test 1 - Flashcards

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INCORRECT CORRECT

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dysphagia

difficulty moving food from mouth to stomach

including behavioral, sensory and preliminary motor acts in prep for swallow: cognitive awareness, recognition of food, physiologic response to smell

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Penetration

introduction of food/liquid/gastric contents into the airway @ level of vocal folds

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Aspiration

intro of food/liquid etc into airway beyond the level of the vocal folds

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Deglutition

the process of swallowing

piecemeal deglutition: multiple swallows per bolus

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Mastication

prep of food for swallowing

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PO + NPO

"Per Os" by mouth
"nil per os" nothing by mouth

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Eructation

ejection of gas or air through the mouth from stomach (belch)

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Regurgitation

voluntary/involuntary return of partly digested food from stomach to mouth

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Emesis

vomiting

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Reflux

a flow back of gastric acid into the esophagus/ pharynx

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Lingual

having to do with the tongue

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Lingual Sweeping

movement of the tongue in formation of the bolus

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buccal cavity

area between teeth and cheek

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Pharyngeal

having to do with the pharynx-canal between nasal passages/ velum to UES

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UES

Upper Esophageal Sphincter

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Pharyngeosophogeal (PE segment)

upper esophageal sphincter
immediate esophageal region
and immediate pharyngeal region

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Cricopharyngeus

component of the inferior constrictor involved in the UES

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LES

Lower esophageal sphincter

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VFSS

Videofluoroscopic Swallow Study: better than MBS b/c nurses get confused when you order it.

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MBS

Modified Barium Swallow

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FEES

Flexible Endoscopic Evaluation of Swallowing

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Stages of Swallow

Oral prep: bolus placement + mastication/ sweeping
Oral: oral transit of bolus anterior to posterior
Pharyngeal: transit of bolus from tongue base to UES
Esophageal: esophageal transit

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Oral Prep stage

Velum depressed-breath through nose
food presented
tongue dishes in anticipation
lip used to clear spoon teeth used to clear fork
facial muscles help impound food
food on tongue is moved to molars
grinding action crushes food
action milks salivary glands to mix saliva with food
move bolus on tongue to test consistency, move back to molars
NO mastication for liquids, sequential swallows are possible

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Muscles contracted for chewing

massester
temporalis
medial and lateral pterygoids
muscles of the tongue

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Oral stage (1-1.5 seconds)

tip of tongue on superior alveolar ridge (presses tongue to hard palate
bolus has been prepared
tongue pumps bolus back
tongue elevates in front
hyoid elevates slightly secondary to tongue elevation
squeezes bolus back toward fauces
bolus contacts fauces, posterior tongue and soft palate
either or both of these sites may trigger pharyngeal phase

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Pharyngeal stage (1 sec or less) Major events

respiration stops and is protected at three different levels
1. velum elevates to close velopharyngeal port
2. Larynx elevates and protracts
3. UES opens

Pharyngeal peristalsis moves bolus to esophagus

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Pharyngeal transit time

= time take for bolus to move from initiation of pharyngeal swallow to crossing the cricopharyngeal sphincter

1 sec or less

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Details of pharyngeal stage

1. tongue moves posteriorly
2. makes contact w/ posterior pharyngeal wall- seals oral cavity from pharyngeal cavity to increase pressure in oropharynx
3. tongue carries bolus to oropharynx
4. pharyngeal wall moves to meet tongue
5. hyoid bone is pulled backward as tongue moves back
6. mandibular muscles contract to stabilize mandible/ tongue
7. mandible is elevated
masseter muscles will tense (not for people w/ tongue thrust)

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Pharyngeal peristalsis

1. velum elevates
2. larynx elevates to nearly meet hyoid and protracts
-hyolaryngeal excursion
3. pharynx contracts in peristaltic wave (forces bolus down)
- sequential contraction of superior, middle, inferior constrictors
-completely obliterates space in the pharynx (like tube of tooth paste
4. piston of tongue increases pharyngeal pressure
5. pressure drives bolus inferiorly (positive pressure behind bolus)
(negative " in esophagus

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UES Opening (5 phases of relaxation of UES) 1-3

