1. Anatomy and Physiology of Normal Deglutition
Anatomic Structures
Oral
Pharynx
Larynx
Esophagus

2. ORAL Lips anteriorly Teeth (24 Decidous, 32 Permenant) Hard Palate
Soft Palate
Uvula
Mandible
Floor of Mouth
Tongue
Faucial Arches
Know this

4. Natural Cavities/Spaces
Sulci
Natural Cavities/Spaces
Anterior Sulcus
Lateral Sulcus
Why would we be concerned about the sulci?
-Residue

5. Musculature of the Floor of Mouth
Mylohyoid
Geniohyoid
Anterior Belly of Digastric
All of which attach to the body of the madible anteriorly and the body of the hyoid bone posteriorly

6. Hyoid
Forms foundation of the tongue Larynx is supended from the Hyoid Bone by the Thyrohyoid Ligament and Thyrohyoid muscle If the Hyoid elevates and moves forward, the larynx will move upward and forward unless it is stabilized by other muscles If one of these components are weak-the rest will become weak The hyoid is the anchor

7. Pharyngeal (Tongue base)
Oral
Tip
Blade
Front
Center
Back
Ends at Circumvallate Papillae
Active Under Cortical/Voluntary Neural control
Pharyngeal (Tongue base)
Begins at the Circumvallate Papillae, ends at the Hyoid bone
Active during pharyngeal swallow
Involuntary neural control – brainstem
Can be placed under some degree of voluntary control
Brainstem stroke: may not have a swallow
Stroke in left frontal cortex- Oral apraxia, flaccid dysarthria

8. 4 back
5 tongue base
6 extends from CVP to tip of uvula to hyoid

9. Velopharyngeal closure muscle pulls
Oral Cavity
Hard palate/Maxilla
Velum/soft palate
Uvula
Velopharyngeal closure muscle pulls
Palatopharyngeus
Levator palatal muscle
Superior Pharyngeal constrictor

10. Salivary Glands Viscid – mucus like Serous – watery
Maintain oral moisture
Reduce tooth decay
Assist in digestion
Neutralize stomach acid
Water slide without water= swallowing without saliva

11. Form posterior and lateral pharyngeal walls
Pharyngeal Cavity
3 Pharyngeal constrictors
Superior
Medial
Inferior
Form posterior and lateral pharyngeal walls

12. Form the anterior wall of the pharynx
Pharyngeal cavity
Run laterally to attach to bony and soft tissue structures located anteriorly: pterygoid plates, soft palate, Base Of Tongue, mandible, hyoid bone, thyroid and cricoid cartilages
Form the anterior wall of the pharynx
Inferior fibers of the superior constrictor attach to tongue base/glossopharyngeus muscle. Tongue Base Retraction and Anterior bulging of the post pharyngeal wall at tongue base.
Tongue base has to make contact with the posterior pharyngeal wall—forces food down—creates a negative pressure

13. Pyriform Sinuses
Spaces formed between fibers of inferior constrictor and sides of thyroid cartilage Spaces end at cricopharyngeal muscle
Things enter the airway because they’re trying to find the path of least resistance

14. Cricopharyngeal muscle
Attach to cricoid lamina
Cricoid lamina/cricopharyngeus forms valve into esophagus called the cricopharyngeal region CP
Upper Esophageal Sphincter
Pharyngeal Esophageal segment
These are the AREA not CP itself
Tonic (tone) when awake, loses tonic with sleep
Prevents air into esophagus with respiration
Reduce material backflow into pharynx
Sphincter 2-4 cm zone of elevated pressure – greatest pressure immediately prior to swallow and during inspiration

15. Esophagus
Collapsed muscular tube cm long with sphincter at each end UES/LES Pharynx open vs. esophagus closed Sits behind trachea – TE wall (party wall) LES (esophagus and stomach) keep food and secretions in
2 layers of muscle: inner circular and outer longitudinal
Esophagus is always closed unless there is food in it
Peristalsis- process of pulling—what is moving things down
UES/LES work in unison—if one isnt up to speed that affects the other

16. Larynx
Base of tongue, pharynx opens into larynx Topmost epiglottis Attached into hyoid bone by a ligament Base attached to thyroid notch
Epiglottis inversion- pressure from tongue base retraction and muscles(head/neck cancer patients lack this)

17. Larynx Wedge-shaped space is the Valleculae
Open into larynx is Laryngeal Vestibule, which ends at superior surface of false folds
Aryepiglottic folds form lateral walls
Arytenoids tilt anteriorly during swallowing, thought to be from pull of the thyroarytenoid muscle fibers.
Tilt contributes to closure of airway
True cords form last level of airway protection
Penetration- goes into the laryngeal vestibule

