towards the British flag, he could vouch for it
that they would ten times rather be under the British than under
the German flag.”
Colonial Loyalty.
The German Chancellor is equally unfortunate in his
references to the “Colonial Empire.” So far from British policy
having been “recklessly egotistic,” it has resulted in a great rally of
affection and common interest by all the British Dominions and
Dependencies, among which there is not one which is not aiding
Britain by soldiers or other contributions or both in this war.
With regard to the matter of treaty obligations generally, the
German Chancellor excuses the breach of Belgian neutrality by
military necessity—at the same time making a virtue of having
respected the neutrality of Holland and Switzerland, and saying
that it does not enter his head to touch the neutrality of the
Scandinavian countries. A virtue which admittedly is only practised
in the absence of temptation from self-interest and military
advantage does not seem greatly worth vaunting.
To the Chancellor’s concluding statement that “To the German
sword” is entrusted “the care of freedom for European peoples and
States,” the treatment of Belgium is a sufficient answer.
Passing summarily in review the causes of the war touched upon

in the foregoing pages, the reader will have discerned that the true
interest of the story of the scrap of paper lies in the insight it affords the
world into the growth, spread, and popularization of the greatest of
human conceptions possible to a gifted people, whose religious faith
has been diverted to the wildest of political ideals and whose national
conscience has been fatally warped. For the Germans are a highly
dowered, virile race, capable, under favourable conditions, of
materially furthering the progress of humanity. In every walk of
science, art, and literature they have been in the van. Their poetry is
part of the world’s inheritance. Their philosophy at its highest level
touches that of ancient Greece. Their music is unmatched. In
chemistry and medicine they have laboured unceasingly and with
results which will never be forgotten. Into the dry bones of theology
they have infused the spirit of life and movement. In the pursuit of
commerce they have deployed a degree of ingenuity, suppleness, and
enterprise which was rewarded and may be summarized by the result
that, during the twelve years ending in 1906, their imports and exports
increased by nearly one hundred per cent.
But the national genius, of which those splendid achievements are
the fruits, has been yoked to the chariot of war in a cause which is
dissolvent of culture, trust, humanity, and of all the foundations of
organized society. That cause is the paramountcy of their race, the
elevation of Teutonism to the height occupied among mortals by
Nietzsche’s Over-man, whose will is the one reality, and whose
necessities and desires are above all law. Around this root-idea a vast
politico-racial system, partaking of the nature of a new religion, has
been elaborately built up by the non-German Prussians, and accepted
and assimilated by a docile people which was sadly deficient in the
political sense. And it is for the purpose of forcing this poisonous creed
and its corollaries upon Europe and the world that the most
tremendous war of history is now being waged. This remarkable
movement had long ago been studied and described by a few well-
informed and courageous British observers, but the true issues have
been for the first time revealed to the dullest apprehension by the
historic episode of the scrap of paper.
It is only fair to own that the Prussianized Germans have fallen
from their high estate, and become what they are solely in
consequence of the shifting of their faith from the spiritual to the
political and military sphere. Imbued with the new spirit, which is
impatient of truth when truth becomes an obstacle to success, as it is
of law when law becomes a hindrance to national aims, they have
parted company with morality to enlist in the service of a racial revival
based on race hatred. Pan-Germanism is a quasi-religious cult, and its
upholders are fanatics, persuaded of the righteousness of their cause,
and resolved, irrespective of the cost, to help it to triumph.
The non-German State, Prussia, was the bearer of this exclusively
Germanic “culture.” It fitted in with the set of the national mind, which
lacked political ideals. Austria, however, occupied a position apart in
this newest and most grandiose of latter-day religions. She was but a
tool in the hands of her mighty co-partner. “The future,” wrote the
national historian Treitschke, “belongs to Germany, with whom Austria,
if she desires to survive, must link herself.” And the instinct of self-
preservation determined her to throw in her lot with Prussianized
Germany. But even then, it is only fair to say that Austria’s conception
of her functions differed widely from that of her overbearing Mentor.
Composed of a medley of nationalities, she eschewed the odious
practice of denationalizing her Slav, Italian, and Roumanian peoples in
the interests of Teutondom. One and all they were allowed to retain
their language, cultivate their nationality, and, when feasible, to govern
themselves. But, congruously with the subordinate rôle that fell to her,
she played but a secondary part in the preliminaries to the present
conflict. Germany, who at first acted as the unseen adviser, emerged
at the second stage as principal.
We cannot too constantly remember the mise en scène of the
present world-drama. Germany and Austria were dissatisfied with the
Treaty of Bucharest, and resolved to treat it as a contemptible scrap of
paper. They were to effect such a redistribution of territory as would
enable them to organize a Balkan Federation under their own auspices
and virtual suzerainty. The assassination of Archduke Franz Ferdinand
offered them a splendid opening. On pretext of punishing the real
assassins and eradicating the causes of the evil, Austria was to
mutilate Servia and wedge her in among Germanophile Balkan States.
The plan was kept secret from every other Power, even from the Italian
ally—so secret, indeed, that the Russian Ambassador in Vienna was
encouraged to take leave of absence, just when the ultimatum was
about to be presented, which he did. The German Kaiser, while
claiming to be a mere outsider, as uninitiated as everybody else, was a
party to the drafting of the ultimatum, which, according to his own
Ministers, went the length of demanding of Servia the impossible. That
document was avowedly intended to provoke armed resistance, and
when it was rumoured that the Serbs were about to accept it integrally,
Austrians and Germans were dismayed. It was the Kaiser himself who
had the time-limit for an answer cut down to forty-eight hours in order
to hinder diplomatic negociations; and it was the Kaiser’s Ministers
who, having had Sir Edward Grey’s conciliatory proposals rejected,
expressed their sincere regret that, owing to the shortness of the time-
limit, they had come too late.
When the Belgrade Government returned a reply which was fitted
to serve as a basis for an arrangement, it was rejected by the Austrian
Minister almost before he could have read it through. While the Kaiser
in his letter to the Tsar, and the Imperial Chancellor in his talks with our
Ambassador, were lavishing assurances that they were working hard
to hold Austria back, the German Ambassador in Vienna, through
whom they were thus claiming to put pressure on their ally, was openly
advocating war with Servia, and emphatically declaring that Russia
would have to stand aside. At the same moment Germany’s military
preparations were secretly being pushed forward. But Austria,
perceiving at last that the Germans’ estimate of Russia’s weakness
was unfounded, and she herself faced with the nearing perils of an
awful conflict with the great Slav Empire, drew back and agreed to
submit the contentious points to mediation. Thereupon Germany
sprang forward, and, without taking the slightest account of the Servian
question, presented twelve-hour ultimatums to Russia and to France.
Thus the thin pretension that she was but an ally, bound by the
sacredness of treaty obligations to help her assailed co-partner, was
cynically thrown aside, and she stood forth in her true colours as the
real aggressor.
In her forecast of the war which she had thus deliberately brought
about the sheet-anchor of her hope of success was Great Britain’s
neutrality. And on this she had built her scheme. Hence her solicitude
that, at any rate, this postulate should not be shaken. Her infamous
offer to secure it was one of the many expedients to which her Kaiser
and his statesmen had recourse. But they had misread the British