1. inhibition of the tonic contraction of the cricopharyngeus (1sec before UES opens)
-happens immediately after inferior pharyngeal constrictor activate
2. Opening of cricopharyngeal sphincter occurs
-anterior portion of UES pulled open subsequent to relaxation of CPM
3. Distention of UES by pressure applied by bolus: weight and volume of bolus facilitates UES Opening (bite of sandwich = different than liquid)

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UES Opening (5 phases of relaxation of UES) 4-5

4. Passive collapse of the distended UES as bolus passes sphincter
-epiglotis folds down to protect the airway, true+false folds slam shut
5. closure of UES by active contraction of CPM

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Forces that facilitate opening of UES

bolus size and weight
superior + anterior traction force of suprahyoid muscualture and superior traction force the muscles shortening the pharynx

pressures are more important than peristalsis

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Protection of Airway

as bolus moves down airway is protected

true vocal folds clamp, then false folds clamp

lower vestibular closes via arytenoids abducting

then upper vestibule closes via epiglottis dropping down over airway

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Bolus passes through PE segment and clears larynx

PE segment closes
larynx lowers
velum lowers
larynx opens from superior to inferior
expiration occurs (typically we swallow on an exhale)
-blows residue from laryngeal vestibule

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Esophageal stage

negative pressure
bolus is transported to LES
transit via peristalsis of smooth and striated muscle
approximately 8-20 seconds from UES to LES

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Transit times

oral transit time : 1-1.5 secs (affected by bolus size and viscosity

higher viscosity bolus moves slower
Larger bolus moves slower

Trigger of pharyngeal phase
>30 years = .1 sec
< 60 years = .4 sec

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Variations in normal swallow Volume Effects

Increased volume can result in simultaneous oral and pharyngeal activity
As volume increases timing of tongue base retraction occurs later in the swallow; however contact always made at bolus tail

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Variations in normal swallow Viscosity

pressure and muscular activity increases
duration of VP closure and UES opening & laryngeal closure increase

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Variations in normal swallow cup drinking

early airway closure, some preelevation of larynx as cup approaches lips

consistent airway closure 5-10 secs

repeated tongue base retraction, pharyngeal constriction, & UES opening with each consecutive swallow

Straw drinking: bolus presented via suction (not inhalation)

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Variations in normal swallow chug-a-lug

pull larynx forward opening UES volitionally
Hold breath
sword swallowers

pharyngeal swallow w/ no oral swallow
-secretions/residue collect in pharynx

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pharyngeal swallow

1.elevation and retraction of the velum, complete closure of VP to prevent material from entering nasal cavity
2. elevation +anterior movement of hyoid and larynx
3. closure of larynx @ all 3 sphincters
4. opening of the cricopharyngeal sphincter to allow food to pass from pharynx to esophagus
5. ramping of base of tongue to deliver bolus
6. progressive top to bottom contraction in pharyngeal constrictors

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physiology of swallow

willingness to eat
-appetite
-pleasurable smell
-salivation

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parotids sublinguals

mucus like secretions

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submandibular

fluid like secretions

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Ability to close lips

Oral prep
contract lip muscles: orbicularis oris (surounds mouth)
-VII FACIAL NERVE

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Mastication

Oral prep
Temporal mandibular joint (TMJ)
Muscles: Masseter, temporalis, pterygoids-lateral + medial
-V TRIGEMINAL NERVE

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ability to position bolus in mouth

Oral Prep

tongue mobility- intrinsic tongue muscles + extrinsic
contract cheek muscles- buccinator

move bolus anterior to posterior + initiate pharyngeal swallow
-XII HYPOGLOSSAL
- VII FACIAL
-IX GLOSSOPHARYNGEAL

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Muscles of mastication Temporalis + Masseter + internal/medial pterygoid

elevate mandible
V3 Trigeminal (mandibular nerve)

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muscles of mastication external/lateral pterygoid

protract mandible
V3 Trigeminal (mandibular nerve)

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Buccinator

Buccal branch of VII Facial
-keeps food between molars, expels air forcibly

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Orbicularis Orbis

VII Facial Nerve Buccal branch
labial seal

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Intrinsic muscles of the tongue

