George Larson (70s)

and 

Jeri Logemann (80s)

1.) The Clinical Examination

2.) Management (ie: compensatory maneuvers to reduce aspiration and choking)

1.)She worked at Northwestern.

2.)She Developed the Cookie Swallow Test (a modified barium swallow study)

3.)She produced a landmark publication (1983) about basic phys, asst, and tx for dysphagia 

4.)She Emphasized specialized training 

-respiration

-salivation

-nutrition

-quality of life

-Multidisciplinary

-Holistic

-Patient Specific

It would differ depending on the setting.

 For example in acute care, focus on keeping the client alive.

In long term care, focus on quality of life and ongoing needs 

- SLP

- Radiologist

- Dietician

- Referring Physician

-Admin swallowing exam

- Co-admin videofluoroscopic exam

-Det oropharyngeal physiology

-Screens for esophageal dysphagia and nutrition

-Rx textures, strategies and compensations

Manages and monitors for change

-Co-admin on videofluoroscopic exam

-Det oropharyngeal anatomy

-Collaborate with radiation technologist

- Screens for oropharyngeal and esophageal dysphagia

- Admin nutritional clinical exams

- Rx nutritional intake 

- Manages and monitors for change

- Overviews medical conditions

- Overview meds

-Dependent on etiology

1 - screening

2 - clinical assmt*

3 - instrunmental assmt

4 - management*

5 - treatment

6 - discharge *

Determine swallowing status

Ensure Nutritional Intake

(Screen, Clinical Assmt, Instrunmental Assmt, Management)

* will be same for recuperative vs degenerative

- Clinical Assessment / Instrunmental Assmt

-Focus on treatment (with some management too)

- Ensure feeding independence

-Stabilize function

- clinical/instrun assmt

- ensure feeding independence

- Management of dyphagia is focus (with some treatment too)

- Screening, Assessments 

-Stabilize quality of life

-Manage dysphagia

-Maximize eating enjoyment

Clinical/Instrunmental Assmnt to determine swallow status

- Focus will be on treatment (and a bit of management)

- Focus on rehab

- Ensure Q of L and function

- to prevent pulmonary complications related to aspiration

- to prevent dehydration and malnutrition

- following acute stroke

- following anterior approach cervical spine surgery

- follwing prolonged intubation after CV surgery

- following extubation in critically ill trauma patients

- mental health patients 

- Oral Prep

- Oral Transit

- Pharyngeal Phase

- Esophageal phase

-labial seal established

- facial tone prevents bolus from getting lost in buccal cavs

-rotary jaw and lat tongue movement to shift bolus

-anterior pulling of palate, pulling towards base of tongue ,preventing bolus going down too early

-salivation

-tongue groove

What muscle is important for labial seal? 

What innervates it?

Orbicularis Oris

Innervated by CN VII

What muscle keeps food from getting stuck in buccal cavities?

What innervates it?

The Buccinator

Facial Nerve CN VII

What muscle assists with the anteior pulling of the soft palate to prevent bolus from moving into pharynx?

What innervates it?

The Palatoglossus

(CN X and XI, through plexus)

Parotid (CNIX)

Submandibular (CNVII) 75%

Sublingual (CNVII)

What muscles contribue to tongue groove establishment?

What innervates them?

Genioglossus (XII)

Transverse (XII)

-tongue elevation anteriorly to posteriorly

-bolus moved through oral cavity in groove bet tongue and palate

- velum/soft palate starts to raise

-hyoid starts to move ant and sup

-lateral walls of pharynx contract

- post pharynx walls forward

What muscles help to close off the nasopharynx?

What innervates them?

- Levator Veli Palatini  (CNX and XI)

- Tensor Veli Palatini (CNV) 

- Uvula (CNX and XI)

-VP seal

-Superior dispacement of hyoid/larynx

-Pharyngeal elevation

-Reflexing cessation of breathing

-Stripping wave

-Epiglottis retroflexion

-Intrinsic laryngeal muscles contract

-UES opens 

In people who have COPD exacerbation state

- any kind of lung problem really, because body will try to breather before it swallows

What muscles elevate the hyoid for a swallow?

And what is their innervation?

Post Digastric (VII)

Anterior Digastric (V)

Mylohyoid (V)

Geniohyoid (XII)

Hyoglossus (XII)

Styloglossus (XII)

What muscles contribute to pharyngeal elevation?

What is their innervation?

