1. Disorders of Deglutition Chapter 4

2. Review/Introduction Oral Preparatory Phase: Initiated by sensory recognition of food approaching and being placed in the mouth. Designed to break down food for the swallow, mix it with saliva, and form a cohesive bolus ready for swallowing. Oral Phase: Initiated by the seal created by the anterior and lateral tongue to the alveolar ridge to hold a prepared bolus. The anterior midline of the tongue initiates backward movement of the bolus with an upward, backward movement. Consists of lingual propulsion of the bolus through the oral cavity. – Under voluntary cortical control, but plays a role in the reflexive triggering of the pharyngeal swallow.

3. Oral transit time: time taken from the initiation of tongue movement to begin the voluntary oral stage until the bolus head reaches the point where the lower edge of the mandible crosses the tongue base and triggers a pharyngeal swallow. – 1 to 1.5 seconds; increases slightly as bolus viscosity increases; increases slightly with age (over 60 increases by ~.25 seconds) – Slow oral transit time is defined by any dysfunction observed within the oral phase

4. Pharyngeal Phase: Initiated with the triggering of the pharyngeal swallow and continues until the bolus passes through the cricopharyngeal region, UES, or PE segment. Triggered by sensory input to predominantly cranial nerve IX (Glossopharyngeal Nerve) when the head of the bolus reaches any point from the anterior faucial arch to the point where the lower edge of the mandible crosses the base of the tongue (level 6).

5. Pharyngeal transit time: time elapsed from the triggering of the pharyngeal swallow (onset of laryngeal elevation) until the bolus tail passes through the cricopharygneal region or pharyngealoesophageal (PE) segment. – Maximum of 1 second; usually less (.35 to.48 seconds), regardless of age or material swallowed

6. Pharyngeal delay time: begins from the point where the lower edge of the mandible crosses the tongue base and ends when laryngeal elevation begins – Bolus goes back before the swallow is triggered – Normal delay: Young adults: 0 to.2 seconds Older adults (over age 60):.4 to.5 seconds Infants/young children: bolus may collect in valleculae before the pharyngeal swallow is triggered. – Abnormal delay: A delay greater than 2 seconds or a shorter delay that results in aspiration regardless of age. Infants/young children: Abnormal delay is >1 second between the last tongue pump and the onset of the pharyngeal swallow, or aspiration occurring during bolus collection.

7. Figures 4.11 & 4.12 Delayed pharyngeal swallow triggering The dot is where the swallow should be triggered, but there is a bolus under it

8. Oropharyngeal swallow time Oral transit time + pharyngeal transit time = oropharyngeal swallow time – Determines whether or not a patient is going to get sufficient nutrition/and or hydration by mouth. Longer oropharyngeal swallow times are likely to result in decreased oral consumption.

9. Disorders of Deglutition Described by their clinical or radiographic symptomatology and specific abnormalities in anatomy or neuromuscular functioning that result in the disturbed motility seen on a MBSS or at bedside. – Looking clinically, radiologically, and anatomically Must differentiate between anatomic and neuromuscular dysfunctions in order to design a proper treatment plan. – If half of the tongue is missing, they will have a different TX plan that that who just has weakness Aspiration and residue are symptoms of a variety of disorders, NOT disorders themselves. – WE TREAT THE DYSFUNCTION – We can be given symptoms (ex aspiration) but we will need to know how and why in order to treat

10. MBSS/VSS Define: – anatomic and/or neuromuscular dysfunctions present, – identify timing of aspiration (before, during, or after the swallow), – trial treatment strategies in attempt to improve swallow safety. Recommend whether the patient can safely eat/drink by mouth and what consistencies are safest Construct a treatment plan for the specific swallowing disorder. Therapy is designed to eliminate aspiration by treating the dysfunction. (NOT SYMPTOM) “Modifieds starts when the pt aspirates”

11. Views seen by a MBSS Lateral view: – examines oral and pharyngeal transit times; – pharyngeal delay time; – movement patterns of the bolus and oropharyngeal structures in the oral prep, oral, pharyngeal, and cervical esophageal phases; – approximate amount and cause of any aspiration that occurs. Anterior/Posterior view: – examines the symmetry of structures and function in the oral cavity and pharynx during swallowing and in the larynx during phonation. – Difficulty to determine the occurrence and amount of aspiration 2/2 (secondary to) the trachea and esophagus overlapping each other. – So having 2 views will give you better idea