Attachments within tongue
XII Hypoglossal Nerve
Superior longitudinal -Shorten tongue, turns tip and sides up
Inferior longitudinal- shorten tongue, turns tip and sides down
Transversus- narrow and elongates
Verticalis- flattens and widens

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Extrinsic muscles of the tongue

Attachments not within tongue
XII Hypoglossal
Genioglossus -protracts and depresses tongue
hyoglossus- depresses tongue
palatoglossus- XII + pharyngeal plexus- elevates floor of tongue closing oral cavity from oropharynx
Styloglossus- IX+ pharyngeal plexus
-retracts and elevates tongue

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pharyngeal plexus

X vagus motor + IX glossopharyngeal sensory

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Soft palate muscles

levator veli palatini- X Vagus-pulls palate up+back toward pharyngeal wall, closes VP

musculus uvulae- XI accessory - pulls up uvula

tensor veli palatini - V3 trigeminal mandibular nerve- tightens soft palate

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Pharyngeal stage: ability to raise and close larynx

Thyroid, cricoid, arytenoid, hyoid

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nasopharynx

extends from posterior choanae of the nose to the soft palate
not visible

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oropharynx

visible from mouth
extends soft palate superiorly to vallleculae inferiorly (to tip of epiglottis)
posterior + lateral walls formed by superior + middle pharyngeal constrictors

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Hypopharynx

inferior to tip of epiglottis,
posterior + lateral walls formed by superior + middle pharyngeal constrictors
extends inferiorly to the CP, where pharynx empties into esophagus

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Pharyngeal constrictors

X Vagus
inferior constrictor- strongest+thickest
middle constrictor- fan shaped, striated
superior constrictor- weakest

IX Glossopharyngeal
stylopharyngeus muscle: runs along sides of constrictor muscles, helps pharyngeal contraction, elevates pharynx and larynx

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salpingopharyngeus

shortener + elevator
controls eustation tube

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Intrinsic Muscles of Larynx

X Vagus
cricothyroid-lengthen + stretch vocal folds
post/lat cricoaryntenoids -abduct + adduct vocal folds
interarytenoids- work with oblique arytenoid to whisper (adduct and narrow folds)

thyroarytenoid - sphincter of vestibule, narrowing laryngeal inlet

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Extrinsic muscles of the larynx + cricopharyngeus

elevate and protract, retracts hyoid


Cricopharyngeus- makes up UES,
relaxes .1 seconds before it opens,

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Cranial nerves of swallow oral prep + oral

VII Facial holds mouth shut

V Trigeminal- sensory input, relays position of food bolus in mouth

V Trigeminal- motor controls chewing

IX Glossopharyngeal- senses arrival of bolus at palate (beginning of pharyngeal stage)

XII Hypoglossal- pushes chewed bolus to back of soft palate

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Cranial nerves of swallow pharyngeal

V+VII+XII pull hyoid up and forward, bringing larynx to back of tongue (helps move UES, helps move epiglottis to protect airway
IX Glossopharyngeal- assists in hyoid elevation as well as constriction of pharynx
X Vagus (rapid succession)
1.elevates palate to occlude nasopharynx
2. closes laryngeal vestibule with true and false folds
3. contracts middle and inferior pharyngeal constrictors(peristalsis)
4. relax cricopharyngeal sphincter to let bolus enter esophagus
5. initiates peristalsis in the esophagus

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V Trigeminal

Motor
-mastication
-hyolaryngeal excursion
-tensing velum

Sensory
-bolus manipulation
-sensation in mouth, cheeks and anterior 2/3 of tongue (not taste)

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VII Facial

Motor
-lip closure
-buccal tone
-hyolaryngeal excursion

Sensory
-taste anterior 2/3 tongue
-salivation (submandibular + sublingual salivary glands)

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IX Glossopharyngeal

Motor
-pharyngeal constriction
-pharyngeal shortening

Sensory- taste+sensation posterior 1/3 of tongue, velum, fauces, superior portion of pharynx
salivation (parotid salivary glands)

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X Vagus Motor

VP closure-levator veli palatini
tongue base retraction-palatoglossus
pharyngeal squeeze-constrictors
airway closure- all intrinsic laryngeal muscles
UES closure/opening- Cricopharyngeus
esophageal motility

only nerve that influences structures below neck

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X Vagus Sensory

sensory info from velum, posterior and inferior portions of pharynx, all sensation in larynx, esophagus

