1. Review: Osteophyte pic1: esophagus has air

2. Cricopharyngeal bar

3. Laryngectomy: No CP myotomy

4. Esophageal Phase Cervical Esophageal phase of swallowing involves the initial peristaltic wave in the esophageal musculature CANNOT be modified by therapy; however postural changes can be helpful Observable in a lateral view during MBSS If esophageal dysfunction is suspected, a barium swallow should be performed after the MBSS or a referral to a GI specialist is recommended. – MBSS is performed 1 st to r/o aspiration. If aspiration is evident, the barium swallow is deferred until the risk of aspiration is eliminated.

5. Esophageal Phase SLP need to be knowledgeable about esophageal disorders that can masquerade as pharyngeal swallowing disorders bc they cause backflow into the pharynx, causing aspiration.

6. Esophageal Phase Symptom: Esophageal to Pharyngeal Backflow Dysfunction: Achalasia (failure of the LES to relax), reflux, tumor, stenosis, etc Normal: Material enters stomach and does NOT backflow into esophagus or pharynx Abnormal: Backflow of material from the esophagus enters the pharynx by opening of the UES. May cause aspiration or symptoms of pharyngeal swallowing disorder. Achalasia, reflux, tumor, stenosis results in esophageal to pharyngeal backflow

7. Esophageal Phase Symptom: Food entering the esophagus flows back into the trachea via a hole in the party wall/Tracheoesophageal (TE) wall; aspiration after the swallow below the level of the glottis – Usually located at the level of the 1 st to 3 thoracic vertebrae which can be shadowed by the shoulders in a lateral view. An obliqued position (shoulders turned diagonally while pt’s head and body remain in the lateral view) can improve visualization of this part of the esophagus and trachea. Swallows are repeated with the fluoro tube lowered to the base of the cervical esophagus. Dysfunction: Tracheoesophgeal fistula Normal: TE or party wall is intact with no evidence of swallowed material entering soft tissue or airway Abnormal: a fistula tract allows food from the esophagus to backflow into the trachea – Patients will have symptoms of aspiration (coughing after the swallow) – If the MBSS is normal, an evaluation of the esophagus is recommended to r/o a TE fistula Tracheoesophageal fistula can result in aspiration after the swallow below the level of the glottis

8. Esophageal Phase Symptom: Round balloon that fills with radiopaque material as the pt swallows; usually empties after the swallow and can backflow into the pharynx or airway Dysfunction: Zenker’s Diverticulum – Side pocket that forms when pharyngeal or esophageal muscle herniates – Located in cricopharyngeal region/UES – Why? Increased pharyngeal pressure is required to push bolus through a hypertonic UES, thus causing the tissue to herniate over time. Normal: bolus cleanly passes through UES Abnormal: material fills into herniated soft tissue during the swallow which may backflow into the pharynx or airway Zenker’s Diverticulum may result in backflow of swallowed contents into the pharynx or airway after the swallow

9. Figure 4.30

10. Gastroesophageal Reflux Backflow of food and stomach acid from the stomach to the esophagus 2/2 failure of LES to keep food in stomach May see redness in the arytenoid area during a laryngoscopy Pt may complain of a burning sensation in pharynx or esophagus, frequent gagging or coughing Aspirated material that contains any gastric acid is more irritating to the lungs than aspirated saliva or food. NOT diagnosed during a MBSS. If suspected, consult a GI specialist.

11. Esophageal Phase Symptom: Reflux or Gastroesophageal Reflux Disease (GERD) Dysfunction: LES dysfunction Normal: material enters stomach with no evidence of backflow Abnormal: material backflows from the stomach to the esophagus LES dysfunction results in reflux

12. Posterior-Anterior View Examines symmetry of structures and function in the oral and pharyngeal cavity during swallowing and of the larynx during phonation. Normal: bolus divides fairly equally to pass down the two-sides of the pharynx and esophagus in 80% of normal swallowers; 20% swallow unilaterally – Difficulty to determine the occurrence and amount of aspiration 2/2 the trachea and esophagus overlapping each other.