12. Lateral view vs. A/P view Hard to tell difference bw larynx and pharynx in a/p

13. Symptoms vs. Disorders/Dysfunction Symptoms are what is observed that is indicative of a swallowing disorder/dysfunction. The dysfunction results in the symptom. – What we treat Table 4.1 (study**)

17. Disorders in the Oral Preparation for the swallow Symptom: Cannot hold food in the mouth anteriorly; food falls from the mouth (anterior spillage) Dysfunction: Reduced lip closure Normal: lips close and remain closed during all phases of the swallow to keep food in mouth anteriorly. Requires nasal breathing. – Check patency of the nasal airway b/c mouth breathers keep lips open during mastication and oral manipulation. Abnormal: food falls from the mouth – Reduced lip closure results in anterior spillage from the oral cavity

18. Figure 4.1 Reduced lip closure

19. Oral Preparatory Phase Symptom: Cannot hold a bolus (premature loss of bolus) Dysfunction: Reduced tongue shaping/coordination; decreased downward and forward movement of the soft palate to contact the back of the tongue Normal: bolus is kept cohesive awaiting initiation of the oral phase of the swallow – Unless the patient wants to taste material or otherwise manipulate it in the mouth – Unless premature loss of the bolus over the tongue base and into the pharynx occurs during mastication, but not while holding a liquid or pudding bolus.

20. Oral Preparatory Phase Abnormal: bolus will immediately spread throughout oral cavity – reduced tongue shaping/coordination results in inability to hold the bolus Abnormal: bolus will be prematurely lost over the tongue base and into the pharynx with poor soft palate to back of the tongue contact. Can result in aspiration before the swallow; however depends on amount, consistency, and posture of the patient. – Reduced anterior soft palate positioning and/or poor tongue control results in premature loss of liquid or paste into the valleculae

21. Figure 4.2 Adequate holding of the bolus

22. Oral Preparatory Phase Symptom: cannot form a bolus Dysfunction: Reduced lingual ROM (range of motion) or coordination Normal: during mastication or tasting (oral prep), food is manipulated and moved throughout the oral cavity. Once oral prep is completed, food is pulled together by tongue into a single ball or bolus to initiate posterior movement of the bolus (oral phase).

23. Abnormal: after oral prep is complete, difficulty forming a cohesive bolus and then forced to transfer/initiate a swallow with food spread throughout the oral cavity. – Reduced lingual motion/coordination results in decreased bolus formation/control.

24. Oral Preparatory Phase Symptom: Material falls into the anterior sulcus Dysfunction: Reduced labial tension/tone Normal: anterior sulcus is completely closed preventing food from lodging there Abnormal: Material falls into the anterior sulcus during upon oral placement or during mastication. – Reduced labial tension/tone results in collection of the bolus within the anterior sulcus – Pts: dementia, CVA, Bell’s palsy

25. Oral Preparatory Phase 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 Pts seen: dementia, facial weakness (CVA, Bell’s palsy) – Decreased buccal tension/tone results in bolus collection within the lateral sulcus

26. Oral Preparatory Phase Symptom: Abnormal hold postion Dysfunction: Reduced tongue control; tongue thrust Normal: Bolus is held between the tongue and hard palate in prep for oral phase (tipper) or on the floor of the mouth in front of the retracted tongue tip (dipper- 20% of normal swallowers) – Dipper: tongue moves forward and picks up the bolus and brings it to the surface of the tongue as the swallow begins. This increases oral transit time. More commonly seen in older adults – Tippers and Dippers must shape the tongue around the bolus and seal the sides of the tongue to the lateral alveolar ridge for adequate holding.