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XII Hypoglossal

motor
-tongue motility- extrinsic and intrinsic muscles of tongue
-hyolaryngeal elevation-
-laryngeal excursion (up and out movement)

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dysphagia	difficulty moving food from mouth to stomach including behavioral, sensory and preliminary motor acts in prep for swallow: cognitive awareness, recognition of food, physiologic response to smell
Penetration	introduction of food/liquid/gastric contents into the airway @ level of vocal folds
Aspiration	intro of food/liquid etc into airway beyond the level of the vocal folds
Deglutition	the process of swallowing piecemeal deglutition: multiple swallows per bolus

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Mastication	prep of food for swallowing
PO + NPO	"Per Os" by mouth "nil per os" nothing by mouth
Eructation	ejection of gas or air through the mouth from stomach (belch)
Regurgitation	voluntary/involuntary return of partly digested food from stomach to mouth

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Emesis	vomiting
Reflux	a flow back of gastric acid into the esophagus/ pharynx
Lingual	having to do with the tongue
Lingual Sweeping	movement of the tongue in formation of the bolus

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buccal cavity	area between teeth and cheek
Pharyngeal	having to do with the pharynx-canal between nasal passages/ velum to UES
UES	Upper Esophageal Sphincter
Pharyngeosophogeal (PE segment)	upper esophageal sphincter immediate esophageal region and immediate pharyngeal region

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Cricopharyngeus	component of the inferior constrictor involved in the UES
LES	Lower esophageal sphincter
VFSS	Videofluoroscopic Swallow Study: better than MBS b/c nurses get confused when you order it.
MBS	Modified Barium Swallow

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FEES	Flexible Endoscopic Evaluation of Swallowing
Stages of Swallow	Oral prep: bolus placement + mastication/ sweeping Oral: oral transit of bolus anterior to posterior Pharyngeal: transit of bolus from tongue base to UES Esophageal: esophageal transit
Oral Prep stage	Velum depressed-breath through nose food presented tongue dishes in anticipation lip used to clear spoon teeth used to clear fork facial muscles help impound food food on tongue is moved to molars grinding action crushes food action milks salivary glands to mix saliva with food move bolus on tongue to test consistency, move back to molars NO mastication for liquids, sequential swallows are possible
Muscles contracted for chewing	massester temporalis medial and lateral pterygoids muscles of the tongue

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Oral stage (1-1.5 seconds)	tip of tongue on superior alveolar ridge (presses tongue to hard palate bolus has been prepared tongue pumps bolus back tongue elevates in front hyoid elevates slightly secondary to tongue elevation squeezes bolus back toward fauces bolus contacts fauces, posterior tongue and soft palate either or both of these sites may trigger pharyngeal phase
Pharyngeal stage (1 sec or less) Major events	respiration stops and is protected at three different levels 1. velum elevates to close velopharyngeal port 2. Larynx elevates and protracts 3. UES opens Pharyngeal peristalsis moves bolus to esophagus
Pharyngeal transit time	= time take for bolus to move from initiation of pharyngeal swallow to crossing the cricopharyngeal sphincter 1 sec or less
Details of pharyngeal stage	1. tongue moves posteriorly 2. makes contact w/ posterior pharyngeal wall- seals oral cavity from pharyngeal cavity to increase pressure in oropharynx 3. tongue carries bolus to oropharynx 4. pharyngeal wall moves to meet tongue 5. hyoid bone is pulled backward as tongue moves back 6. mandibular muscles contract to stabilize mandible/ tongue 7. mandible is elevated masseter muscles will tense (not for people w/ tongue thrust)