18. Larynx 3 levels of sphincter in the larynx
Epiglottis and aryepiglottic folds
Arytenoids
False Cords
Above the true chords is your laryngeal vestibule

19. Larynx Larynx elevates
Pull anteriorly and lowers for various activities
Hyoid bone serves as foundation for the tongue
When one structure moves, it often pulls on and moves attached structures
Elevation is up
Excursion is the tilt

21. Physiology Oral prep: food manipulated/masticated
Oral phase of swallow: tongue propels food post till pharyngeal swallow triggered
Pharyngeal Phase: bolus moved through pharynx
Esophageal phase: cervical – thoracic to stomach
*duration and characteristics depend on volume and type
*580 swallows per day
*respiration and swallow are reciprocal – halts w/ pharyngeal phase in all ages

22. 1. Oral Prep Needs sensory recognition Movement varies w/ viscosity
Requires open nasal airway and nasal breathing
Tippers and Dippers
Tippers – food held midline w/ tip elevated and contact w/ alveolar ridge
Dippers – 20%, food held floor of mouth in front of the tongue
Tongue thrust – tongue moves anteriorly w/ the bolus pushing food from the mouth. Seen w/ adults with frontal lobe damage and children w/ CP.

23. Oral Prep
Soft palate is pulled down and forward, sealing off the oral cavity from pharynx
Mastication involves a rotary lateral movement of mandible and tongue. Tongue mixes food w/ saliva w/ peripheral feedback to position bolus on teeth and prevent injury to tongue
Tension in buccal musculature closer of lateral sulcus
After chewing, tongue pulls food into semi-cohesive bolus before oral stage of swallow initiated

24. Oral Prep
Active chewing, soft palate not pulled down, thus premature spillage common, not normal during hold phase of liquid/pudding
Volume of bolus swallowed varies w/ viscosity; this downsizing w/ viscosity allows easier passage through pharynx and UES. Larger volumes, the tongue will subdivide
Larynx and pharynx are at rest during oral prep phase
Great deal of sensory info is processed from sensory receptors throughout the oral cavity

25. 2. Oral Phase Initiated when tongue begins post movement of bolus
Sides and tip of tongue anchor against the alvelor ridge. Central groove is formed and acts as a chute
Viscosity thickens, pressure of the oral tongue against palate increases – negative pressure of tension of buccal musculature
1-1.5 seconds
Needs labial seal, intact lingual movement, intact buccal musculature, normal palatal muscle, and ability to breath through nose

26. Bolus propulsion

27. 3. Triggering of Pharyngeal Swallow
As the tongue movement propels the bolus post, sensory receptors in the oropharynx and tongue are stimulated, sending sensory info to cortex and brainstem
Bolus head passes faucial arches and tongue base crosses the lower rim of the mandible, oral stage is terminated and pharyngeal swallow is triggered
If pharyngeal stage is not triggered by that time, delayed
Humans cannot swallow unless there is something in their mouth
Once triggers pharyngeal swallow—all involuntary

28. Triggering Pharyngeal Swallow
Sensory portion of pharyngeal swallow cranial IX, X, XI. Impulses travel to the swallow center in brainstem. Motor IX and X
Cortical recognition of bolus critical to initiation of oral phase

29. 4. Pharyngeal Swallow
1. Velopharyngeal closure: elevation and retraction of the velum and complete closure of the velopharyngeal portion to prevent material from entering nasal cavity. Enables build up of pressure in the pharynx.

30. Pharyngeal Swallow
2. Elevation and anterior movement of the hyoid and larynx: Elevate and move anteriorly by the pull of the floor of mouth muscles (anterior belly of digastric, myolohyoid, geniohyoid, laryngeal elevator-thyrohyoid). Average elevation 2 cm. Elevation contributes to closure of the airway, forward movement contributes to opening of the UES.
ELEVATES AND MOVES ANTERIORLY
**********KNOW KNOW KNOW***************

31. Pharyngeal Swallow
3. Closure of the Larynx: all 3 sphincters – true folds, laryngeal entrance (false folds, anterior tilt arytenoids, thickening of epiglottic base) and epiglottis. Airway closed 1/3-2/3 second and 5 seconds w/ sequential cup drinking. TVC close when larynx has elevated approx 50% of max elevation.

32. Pharyngeal Swallow
4. Cricopharyngeal opening: tension in the cricopharyngeal muscle portion of the sphincter is released. Laryngeal anterior-superior motion opens the sphincter, sphincter is yanked open by the motion of the larynx resulting from the upward and forward pull of the floor of mouth muscles. Pressure w/in bolus widens the opening. Once passed, larynx lowers and cricopharyngeal muscle returns to level of contraction.
Chords= last effort for airway protection

33. Pharyngeal Swallow
5. Tongue base and pharyngeal wall action: when bolus reaches tongue base level, tongue base and pharyngeal walls should make complete contact during the swallow. Move towards each other, pressure builds. Pharyngeal wall contracts (causes more pressure) and continues down pharynx to UES.