27. Abnormal: Bolus is not held medially. If held against the front of the teeth, the swallow will be accomplished with a tongue thrusting behavior. – Tongue thrust: forward movement of the tongue towards the lips and central incisors, pushing the bolus forward. Can be so strong it pushes the bolus out of the oral cavity. – Tongue thrust relates to neurologic impairment (i.e. cerebral palsy, stroke, head trauma) – Reduced tongue control/tongue thrusting results in abnormal positioning of the bolus prior to initiation of the oral phase

28. Figure 4.4 Abnormal hold position

29. Disorders in the Oral Phase of the swallow Symptom: Delayed onset of the oral swallow Dysfunction: Apraxia of swallow; reduced oral sensation, oral tactile agnosia for food (lack of recognition of bolus as something to be swallowed) – Can result from a severe neurological impairment (CVA, stroke) Normal: oral manipulation of the bolus Abnormal: significant delay in initiating an oral swallow when given a swallow command. Bolus is held in the mouth with no lingual movement. (put food on mouth, but show no tongue movement) – May vary based on consistency – Reduced oral sensation of food, apraxia of swallow, or oral tactile agnosia results in delayed onset of the oral swallow c/b (characterized by) bolus holding.

30. Oral Phase Symptom: Searching tongue movements Dysfunction: Apraxia of swallow – Often accompanies severe oral apraxia Normal: Tongue forms food or liquid into a cohesive bolus and prepares for A/P transfer Abnormal: searching movements of the tongue, exhibiting good ROM but inability to organize front-to-back lingual and bolus movement. – A lot of groping behavior – Apraxia of the swallow results in searching lingual movements with adequate ROM during A/P transfer. – This is a big component with Parkinson’s pt

31. Apraxia of the swallow What can you do? – Increase sensory stimulation by increasing the pressure of the spoon on the tongue as the bolus is presented, or use a cold, larger, stronger tasting or textured bolus may facilitate more organized tongue movement during the swallow. – Allow pt to feed himself may also facilitate oral activity – Refrain from giving commands to swallow; Apraxia is usually worse when the target activity becomes highly volitional.

32. Oral Phase Symptom: Tongue moves forward to start swallow pushing bolus anteriorly Dysfunction: Tongue thrust Normal: tongue tip is anchored against the alveolar ridge and initiates a swallow by lifting the midline sequentially in an upward and backward direction against the palate – Nearly all infants exhibit a swallowing pattern involving tongue protrusion, but by six months of age most lose this reflex allowing for the ingestion of solid foods Abnormal: tongue thrusts forward towards the central incisors, can push food from the mouth. – Usually preceded by an abnormal hold position – Tongue thrusting actions resulted in forward movement of the bolus while attempting to initiate a swallow Figure 4.5

34. Oral Phase Symptom: Residue in anterior sulcus (also in oral prep) Dysfunction: Reduced labial tension/tone Normal: anterior sulcus is free from food/liquid during the initiation of the oral phase of the swallow Abnormal: Bolus lodges in the anterior sulcus – Seen with oral cancer patients whose anterior floor of the mouth was surgically resected. – Reduced labial tension/tone resulted in residue in the anterior sulcus

35. Figure 4.6

36. Oral Phase Symptom: Residue in lateral sulcus (also seen in oral prep) Dysfunction: Reduced buccal tension/tone Normal: lateral sulcus is free from food/liquid during the oral phase of the swallow Abnormal: bolus falls into the lateral suclus during initiation of the oral phase of the swallow. Buccal muscle tension may contribute to the backward movement of the bolus during oral transit by providing resistance or pressure in the lateral walls of the oral cavity. – What helps keep bolus at midline – Reduced buccal tension/tone results in residue within the lateral sulcus

37. Oral Phase Symptom: Residue on the floor of the mouth Dysfunction: Reduced tongue shaping/coordination or failure of the peripheral seal of the tongue to the anterior and lateral alveolus Normal: Floor of mouth is free from food/liquid during attempts at oral transfer Abnormal: food falls into the anterior or lateral floor of the mouth during attempts at oral transfer – Reduced tongue shaping or seal of tongue to anterior/lateral alveolus results in residue along the floor of the mouth. – Pts seen: those with dentures