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Pharyngeal peristalsis	1. velum elevates 2. larynx elevates to nearly meet hyoid and protracts -hyolaryngeal excursion 3. pharynx contracts in peristaltic wave (forces bolus down) - sequential contraction of superior, middle, inferior constrictors -completely obliterates space in the pharynx (like tube of tooth paste 4. piston of tongue increases pharyngeal pressure 5. pressure drives bolus inferiorly (positive pressure behind bolus) (negative " in esophagus
UES Opening (5 phases of relaxation of UES) 1-3	1. inhibition of the tonic contraction of the cricopharyngeus (1sec before UES opens) -happens immediately after inferior pharyngeal constrictor activate 2. Opening of cricopharyngeal sphincter occurs -anterior portion of UES pulled open subsequent to relaxation of CPM 3. Distention of UES by pressure applied by bolus: weight and volume of bolus facilitates UES Opening (bite of sandwich = different than liquid)
UES Opening (5 phases of relaxation of UES) 4-5	4. Passive collapse of the distended UES as bolus passes sphincter -epiglotis folds down to protect the airway, true+false folds slam shut 5. closure of UES by active contraction of CPM
Forces that facilitate opening of UES	bolus size and weight superior + anterior traction force of suprahyoid muscualture and superior traction force the muscles shortening the pharynx pressures are more important than peristalsis

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Protection of Airway	as bolus moves down airway is protected true vocal folds clamp, then false folds clamp lower vestibular closes via arytenoids abducting then upper vestibule closes via epiglottis dropping down over airway
Bolus passes through PE segment and clears larynx	PE segment closes larynx lowers velum lowers larynx opens from superior to inferior expiration occurs (typically we swallow on an exhale) -blows residue from laryngeal vestibule
Esophageal stage	negative pressure bolus is transported to LES transit via peristalsis of smooth and striated muscle approximately 8-20 seconds from UES to LES
Transit times	oral transit time : 1-1.5 secs (affected by bolus size and viscosity higher viscosity bolus moves slower Larger bolus moves slower Trigger of pharyngeal phase >30 years = .1 sec < 60 years = .4 sec

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Variations in normal swallow Volume Effects	Increased volume can result in simultaneous oral and pharyngeal activity As volume increases timing of tongue base retraction occurs later in the swallow; however contact always made at bolus tail
Variations in normal swallow Viscosity	pressure and muscular activity increases duration of VP closure and UES opening & laryngeal closure increase
Variations in normal swallow cup drinking	early airway closure, some preelevation of larynx as cup approaches lips consistent airway closure 5-10 secs repeated tongue base retraction, pharyngeal constriction, & UES opening with each consecutive swallow Straw drinking: bolus presented via suction (not inhalation)
Variations in normal swallow chug-a-lug	pull larynx forward opening UES volitionally Hold breath sword swallowers pharyngeal swallow w/ no oral swallow -secretions/residue collect in pharynx

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pharyngeal swallow	1.elevation and retraction of the velum, complete closure of VP to prevent material from entering nasal cavity 2. elevation +anterior movement of hyoid and larynx 3. closure of larynx @ all 3 sphincters 4. opening of the cricopharyngeal sphincter to allow food to pass from pharynx to esophagus 5. ramping of base of tongue to deliver bolus 6. progressive top to bottom contraction in pharyngeal constrictors
physiology of swallow	willingness to eat -appetite -pleasurable smell -salivation
parotids sublinguals	mucus like secretions
submandibular	fluid like secretions

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Ability to close lips	Oral prep contract lip muscles: orbicularis oris (surounds mouth) -VII FACIAL NERVE
Mastication	Oral prep Temporal mandibular joint (TMJ) Muscles: Masseter, temporalis, pterygoids-lateral + medial -V TRIGEMINAL NERVE
ability to position bolus in mouth	Oral Prep tongue mobility- intrinsic tongue muscles + extrinsic contract cheek muscles- buccinator move bolus anterior to posterior + initiate pharyngeal swallow -XII HYPOGLOSSAL - VII FACIAL -IX GLOSSOPHARYNGEAL
Muscles of mastication Temporalis + Masseter + internal/medial pterygoid	elevate mandible V3 Trigeminal (mandibular nerve)

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muscles of mastication external/lateral pterygoid	protract mandible V3 Trigeminal (mandibular nerve)
Buccinator	Buccal branch of VII Facial -keeps food between molars, expels air forcibly
Orbicularis Orbis	VII Facial Nerve Buccal branch labial seal
Intrinsic muscles of the tongue	Attachments within tongue XII Hypoglossal Nerve Superior longitudinal -Shorten tongue, turns tip and sides up Inferior longitudinal- shorten tongue, turns tip and sides down Transversus- narrow and elongates Verticalis- flattens and widens