34. Peristalsis
Progressive contraction down a muscular tube **Pressure generated by TBR and pharyngeal wall constriction increases w/ bolus viscosity. Pressure applied to the tail of the bolus.

35. Movement
Velopharyngeal closure and hyolaryngeal excursion occurs simultaneously
Open UES and airway closure
Pressure on bolus
1. oral tongue pushes tail
2. tongue base reaches pharyngeal wall and apply pressure to bolus.

36. Always Remember This
Pharyngeal swallow must trigger for physiological activities (Velar, pharyngeal, tongue base, laryngeal) to occur. These activities occur ONLY as a result of triggering pharyngeal swallow! There is no way to voluntary initiate or modify pharyngeal contraction!

37. Movement
Pharyngeal transit time – time bolus to move from point pharyngeal swallow is triggered through the cricopharyngeal juncture into esophagus. 1 second or less.
Divides at the valleculae w/ ½ flowing down each side of pharynx through pyriform sinuses
Epiglottis directs food around the airway
Joins again at UES

38. Esophageal Phase
Time from UES to LES/stomach varies 8-20 seconds. Bolus pulled through w/ peristaltic wave

39. Mechanism as a Set of Tubes & Valves
Oral cavity – horizontal
Pharynx – verticle
UES – musculoskeletal valve (cricopharyngeal muscle & cricoid cartilage)
LES – muscular sphincter. Keep food/stomach acid in stomach

40. Changes with Age
Infant: tongue fills the oral cavity. Hyoid bone and larynx are up, velum hangs lower, uvula rests inside epiglottis and forms pocket in valleculae. Greatest elongation of the pharynx and downward displacement of larynx occurs during puberty
**Suction

41. Infant
Swallow begins in the fetus. Sucking nipple, infant repeatedly pumps the tongue expressing milk. Normal infants 2-7 pumps. Bolus of adequate size has been formed, triggers pharyngeal swallow. 1ml liquid produces oral then pharyngeal swallow (similar to adult).
Bite achieved approx 7 months
Chewing months
Normal adult pattern 3-4 years
Infants don’t have oral swallow—just pharyngeal

42. Older Adult
Number of chewing strokes related to age and dental status. Increased strokes w/ poor dentition or dentures.
Physiological changes occur 70+. Ossification of thyroid and cricoid cartilages and hyoid bone, appear more prominent.
Larynx may begin to lower. Cervical arthritis, impinge on pharyngeal wall decreases flexibility, decrease strength of pharyngeal contraction.
Patients with dentures arent getting additional sensory output—actually swallow better without them
Posture, posture, posture

43. Age and Swallowing Dipper longer oral stage
More pharyngeal residue- everything is becoming weak and flaccid
Increased penetration w/out aspiration
Longer esophageal transit
Muscles becoming flaccid*

44. Age and Swallowing
Decreased max laryngeal and hyoid anterior and vertical movement indicating reduced neuromuscular reserve (difference between necessary movement and actual motion)

45. Age and Swallowing
Decreased flexibility cricopharyngeal opening – less change as volume increased, exacerbates w/ weakness
Taste – intensity of taste & smell are reduced

46. Coordination of respiration & swallowing
Apneic period – fraction of second. Corresponds w/ closure of airway during pharyngeal stage. Duration increases bolus volumes
Airway opens w/ oral prep, oral, and esophageal stages
Interrupting exhalation and returning to exhalation after the swallow
Slight airflow through the larynx and pharynx after the swallow
May clear any residue from around the airway entrance
Dysphagia patients may more often interrupt inhalation to swallow

47. Variations in normal swallowing
Volume effects – bolus volume creates greatest systematic changes in oropharyngeal swallow. Small volume – each phase, whereas large (10-20ml) simultaneous oral & pharyngeal activity
Increased viscosity – increased pressure. Valve functions all increase slightly in duration
Cup drinking – early airway closure, duration 5-10 seconds
Straw drinking – suction
‘chug-a-lug’ – pull larynx forward & hold breath
Pharyngeal swallow w/ no oral swallow

48. Components of All Swallows
Components that must be present
Oral propulsion bolus into pharynx
Airway closure
UES opening
Tongue base – pharyngeal wall propulsion to carry the bolus through the pharynx and into the esophagus
Variations on normal swallow generally involve changing the timing of these elements, but all must be present and normal for bolus to clear safely and efficiently!
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