38. Figure 4.6 & 4.7 this pt was treated for oral cancer and had floor of mouth resected

39. Oral Phase Symptom: Residue in midtongue depression (anatomical) Dysfunction: tongue scarring – Observed during the oral mech – Tissue is tight and relatively immobile Normal: Tongue is free from food or liquid after the posterior transfer of the bolus Abnormal: Normal tongue tissue around the scar elevates and moves around the scar tissue forming a crevice which food falls into while the patient attempts to swallow. – The greater the lingual struggle to swallow, the worse effect the scar tissue will have on the swallow and the greater the amount of food in the depression created by the scar tissue – Seen with oral cancer patients or trauma to the mouth (knife or gun shot wound) – Tongue scarring results in residue within the midtongue depression

40. Figure 4.8

41. Oral Phase Symptom: Residue of food on the tongue Dysfunction: Reduced tongue ROM or strength Normal: tongue is free of food/liquid after initiating a swallow Abnormal: food sits on the tongue surface or the hard palate and remains there despite numerous attempts to initiate a swallow – Occurs with thicker viscosities Rice, nuts, corn – Any stasis (residue) on the tongue indicates reduced tongue ROM – Any stasis (residue) that increases as viscosity thickens indicates decreased tongue strength. – Reduced lingual ROM/strength results in residue on the tongue

42. Oral Phase Symptom: Disturbed lingual contraction Dysfunction: Lingual discoordination during A/P bolus transfer Normal: tongue tip and sides remain in contact with the anterior and lateral alveolar ridge, while the front and center of the tongue cradle the bolus and then elevate and squeeze or roll the bolus along the hard palate until it reaches the back of the oral cavity or pharynx. – A single and organized action Abnormal: the tongue moves in somewhat random and nonproductive motions resulting in a disorganized anterior to posterior transfer. – Not the same repetitive tongue rolling motion seen with Parkinson's patients. – Decreased lingual coordination results in random and nonproductive lingual contraction upon A/P transfer.

43. Oral Phase Symptom: Incomplete tongue-palate contact Dysfunction: Reduced tongue elevation/vertical ROM Normal: sequential front to back tongue-palate contact which moves the bolus backward/posteriorly Abnormal: incomplete lingual to palate contact which results in bolus may spread throughout the entire mouth while attempting to transfer posteriorly – Reduced lingual elevation results in incomplete tongue to palate contact allowing bolus to spread throughout the oral cavity. – No contact= no pressure

44. Oral Phase Symptom: Residue of food on the hard palate Dysfunction: Reduced tongue elevation or strength Normal: tongue propels bolus posteriorly leaving minimal residue coating oral structures Abnormal: Food collects on the hard palate and remains there after the swallow – Residue increases as viscosities thicken indicates reduced tongue strength bc increased lingual pressure is required to thicker foods cleanly through the oral cavity. – Reduced lingual elevation or strength results in residuals along the hard palate after the swallow. – Thicker viscosities = problems with ROM and strength ? – Thinner viscosities = problems with ROM

45. Figure 4.9 Notice the entire pudding bolus caught on the hard palate.

46. Oral Phase Symptom: Reduced A/P tongue movement Dysfunction: Reduced A/P lingual coordination Normal: smooth front to back action of the midline of the tongue with the sides and tip of the tongue maintaining contact with the lateral and anterior alveolar ridge. Abnormal: multiple, small tongue movements with normal lingual ROM – Decreased lingual coordination results in reduced A/P tongue movement for bolus transfer

47. Oral Phase Symptom: Repetitive lingual rocking-rolling motion of the tongue, preventing material from leaving oral cavity; lingual pumping during A/P transfer Dysfunction: lingual pumping characteristic of Parkinson’s disease Normal: midline of the tongue produces a single upward and backward movement propelling the bolus posteriorly. Abnormal: repetitive upward and backward movements of the central portion of the tongue with the posterior tongue failing to lower at the appropriate time resulting in posterior movement of the bolus to the point where it reaches the hard palate before rolling forward again. The front of the tongue then attempts to reinitiate the swallow. – Lasts 10 seconds or more before a full swallow is initiated. – Lingual pumping characteristic of Parkinson’s disease resulted in incomplete and delayed A/P bolus transfer