Stylopharyngeus (CNIX)

SalpingoPharyngeus (CN X and XI)

Palatopharyngus (CN X and XI)

the chain reaction of muscles and tugging/upward movement

starts with sup constrictors, then med, then inf then cricopharyngeus relaxes

- also brainstem important

-Inferior fibres of inferior constrictor

- The cricopharyngeus

- Upper esophageal fibres

- medical diagnoses

- impaired cognitive status

- delirium/altered conciousness

- dysarthria

- dysphonia

- weak/abnormal volitional cough

-respiratory compromise

-trach history

- dependency for feeding/oral care

pacing, amt on spoonful, positionning

ALSO

why is the person dependent? prob has many other issues too

-multiple medical issues 

-smoking

-tube feeding

-poor oral hygiene

-dysphagia

lung function is compromised, ciliary clearence impaired by tar

saliva aspiration, many clients who are dep for oral care have realy bad oral hygene

also

continuous tube feeds can cause reflux, then reflux can cause pneumonia 

Age

Trach/ventilator dependence

Repeated surgical intervention

multiple intubations/ respiratory history

deconditioning of muscles

- coughing and or choking

- throat clearing

- hydraphonia

- poor management of oral secretions/drooling

- pocketing food

-multiple swallows for bolus

-respiratory detioration

-prolonged mealtimes

-weight loss/nutritional compromise

- head tilt to unimpaired side

- head turn (to weak side)

- chin tuck

- slight recline 

-Oral motor excercies

- Mendelsohn maneuver

- Hard Swallow

- Supraglottic swallow

-sEMG??

-Thermal Stimulation (debatable)

-Texture mod

-v

-VII

-IX

-X

-C 1,2,3

- CN V

- CN VII

- CN IX

-X

-XI

- CN XII

maxillary palatal arch

mandible

ramus of the mandible

cervical vertebra (1-7)

hyoid

dentition

If no teeth, then bone structure will change 

Teeth have sensory info too, no teeth, no sensory 

from centre outwards:

- central insisor

-lateral incisors

- canines

- 1st premolars

- 2nd premolars

-1st molars

- 2nd molars

- 3rd molars 

a normal bite

1st molars should line up

an overbite

The lower incisors frequently do not touch the upper incisors when the back teeth are together

Underbite, mandible forward

can make it hard to bite things 

Vallate

Foliate

Filiform

Fungiform

Looks like a sling,

connects on either side of the cricoid, depressed the esophagus against trachea when at rest

Constricted, tonic at rest 

How many layers of muscle are in the UES?

What are they?

Three

Inner mucosal layer.

Middle circular layer

Outer longitudinal layer 

Striated - higher in UES, in top 1/4

Second quarter - mix or striated and smooth

Smooth - lower down, more automatic. Distal 1/2 is smooth muscle, no control

Outpouchings in the UES

caused by the mucosa that pushes through striations of muscle fibres

Only in striated fibres, can get thru smooth muscles

Cervical

Thoracic

Abdominal

Above the false folds

bound by the epiglottis, AE folds and false folds inferiorly

Bet Tongue and Epiglottis

like little pits

(like funnels towards the UES) formed by the lateral wall of thryoid and inferior constrictor muscle

- some peoples are really big

nasopharynx

oropharynx

laryngopharynx (hypopharynx)

Anything past the tip of the epiglottis all the way down to the UES

Posterior border is the inferioir laryngeal constrictor

Water based component

Thicker compoent

Enzyme (with amylase)

-ant/sup hyoid movement

- bolus gets contract bet epiglot and aryteniods

1.) primary stripping wave, smooth and modulate

2.)secondary striping wave - helps the bolus go down

3.) Tertiary contractions, if still a bill etc stuck, then theses will happen, they are tense and wrinkly

1.) Lingual Driving Force

2.) Pharyngeal Clearing Wave

3.) Hypopharyngeal Suction Pump

striated and circular

under voluntary control

Depresses, opens, protrudes jaw

lateral motions 

Turns the tongue tip up and the lateral margins up,

 shortens the tongue

Does the CN XII innervate all the extrinsic tongue muscles?

NO.

Palatoglossus is innervated by CN X

Also, C1 and C2 through the ansa cervicalis for the others

It elevates the hyoid and depresses the jaw

Innervated by CN V

Elevate hyoid anteriorly, depress jaw

CN XII

Depress jaw/elevate hyoid

CN V

Elevate and retract hyoid

CN VII

opening of UES, heart and soul of the UES

CN X

1.) palatoglossus (CN X and XI)

2.)palatopharyngeus (CN X and XI)

- Cerebral Fibres

- Brainstem Nuclei

-Afferent and Efferent fibres

- afferent sensory fibres up to the post-central gyrus

- efferent motor fibres down from the pre-central gyrus

- integrating areas and representational loci (interneurons)

(in the pons and medulla)

- Sensor nuclei

- Motor nuclei

- Interneuron nuclei

peripheral afferent nerves (CNs, X,XII,IX,X)

peripheral efferent nerves (CNs, X, XII, IX, XII)