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Dysphagia Assessment and Treatment

Planning: A Team Approach, Fifth

New to the Fifth Edition:

Rebecca Leonard, PhD, is a Professor Emerita in the Department of Otolaryngology-Head

Rebecca Leonard, PhD

Copyright © 2025 by Plural Publishing, Inc.

Typeset in 10.5/13 Palatino by Flanagan’s Publishing Services, Inc.

For permission to use material from this text, contact us by

Library of Congress Cataloging-in-Publication Data:

NOTICE TO THE USER

1 Anatomy and Physiology of Deglutition 1

2 History and Physical Examination in Dysphagia 33

3 Clinical Swallow Evaluation 49

4 Endoscopy in Assessing and Treating Dysphagia 65

5 Barium Radiographic Evaluation of the Pharynx and Esophagus 87

6 Dynamic Fluoroscopic Swallow Study: Swallow Evaluation 101

7 DSS: A Systematic Approach to Analysis and Interpretation 121

8 Dynamic Swallow Study: Objective Measures and Normative 141

9 Other Technologies in Dysphagia Assessment 175

10 The Treatment Plan: Behavioral Approaches 187

11 The Treatment Plan: Medical and Surgical Therapies 263

12 Airway Considerations in Dysphagia 273

13 Nutritional Considerations in Dysphagia 287

14 Pediatric Clinical Feeding Assessment 325

15 Esophageal Phase Dysphagia 349

16 Neurogenic Dysphagia 365

17 Dysphagia in Head and Neck Cancer Patients 393

18 Laryngopharyngeal Reflux 425

19 Spinal Abnormalities in Dysphagia 439

Bonus Online-Only Chapter. Telehealth www

The initial publication of Dysphagia As- well-established academic speech-lan-

access to Swallowtail™, a software appli- normal function and the impairments

Chapter 1 Video 8–2. YngEldNormalSwallow

Jacqui E. Allen, MD, FRACS, Department of Otolaryngology-Head

James H. Clark, MD Maggie-Lee Huckabee, PhD

University of Utah Susan McKenzie, MS

Ann E. F. Sievers, RN, MA, CORLN Alice I. Walker, MS

Familiarity with the anatomy and phys- PHYSIOLOGY: SERIES OF

ryngeal structures. The genioglossus of the hyoglossus muscles results in

Figure 1–2. Extracranial course of the facial nerve.

Figure 1–5. Lateral view from videofluoroscopic swallow-

Tongue weakness results in difficulty ogy at the skull base or intracranially.

tongue is carried back to central swal- Mastication, or chewing, of the bolus

Figure 1–7. Trigeminal nerve. Note branches that enter the

Side view Side view

Figure 1–8. Muscles of mastication. From Foundations of Speech and Hearing:

Figure 1–9. Posterior view of the pharyngeal constric-

Figure 1–10. Lateral view of the

Figure 1–11. Lateral view from videofluoroscopic swallowing study:

Figure 1–13. Lateral view from videofluoroscopic swallow-

paralysis (Schiedermayer et al., 2020;

the airway and inhalation. The pharyn- Neural Control of the

to peripheral afferent information. The erator. Many of the neurological dis-

Oculomotor nucleus (CN III) Mesencephalic nucleus of CN V

Hypoglossal nucleus (CN XII)

Spinal accessory nucleus (CN XI)

therefore, receive convergent informa- swallowing interneurons have been

it is not an all-or-none phenomenon traction of esophageal striated muscle

Kraemer, J. (2020). Laryngoscope, 130(10), tional swallowing detected by functional

Temporalis Bolus preparation (mastication)

Elevation of the hyoid bone

Tenses the soft palate during

Sensation from the anterior