48. Oral Phase Symptom: Premature loss of liquid or pudding into the pharynx/uncontrolled bolus during oral prep Dysfunction: Reduced lingual control; reduced lingualvelar seal Normal: Liquid or puree bolus remains cohesive during prep phase, oral phase just prior to triggering of the pharyngeal swallow. – During mastication, premature loss of the bolus into the valleculae is normal as the back of tongue and palatal seal is broken due to vigorous chewing motions. More common with larger volumes Abnormal: Partial or entire bolus has fallen posteriorly into the pharynx during the oral prep or oral phase just prior to the triggering of the pharyngeal swallow. – Abnormal with liquid or pureed textures (1-10ml) – May lodge in the valleculae, pyriform sinuses or fall into an open airway/aspiration before the swallow. Pathway of bolus is determined by pt’s posture, volume and viscosity of bolus. – Pharyngeal swallow has NOT been triggered bc tongue has not completed the oral stage of the swallow – Reduced lingual control/lingualvelar seal results in premature loss of the bolus into the pharynx.

49. Oral Phase Symptom: Piecemeal deglutition Dysfunction: may indicate a fear for swallowing (phagaphobia) Normal: swallow a bolus in a single cohesive mass – Large volumes of 20-30ml are normal Abnormal: swallow only one portion or pieces of the bolus at a time. Requires 2, 3, or more repeated swallows to empty the oral cavity.

50. Review Pharyngeal Phase: Initiated with the triggering of the pharyngeal swallow and continues until the bolus passes through the cricopharyngeal region, UES, or PE segment. Triggered by sensory input to predominantly cranial nerve IX (Glossopharyngeal Nerve) when the head of the bolus reaches any point from the anterior faucial arch to the point where the lower edge of the mandible crosses the base of the tongue (level 6).

51. Pharyngeal transit time: time elapsed from the triggering of the pharyngeal swallow (onset of laryngeal elevation) until the bolus tail passes through the cricopharygneal region or pharyngealoesophageal (PE) segment. – Maximum of 1 second; usually less (.35 to.48 seconds), regardless of age or material swallowed

52. 3 levels of laryngeal closure during the swallow (how Jeri explains it) Aryepiglottic folds and epiglottis Arytenoid approximation and anterior tilt towards base of epiglottis and false vocal folds True vocal folds – Close as the larynx elevates about 50% of its full distance (1cm) – These are not the 3 sphincter levels – The next slides are gonna be based on these 3 levels

53. Transition b/t Oral & Pharyngeal Phase Symptom: Duration of delay; pooling of liquid or food in the pharynx Dysfunction: Delayed triggering of the pharyngeal swallow Normal: triggered when head of the bolus passes the tongue base at the point where the lower edge of the mandible crosses the tongue base. Abnormal: head of the bolus enters the pharynx (valleculae, pyriform sinuses, or open airway) and the pharyngeal swallow has NOT been triggered as indicated by laryngeal elevation – Increases pt’s risk for aspiration before the swallow – Pt’s tend to c/o (complains of) difficulty swallowing liquids Easier to slip through, the thicker the bolus, the slower its gonna move – Larger volumes move more quickly – Location of bolus during the delay depends on gravity, head posture, and food consistency; however is NOT the major symptom of a pharyngeal swallow delay – Critical symptom: location of the bolus head (leading edge of the main portion of the bolus) before the pharyngeal swallow is activated. – MUST be differentiated from premature bolus loss which occurs in the oral prep and oral stage as part of the bolus breaks away from the main portion of the bolus and falls over the tongue base. – Premature loss is NOT a delay in triggering the pharyngeal swallow! – Here the bolus has transferred (so no problem in oral phase)

54. Figure 4.13 Bolus reaches pyriform sinuses before the swallow is triggered. Increased risk for aspiration bc the pyriform sinuses are slightly shortened as the pharynx and larynx elevate during the pharyngeal swallow – The airway is open – This doesn’t mean there is a problem in the UES

55. Figure 4.14 Immediately after the triggering of the pharyngeal swallow, larynx and pyriform sinuses shorten as they elevate allowing the contents from the pyriform sinuses to overflow into larynx. Pyriform sinsus pooling is NOT a cricopharyngeal disorder – The UES is not opening because the swallow has not been triggered! (Occasionally misdiagnosed)

