G. Carnaby & M. Crary Swallowing Research Laboratory

Swallowing is something that we do 2,000 to 3,000 times every day, yet it is a very complex act requiring many muscles coordinated by the brain and brainstem. The swallow mechanism is innervated by 7 pairs of nerves and 26 muscle groups

Three phases of swallowing Oral phase Pharyngeal phase Esophageal phase

Oral phase. Biting and chewing takes place in the mouth. During this stage, food is broken down into smaller pieces and mixes with saliva. This preparation stage is where the pleasure of eating is derived.

Oral phase In this voluntary stage, the tongue pushes the food or liquid to the back of the mouth, where it is positioned to pass into the throat (pharynx). When this stage is completed, there should be no food or liquid remaining in the mouth.

Pharyngeal phase During this phase, the palate, the soft structure that hangs in the back of the throat, elevates to prevent food or liquid from entering the nose. The voice box closes to prevent food from entering the windpipe, and a muscle at the low end of the pharynx relaxes to allow food to enter the esophagus.

Video 1 – slow motion oropharyngeal swallow

Video 2 – Bolus Accommodation examples

Video 3 – endoscopic view normal oropharyngeal swallow

Esophageal phase A series of coordinated muscle contractions pushes the food down the esophagus (food tube) and into the stomach.

Video 4 – example of fluoroscopic clearance

University of Florida Swallowing Research Laboratory

Research Foci Study of normal and abnormal swallowing physiology Development of innovative assessment and treatment ‘tool’s for adult dysphagia Current Projects (examples) Prevention of dysphagia in head/cancer Swallow frequency to screen for dysphagia in stroke Reflux and swallow frequency in acute stroke Oral morbidities in head/neck cancer Swallow abilities in community dwelling elderly

Measurement Capabilities Videofluoroscopy Transnasal endoscopy Transnasal esophagoscopy Lingual-palatal pressure measurement Pharyngeal and upper sphincter manometry High Resolution Manometry MRI sEMG Respiratory measures And More!

“Dysphagia (dis-fag-ia) Defined as difficulty swallowing or the inability to swallow food or fluids”

Estimated to affect 22% of the world’s population >50 years of age Swallowing disorders are becoming a major source of disability –estimated 17 million adults in the US alone Up to 30% of patients in hospitals ~60% of residents in nursing homes Probably 14% of people >65 years of age living in the community Approximately 10 million children in the US

Can occur in all age groups May be a result of many different medical conditions Can be an acute problem or progress slowly over a long period of time Early identification and involvement of health professionals offers a good prognosis for swallowing disorders. Abnormalities of swallowing could be secondary to defects in any of the stages of swallowing enumerated above.

Many people with dysphagia can go unrecognized or undiagnosed until a major medical event occurs.

Aspiration: Passive entry of any food item into the trachea (eg, during inhalation), although the term often is used to denote any entry of material into the trachea in any manner Penetration: Active entry of any food item into the trachea (eg, during swallowing), although the term often is used to denote the entry of any material into the laryngeal vestibule

Videofluoroscopic procedure (xray video) Most widely used determine physiology of swallow Other evaluation tools Fiberoptic endoscopic examination Ultrasound Electromyography Manometry

Videofluoroscopic procedure Also known as modified barium swallow A radiographic study of a person’s swallowing mechanism that is recorded on videotape

Video 5 - Zenker’s Diverticulum

Video 6 – Cricopharyngeal Bar

CP bar

Normal swallow

Video 7 – Stricture in PES with NPR

Video 8 – Liquids pass but not the tablet!

Video 9 – Pills stick in throat and chest

Video 10 – Endoscopic View Dysphagia in Elderly

40%- Report difficulty with swallowing pills 51% women /27% men (44%); ≥65yrs (26%) Problem encountered% reported Stuck in throat80 Bad taste48 Gagging32

14% delayed dosage 8% skipped a dose 4% discontinued 14% discussed issue with a health care provided failure to follow dosing recommendations is associated with poorer health outcomes

1/5 hesitate before taking pills Shape (84%) Size (29%) 1/10- choose based upon anticipated difficulty to swallow Women (14%) Men (4%)

Strategies to assist swallowing pills % reported Drink lots of water55% Gulping water48% Tilt head back43% Place on back of tongue31% Multiple swallows30% Split pills in half17% Deep breath before swallow13%

Little data on the alterations in the swallow system that occurs with pills Swallowing a learnt complex motor task… Shibamoto et al (2007) fMRI to view cortical brain activation with pill swallowing (11mm X 2mm columnar capsule) n=21 healthy persons different brain areas activated during capsule swallowing- i.e. cerebellum

swallow Tongue movement Finger tapping

Review of outpatient with complaints of food/liquid sticking in throat Evaluation of fluoroscopic videos to identify Any confirmation that something does stick Where it sticks Cause of ‘sticking’ What material best identifies the problem

315 outpatients were reviewed 117 patients c/o solid “sticking” 24 patients c/o solid and liquid “sticking” Total of 141 patients with the complaint Prevalence = 45%

Mean Age (in years) : Female:Male = 88:53 Positive fluoroscopic findings 108 patients = 77%

15% of the positive cases = anatomic strictures, pouches etc. 85% of the positive cases = physiologic esophageal dysmotility, achalasia etc.

UES = Upper Esophageal Spincter 15% of positive cases 15% of positive cases had anatomic obstructions

UES = Upper Esophageal Sphincter LES = Lower Esophageal Sphincter 15% of positive cases 85% of positive cases had physiologic obstructions

Marshmallow yielded highest positive result at 53%

45% Prevalence of food sticking symptoms 27% correctly localized obstruction in “throat” Anatomic obstructions, primarily in UES Better localization for anatomic obstructions 73% incorrectly localized obstruction upward in throat Primarily physiologic obstructions

Swallowing is a complex process with interplay among major anatomical components Oral Pharyngeal Laryngeal Dysphagia may be overt or covert Many patients with covert of mild dysphagia remain total oral feeders and take meds orally Food sticking is a common complaint in overt/covert Pills sticking is a common complaint Pill swallowing is different from food/liquid Physiology is different Neurology is different