1.) afferent info goies up to post central gyrus

2.) Integration

3.) efferent info goes back down from precentral gyrus

The insula 

Internal capsule

Pars triangularis

Gustatory area

Concious perception of taste

(lights up during volitional part of swallow)

involuntary - reticular formation (brainstem)

voluntary - insula 

- alertness, fatigue and motivation

- walking, sleeping, eating

-integration of involuntary swallow

General sensation to the oropharynx and post 1/3 of tongue

taste to posterior 1/3 of tongue

General sensation to the pharnyx, larynx and esophagus

Taste sensation to the epiglottis 

-CN IX and X ( the posterior faucial pillars (X), base of tongue(IX) and oropharyngeal mucosa(IX))

- Electric stim of sup laryngeal nerve (reflexive swallow)

-Mechanic stim to post pharyngeal arches or pharyngeal wall evokes a swallow

The muscles of mastication (V3)

Muscles of the hyoid (anterior digastric, mylohoid)

Tensor Veli Palatini

muscles of the soft palate and pharynx (except tensor veli palatini (V)and stylopharyngeus(IX))

muscles of the larynx and esophagus

the intrinsic muscles of the tongue

(extrinsic... but then thru CI and C2)

geniohyoid and thryrohyoid

the extrinsic tongue muscles (through a XII deviation, except palatoglossus (X))

Ansa Cervicalis

1) Reflex chain

2) Central pattern generator

What is the basic theory behind the reflex chain hypothesis?

Who created it?

the system depends on continuous feedback involving the stimulation of sensory receptors to trigger the next step (oral transit and pharyngeal phases)

Focus is on triggers (bolus, movement of tongue etc)

Sensory threshold must be reached to trigger next phase

Hartley and Hume

What is the idea behind the central pattern generator?

who created it?

once swallowing is initiated, a network of neurons in the medulla perform the swallow (independent of other sensory feedback)

(other exs are walking and inspriation)

Breathing being close to the CPG for swallow helps to coordinate swallow and breath cessation

Dodds 1989 (evil to monkey dude)

Sensory input

(triggers)

Brainstem interneurons

(sequentially excites)

Motor Output

Sequential muscle contraction

helps to determin chain reaction effects if one or more stages is compromised

(oral prep, oral transit, pharyngal, esophageal)

preprogrammed response or pattern occurs when triggered (when medullar swallowing centre intact)

Provides insight into influences from other systems (dec alertness, respiratory patterns)

A brain dead individual with an intact brainstem will still be able to breathe/have an pharyngeal swallow if triggered

Volitional - usually involves a saline bolus

Reflexive - usually involves saliva swallows when subjects are unaware that they are being evaluated for this purpose

Yes. but it's random, not really a rule to which side it goes to.

Soo... unilateral stroke could therefore really affect a swallow depending on what side it's on

Is there any cortical representation for reflexive swallows?

(acc to recent research)

yes. in the sensorimotor cortex.

volitional swallows may be represented in more expanded cortical regions

(recent research says)

1.) Primary Afferent (V, VII, IX, X) -to-

2.) Medulla, the fasciculus solitarius -to-

3.) Cortex (to post-central gyrus and pre-central gyrus)

4.) Back down to Medulla (fasciculus solitarius)

5.)Down Nucleus Tractus Solitarius and Reticular Formation (which is the central pattern generator)

6.) Motor nuclei in the pons and medulla (V, VII, IX, X, XII)

7.) Primary Motor Neurons out to muscles 

-tongue elevation in anterior to posterior direction moving bolus through oral cavity.

  -Base of tongue retraction begins in this stage  - hyoglossus Active here for initiation of base of tongue retraction

Tongue tip gets stabilized on hard palate by genioglossus which then starts the elevation of the hyoid. 

-Responsilibity of the hyoglossus STARTS TO shift to elevation.

Oral Transit:  More for tongue retraction

Pharyngeal: More for elevation of hyoid

* although elevation will start to happen at end of oral transit too.

Hyoglossus and 

Styloglossus

- then returns to tonic contraction via cranial nerve 10 (cricopharyngeus, ext sup laryngeal nerve)

Some CNs have their own nuclei, others send info to the NTS

* Important for central pattern generator theory, NTS send sensory info to interneurons (in reticular formation)

GO DRAW THE PATHWAYS!!!

(1st draw bulbar pathways)

RCH describes swallowing as a chain of reflexive events

CPG describes the pharyngeal swallow as a reflex that happens without any sensory feedback

Sensory input to generator neurons (Nucleus Tractus Solitarius)

then goes to Reticular Formation

then info set out to 4 nuclei

1.) nucleus ambiguus

2.) Hypoglossal nucleus

3.) motor trigeminal nucleus

4.) facial motor nucleus