56. Pharyngeal Phase Symptom: Nasal penetration during the swallow Dysfunction: reduced velopharyngeal closure Normal: Velum makes contact with posterior wall of the pharynx ONLY when the bolus passes the velopharyngeal port. – Lasts a fraction of a second Abnormal: inadequate velopharyngeal closure causes backflow into the nose during the swallow – If nasal backflow occurs later in the swallow, the dysfunction may be lower down in the pharynx. – If the bolus cannot pass through the pharynx into the esophagus, food and liquids will often move upward as a result of the struggling action in the pharynx into the nasopharynx Reduced velopharyngeal closure results in nasal penetration during the swallow.

57. Figure 4.15

58. Pharyngeal Phase Symptom: minimal passage of the bolus through the pharynx 2/2 Pseudoepiglottis – Fold in mucosa at the base of the tongue s/p (status post) a total laryngectomy – Appears to be an epiglottis when viewed radiographically- lateral view – At rest appears benign bc it collapses against the base of the tongue and leaves an open pharynx posteriorly. Dysfunction: Pseudoepiglottis; anatomical; s/p a Total Laryngectomy Normal: Epiglottis is present and intact Abnormal: During the swallow pharyngeal constrictors will pull the tissue fold posteriorly and narrow the pharynx, allowing minimal passage of food past the pseudoepiglottis. Pseudoepiglottis results in minimal passage of the bolus through the pharynx

59. Figure 4.16 (this is reverse contrast, bolus = white)

60. Pharyngeal Phase Symptom: Bony outgrowth from cervical vertebrae that restrict bolus flow through the pharynx (“bone spurs”) (anatomical) Dysfunction: Cervical osteophytes Normal: this isn’t normal… Abnormal: interference with the swallow by narrowing the pharynx, or directing the bolus towards the airway Cervical osteophytes resulted in restricted bolus flow through the pharynx – Pt’s may experience a sensation of a swallowing disorder; “something is there” when they swallow

61. Figure 4.17

62. Pharyngeal Phase Symptom: Residue on 1-side of the pharynx and in the pyriform sinuses Dysfunction: Unilateral pharyngeal wall weakness Normal: Pharyngeal walls and pyriform sinuses are free from food or liquid after the swallow Abnormal: Food clings to the pharyngeal wall or collect in the pyriform sinus on the weak side – Visible on an A/P view – **residue will always be on the weak side

63. Pharyngeal Phase Symptom: Coating on the Pharyngeal walls after the swallow Dysfunction: reduced pharyngeal contraction bilaterally Normal: Minimal or no residuals along the pharyngeal wall (minimal as if barium has mixed with saliva or mucous and can coat structures) – Amount of coating can vary with the type of barium contrast given – Older adults will exhibit a slight increase in residue as compared to younger adults – A dry swallow is often performed immediately after the swallow to clear this residue Abnormal: any significant amount of residual material is visible on the pharyngeal walls; judged by the density of the material – The darker the material, the more there is – Larger amounts of pharyngeal residue after the swallow increase a pt’s risk for aspiration after the swallow Reduced pharyngeal constriction (B) results in coating of the pharyngeal walls after the swallow.

64. Figures 4.18 & 4.19 Normal: 32 yr old (but they don’t think this is normal) 1/3 valleculae filled = minimal 2/3 valleculae filled = moderate Most to all filled = severe Normal: 74 yr old

65. Pharyngeal Phase Symptom: Vallecular residue after the swallow Dysfunction: Reduced base of tongue posterior movement/retraction Normal: tongue base moves posteriorly to contact the anteriorly bulging pharyngeal wall when the bolus tail reaches the tongue base and/or vallecular level to fully clear the bolus from the valleculae. – Tongue base moves 2/3 of the distance and the posterior pharyngeal wall encompasses the remaining 1/3. – Clearance of the valleculae is largely due to tongue base movement Abnormal: tongue base does not make contact with the anteriorly bulging of the pharyngeal wall resulting in residuals collecting in the valleculae after the swallow. – If residue is large enough, can result in aspiration after the swallow – If sensation/awareness of residue is good, a spontaneous dry swallow will be performed to try to clear residue Reduced base of tongue retraction results in vallecular residue after the swallow