13. Oral Preparatory Phase: A/P view A/P view allows SLP to examine: – 1: tongue’s ability to lateralize material – 2: pattern of jaw movement during mastication – 3: shape of tongue during bolus holding with the sides of the tongue in contact with the lateral alveolus and the central groove midline surrounding the bolus

14. Oral Preparatory Phase: A/P view Symptom: Unable to align teeth/improper occlusion for chewing Dysfunction: Reduced mandibular movement/ROM – Usually occurs when there has been removal of part of the mandible Normal: teeth align properly for mastication Abnormal: incomplete mastication Reduced mandibular ROM results in incomplete mastication 2/2 improper teeth occlusion for chewing

15. Oral Preparatory Phase: A/P view Symptom: Unable to lateralize material with tongue Dysfunction: Reduced tongue lateralization Normal: tongue moves food from side to side for chewing with teeth Abnormal: incomplete mastication of food Reduced tongue lateralization results in incomplete mastication of food 2/2 inability to move bolus between teeth

16. Oral Preparatory Phase: A/P view Symptom: Unable to mash material with tongue 2/2 inability to lateralize food to teeth for chewing Dysfunction: Reduced tongue elevation/ROM Normal: tongue mashes food to hard palate to compensate for poor lingual lateralization Abnormal: inability to mash food against hard palate Reduced tongue ROM results in inability to mash food against hard palate

17. Oral Preparatory Phase: A/P view Symptom: material falls into the lateral sulcus Dysfunction: Reduced buccal tension/tone Normal: Buccal tension/tone closes the lateral sulcus and prevents material from lodging there and directs bolus medially towards the tongue. Abnormal: Material falls into the lateral sulcus during mastication – Decreased buccal tension/tone results in bolus collection within the lateral sulcus

18. Oral Preparatory Phase: A/P view Symptom: Material falls into the floor of the mouth Dysfunction: Reduced tongue control Normal: food is free from floor of the mouth during mastication Abnormal: food falling into the floor of the mouth during mastication Reduced tongue control results in material falling into the floor of the mouth during mastication

19. Oral Preparatory Phase: A/P view Symptom: Decreased bolus formation; Bolus spreads across mouth Dysfunction: Reduced lingual shaping and fine tongue control Normal: tongue shapes around bolus to hold cohesive Abnormal: bolus is spread throughout oral cavity Reduced lingual shaping and fine motor control results in decreased bolus formation

20. Pharyngeal Phase: A/P view Symptom: Unilateral vallecular residue Dysfunction: Unilateral dysfunction in posterior movement of the tongue base or the pharyngeal constrictors Normal: valleculae is free from residue Abnormal: food is left on only one side of the valleculae after the swallow Unilateral weakness in posterior movement of the tongue base or pharyngeal constrictors result in unilateral vallecular residue on the weak side

21. Figure 4.31

22. Pharyngeal Phase: A/P view Symptom: Residue in one pyriform sinus Dysfunction: Unilateral dysfunction of the pharyngeal walls Normal: pyriform sinuses are free from significant residue Abnormal: residue within the pyriform sinuses Unilateral weakness of the pharyngeal constriction results in residue on the weak side of the pyriform sinuses

23. Figure 4.32

24. Figure 4.33 (fairly symmetrical residue) V PW PS

25. Pharyngeal Phase: A/P view Symptom: May cause aspiration during the swallow Dysfunction: Reduced vocal fold adduction – can be evaluated when pt’s head is tilted backward, with the mandible out of view – Ask pt to say “ah, ah, ah” rapidly to localize vf; then have pt inhale, prolong “ah” for several seconds, and repeat. – Look for symmetry with adduction and abduction – Reduced movement of one side indicate possible unilateral vf paresis or paralysis – May cause aspiration during the swallow 2/2 decreased airway closure Normal: vocal folds adduct completely during the swallow for airway protection Abnormal: Aspiration noted during the swallow; however if laryngeal closure is achieved above the level of the tvf, aspiration may not be witnessed. Reduced vocal fold adduction may result in aspiration during the swallow.

26. Pharyngeal Phase: A/P view Symptom: Dysfunction:Unequal height of vocal folds Occasionally seen in partially laryngectomized patients Reconstructed larynx on one side does not meet up with unoperated side during laryngeal closure even if both sides move well Normal: vocal folds adduct completely during the swallow Abnormal: two sides of larynx do not meet each other during laryngeal closure (incomplete closure) – May result in aspiration during the swallow

27. Figure 4.34

28. Questions?