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Extrinsic muscles of the tongue	Attachments not within tongue XII Hypoglossal Genioglossus -protracts and depresses tongue hyoglossus- depresses tongue palatoglossus- XII + pharyngeal plexus- elevates floor of tongue closing oral cavity from oropharynx Styloglossus- IX+ pharyngeal plexus -retracts and elevates tongue
pharyngeal plexus	X vagus motor + IX glossopharyngeal sensory
Soft palate muscles	levator veli palatini- X Vagus-pulls palate up+back toward pharyngeal wall, closes VP musculus uvulae- XI accessory - pulls up uvula tensor veli palatini - V3 trigeminal mandibular nerve- tightens soft palate
Pharyngeal stage: ability to raise and close larynx	Thyroid, cricoid, arytenoid, hyoid

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nasopharynx	extends from posterior choanae of the nose to the soft palate not visible
oropharynx	visible from mouth extends soft palate superiorly to vallleculae inferiorly (to tip of epiglottis) posterior + lateral walls formed by superior + middle pharyngeal constrictors
Hypopharynx	inferior to tip of epiglottis, posterior + lateral walls formed by superior + middle pharyngeal constrictors extends inferiorly to the CP, where pharynx empties into esophagus
Pharyngeal constrictors	X Vagus inferior constrictor- strongest+thickest middle constrictor- fan shaped, striated superior constrictor- weakest IX Glossopharyngeal stylopharyngeus muscle: runs along sides of constrictor muscles, helps pharyngeal contraction, elevates pharynx and larynx

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salpingopharyngeus	shortener + elevator controls eustation tube
Intrinsic Muscles of Larynx	X Vagus cricothyroid-lengthen + stretch vocal folds post/lat cricoaryntenoids -abduct + adduct vocal folds interarytenoids- work with oblique arytenoid to whisper (adduct and narrow folds) thyroarytenoid - sphincter of vestibule, narrowing laryngeal inlet
Extrinsic muscles of the larynx + cricopharyngeus	elevate and protract, retracts hyoid Cricopharyngeus- makes up UES, relaxes .1 seconds before it opens,
Cranial nerves of swallow oral prep + oral	VII Facial holds mouth shut V Trigeminal- sensory input, relays position of food bolus in mouth V Trigeminal- motor controls chewing IX Glossopharyngeal- senses arrival of bolus at palate (beginning of pharyngeal stage) XII Hypoglossal- pushes chewed bolus to back of soft palate

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Cranial nerves of swallow pharyngeal	V+VII+XII pull hyoid up and forward, bringing larynx to back of tongue (helps move UES, helps move epiglottis to protect airway IX Glossopharyngeal- assists in hyoid elevation as well as constriction of pharynx X Vagus (rapid succession) 1.elevates palate to occlude nasopharynx 2. closes laryngeal vestibule with true and false folds 3. contracts middle and inferior pharyngeal constrictors(peristalsis) 4. relax cricopharyngeal sphincter to let bolus enter esophagus 5. initiates peristalsis in the esophagus
V Trigeminal	Motor -mastication -hyolaryngeal excursion -tensing velum Sensory -bolus manipulation -sensation in mouth, cheeks and anterior 2/3 of tongue (not taste)
VII Facial	Motor -lip closure -buccal tone -hyolaryngeal excursion Sensory -taste anterior 2/3 tongue -salivation (submandibular + sublingual salivary glands)
IX Glossopharyngeal	Motor -pharyngeal constriction -pharyngeal shortening Sensory- taste+sensation posterior 1/3 of tongue, velum, fauces, superior portion of pharynx salivation (parotid salivary glands)

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X Vagus Motor	VP closure-levator veli palatini tongue base retraction-palatoglossus pharyngeal squeeze-constrictors airway closure- all intrinsic laryngeal muscles UES closure/opening- Cricopharyngeus esophageal motility only nerve that influences structures below neck
X Vagus Sensory	sensory info from velum, posterior and inferior portions of pharynx, all sensation in larynx, esophagus
XII Hypoglossal	motor -tongue motility- extrinsic and intrinsic muscles of tongue -hyolaryngeal elevation- -laryngeal excursion (up and out movement)

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