66. Figure 4.20

67. Pharyngeal Phase Symptom: Coating/residue in a depression on the pharyngeal wall Dysfunction: Scar tissue; Pharyngeal pouch Normal: Pharyngeal wall is free from significant residuals after the swallow Abnormal: Material will collect in a depression on the pharyngeal wall indicating the beginning of a pharyngeal pouch or scar tissue – Pharyngeocutaneous fistula will often heal at the internal end of the fistula and cause a scar tissue depression which will collect material during and after the swallow – Increases pt’s risk for aspiration after the swallow if the residue is a large amount Pharyngeal pouch or scar tissue results in residue within a depression along the pharyngeal wall

68. Pharyngeal Phase Symptom: Reduced laryngeal elevation Dysfunction: Residue at the top of the airway (penetration) Normal: pharyngeal swallow is triggered, larynx elevates and moves anteriorly to tuck itself under the base of the tongue as a component of airway protection (2cm). Arytenoid cartilages approximate the base of the epiglottis and tilt forward to contact the thickening base of the epiglottis to close the entrance to the airway

69. Abnormal: Pharyngeal swallow is triggered, laryngeal elevation/excursion and arytenoid tilting is reduced, leaving the airway slightly open, resulting in residuals on top of the larynx after the swallow (penetration). – Pharyngeal contraction cannot fully clear residuals from the top of the airway when the larynx is not fully elevated – Increases pt’s risk for aspiration after the swallow – When penetration occurs via the interaryentoid space and remains in the airway entrance, aspiration after the swallow usually occurs – Some patients can compensate for reduced elevation by tilting arytenoids more anteriorly than normal to close the airway entrance and will not experience any penetration despite reduced laryngeal elevation. So will compensate by more tilting – Some patients have premature arytenoid tilting before the swallow begins, closing the airway entrance before and during the swallow of larger volumes Reduced laryngeal elevation results in residue at the top of the airway (penetration)

70. Pharyngeal Phase Symptom: Laryngeal penetration and aspiration after the swallow – Penetration: material entering the vestibule or entrance of the airway without dropping below the surface of the true vocal folds – Aspiration: entry of material below the level of the true vocal folds – Symptoms of a variety of swallowing problems Dysfunction: Reduced closure of the airway entrance (Arytenoid to base of epiglottis and false vocal folds) Normal: material does NOT enter the laryngeal vestibule or airway – Penetrated material is squeezed out during the swallow as the larynx lifts and closes inferiorly to superiorly (transient penetration) Abnormal: Material enters the laryngeal vestibule or airway – Larynx fails to lift adequately and penetrated material remains in the larynx after the swallow or is then aspirated as the patient inhales after the swallow.

71. Etiologies of Laryngeal Penetration 1: Penetration can occur if the larynx does not lift adequately, leaving the airway entrance slightly open. Decreased laryngeal elevation can result in penetration (Figure 4.21 & 4.22) (first is minimal and the second is a little bit more)

72. Etiologies of Penetration 2: Penetration can occur if the arytenoid cartilage fails to tilt forward adequately to close off the airway entrance. Decreased arytenoid approximation and tilting can result in penetration. (Figures 4.24 tvf & 4.25 tvf- supraglottic laryngectomee)

73. Etiologies of Penetration 3: Penetration can occur if the larynx lifts too slowly – If laryngeal elevation is adequate, just slow, all of the penetrated material will usually be cleared from the airway entrance – If laryngeal elevation is too slow, bolus can fall into the airway before the pharyngeal swallow triggers. Therefore, Penetration would result from a delay in triggering the pharyngeal swallow. (Figure 4.23) – If penetration occurs 2/2 delayed pharyngeal swallow and the true vocal folds are closed during the delay, food or liquid may enter the vestibule but not fall below the surface of the true vocal folds. If the larynx lifts adequately and closes from the true vocal folds upward, the penetrated material will usually clear efficiently from the airway. (Figure 4.26)

74. Figure 4.23 (to tvc before swallow)

75. Figure 4.26 (sequential)

76. 3 levels of where penetration can occur 1: middle of the aryentoid cartilage 2: surface of the false folds 3: surface of the true folds – Most concerning

77. Pharyngeal Phase Symptom: Aspiration during the swallow Dysfunction: Reduced laryngeal closure from bottom to top (true vocal folds, arytenoid approximation/tilting, aryepiglottic folds/epiglottis Normal: Airway closes adequately to prevent any material from entering larynx Abnormal: Larynx does not close adequately from bottom to top during the swallow and results in aspiration during the swallow. Reduced laryngeal closure results in aspiration during the swallow ONLY ETIOLOGY FOR ASPIRATION DURING THE SWALLOW! – The rest are either before or after

78. Figure 4.27

79. Pharyngeal Phase Symptom: Residue in pyriform sinuses bilaterally Dysfunction: Reduced anterior laryngeal motion; and/or Cricopharyngeal (UES) dysfunction or stricture at the level of the opening of the esophagus Normal: Little/no residue in the pyriform sinuses after the swallow Abnormal: significant residue evident within the pyriform sinuses after the swallow – To determine if cricopharyngeal dysfunction/stricture is the true dysfunction, all other aspects of the swallow must be normal including triggering of the pharyngeal swallow. Remember, vertical hyolaryngeal movement controls cricopharyngeal opening and relaxation of the cricopharyngeal muscle, therefore if pharyngeal swallow is NOT triggered a cricopharyneal disorder cannot be diagnosed. Requires pharyngeal manometry and videofluoroscopy.

80. Figure 4.28 Reduced hyolaryngeal motion 3 yr old with h/o (history of) head injury with residue in the pyriform sinuses 2/2 reduced anterior laryngeal movement

81. Pharyngeal Phase Symptom: Residue throughout the pharynx (valleculae, pharyngeal walls) in addition to pyriform sinus residue Dysfunction: generalized dysfunction in pharyngeal pressure generation during the swallow – Includes reduced posterior movement of the tongue base, reduced pharyngeal wall movement and often reduced laryngeal elevation – NOT a isolated cricopharyngeal problem Normal: Little/no residue noted throughout the pharynx Abnormal: significant residue within the valleculae, pharyngeal walls, and pyriform sinuses Decreased pharyngeal pressure generation 2/2 reduced tongue base retraction, pharyngeal wall movement, (and laryngeal elevation) results in scattered residue throughout the pharynx. When its scattered, it’s concerning bc can go in airway

82. Figure 4.29

83. 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 – Ex: with reflux, important that they sit up right 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. Some of these pts will then have an EGD

84. 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.

85. 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

86. 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 (below the cords) – 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

87. 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 Can eat and drink safely, but can get bothersome or it can promote backflow so that is when it would be treated This looks more like a filled pocket (like a teardrop) whereas a Cricopharyngeal bar looks more like a finger and is in the sphincter itself We cannot diagnose these

88. Figure 4.30

89. 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 – We could note this during a FEES or stroboscopy 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. – Refer for Barium Sofogram – Reflux is when it goes to stomach and then comes up, backflow is when above the stomach and comes back up

90. 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 Some of these pts will complain of having a globus pallidus sensation (feeling it in throat) and that is because the UES mm is working overtime to keep esophagus closed so the pressure is built up here

91. 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.

92. 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 Is it cupping it?

93. 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 (head/neck cancer pts) Normal: teeth align properly for mastication Abnormal: incomplete mastication Reduced mandibular ROM results in incomplete mastication 2/2 improper teeth occlusion for chewing Hard to see if pt has dentures hard to see b/c cant see teeth

94. 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

95. Oral Preparatory Phase: A/P view Symptom: Unable to mash material with tongue 2/2 inability to lateralize food to teeth for chewing – Normally they push food to roof of mouth 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

96. 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

97. 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

98. 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

99. 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

100. Figure 4.31

101. 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

102. Figure 4.32

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

104. 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.

105. Pharyngeal Phase: A/P view Symptom: no real 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

106. Figure 4.34

107. Questions?