SwallowingCourse(RHS…)Dr/Mohamed Farahat Ibrahim, M.D., Ph.D.

Professor, Consultant Phoniatrician

(Communication and Swallowing Disorders)

Chairman, Communication and Swallowing Disorders Unit (CSDU)

King Abdulaziz University Hospital

Supervisor, Swallowing disorders clinic

King Khalid University Hospital

King Saud University, Riyadh, Saudi Arabia.

http://fac.ksu.edu.sa/mfarahat

Coursestructure

1. Anatomy and Physiology of swallowing.

2. Etiology of oropharyngeal dysphagia,

preliminary assessment.

3. FEES & MBS.

4. Management of oropharyngeal dysphagia.

CourseObjectives

• Knowthenormalanatomyofswallowing• Knowthenormalphysiologyofswallowing• Enumeratedifferentetiologiesoforopharyngealdysphagia

• Beabletodobedsideassessment• InterpretMBSandFEESprocedures• WriteMBSandFEESreports• Putashort-termandlong-termtreatmentplan

Generalrules

• Notallinformation,buttheimportant

• Notes

• Questions,anytime

• Moreexplanation

• Reactionsandfeedback

13-Mar-17 SwallowingCourse/AnatomyandPhysiology 4

Recommendedreadings

HistoricalPerspective“Swallowing”

• Swallowing addressed in CP children by“speech specialists” in 1930s

HistoricalPerspective“Swallowing”

HistoricalPerspective“Swallowing”

• First article in SLP literature: Larsen, 1972– JSHD “Rehabilitation for dysphagia paralytica”

– Introduced aspects of the clinical exam, radiographic techniques,postural adjustment, dietary changes, electrical stimulation andmaneuvers

13-Mar-17 SwallowingCourse/AnatomyandPhysiology 8

LarsenGL.Rehabilitationfordysphagia paralytica.JSpeechHearDisord.1972May;37(2):187-94.

HistoricalPerspective“Swallowing”

• Between 1968-1970, Logemann began to studyParkinson patients with radiographic techniques– Landmark text, Evaluation and Treatment ofSwallowing Disorders 1983

– Introduced the MBS; provided objective data relativeto maneuvers, diet consistencies and posturaladjustments; extensive influence on educationalstandards and policies

Logemann JA, Blonsky ER, Boshes B. Editorial: Dysphagia in parkinsonism. Br J Radiol. 1970 Jul;43(511):456–457.Logemann JA. Evaluation and Treatment of Swallowing Disorders. 1st ed. Austin, TX, Pro-Ed Publishers; 1983.

HistoricalPerspective“SpeechandLanguage”

• FormativeYears(1900-1925):Firstschool-basedprogram(1910)- ASHA

• ProcessingPeriod(1945-1965):Assessmentandintervention(internalandpsychological)

• LinguisticEra(1965-1975):Separationbetweenspeechandlanguagedeficits

• PragmaticsRevolution:Shapingofprofessionalpractice,ecologicalfactorsDuchan, J.F. (2008). Getting here: A short history of speech pathology in America. Retrieved July 15, 2009, fromhttp://www.acsu.buffalo.edu/~duchan/new_history/overview.html.Smith, Deborah D.; Tyler, Naomi Chodhuri (2009). Introduction to Special Education: Making A Difference (7th Edition). Englewood Cliffs, N.J: PrenticeHall. ISBN 0-205-60056-5. OCLC 268789042

“Beforeyouexaminethebodyofapatient,bepatienttolearnhisstory.Foronceyoulearnhisstory,youwillalsocometoknowhisbody.”

SuzyKassem

13-Mar-17 SwallowingCourse/AnatomyandPhysiology 12

I- OralCavity

• Lips,cheeks• Teeth,gingiva• Tongue• Vestibules

13-Mar-17 SwallowingCourse/AnatomyandPhysiology 13

I- OralCavity(Cont.)Tongue

13-Mar-17 SwallowingCourse/AnatomyandPhysiology 14

I- OralCavity(Cont.)Tonguemuscles

13-Mar-17 SwallowingCourse/AnatomyandPhysiology 15

Extrinsic(4) Intrinsic(4)

Position Shape

II- SoftPalate

13-Mar-17 SwallowingCourse/AnatomyandPhysiology 16

• Muscles(5)• Functions(5)

II- SoftPalate

13-Mar-17 SwallowingCourse/AnatomyandPhysiology 17

III- Pharynx

13-Mar-17 SwallowingCourse/AnatomyandPhysiology 18

• Compartments(3)• Walls(3)• Muscles(3)

III- Pharynx

13-Mar-17 SwallowingCourse/AnatomyandPhysiology 19

• Compartments(3)• Walls(3)• Muscles(3)

IV- Larynx

• RHS466• Sphinctericaction• Laryngealsuspension!!

13-Mar-17 SwallowingCourse/AnatomyandPhysiology 20

Sternothyroid Muscle

Suprahyoid muscles:DigastricusMylohyoideusStylohyoideus

Infrahyoid muscles:SternohyoideusOmohyoideus

Summary

• Oralcavity(Tongue:4extrinsic,4intrinsic)

• Softpalate(5muscles,5functions)

• Pharynx(3compartments,3walls,3muscles)

• Larynx(Sphincter,laryngealsuspension)

13-Mar-17 SwallowingCourse/AnatomyandPhysiology 21

NeuralControlofswallowing

• Receptors(types,sites?)

• Afferent

• Efferent

• Swallowingcenter

• Suprabulbar &Cortical

13-Mar-17 SwallowingCourse/AnatomyandPhysiology 22

13-Mar-17 SwallowingCourse/AnatomyandPhysiology 24

DysphagiaApplication(iTunes)

13-Mar-17 SwallowingCourse/AnatomyandPhysiology 25

OralpreparatoryphaseOral Cavity:Boluscontainmentandpresentation

1. Containment- Lips,Cheeks

ClosureAdequatetension

2. Boluspreparationa. Teeth: masticationb. Tongue:drivingforcetoinitiallypropelthebolusc. Gingivalandbuccalgutters:channelthebolusd. Softpalate(Shutoff!)

13-Mar-17 SwallowingCourse/AnatomyandPhysiology 26

• Transferphase?• Reductionphase?

Taste,temperature,viscosityandsizeofbolusaresensed

OraltransportphaseOropharynx: Deliverysystem

1. Oropharyngeal propulsionpumpa. Soft palateb. Lateralpharyngealwallsc. Baseoftongue

2. Velopharyngeal functiona. Softpalate:elevatesastonguepropelsb. Tongueelevation:necessaryforpropulsion

13-Mar-17 SwallowingCourse/AnatomyandPhysiology 27

Thetongueistheprimarymanipulatoroffoodduringtheoralphase

Hypopharynx1. Muscular propulsiona. Pharyngealconstrictorsb. Piriformsinusesc. Cricopharyngeal function

2. Laryngeal protectiona. Closure:glottis,ventricularbands,epiglottisb. Pharyngealsqueezec. Hyoidelevation

13-Mar-17 SwallowingCourse/AnatomyandPhysiology 28

Pharyngealphase

INVOLUNTARY

Tongue elevation è Velopharyngeal valve closure è forwardmotion of the hyolaryngeal mechanism (increase opening of UES)Laryngeal elevation è relaxation of the cricopharyngeusmusculature

• Size

• Consistency

• swallowingevent“single/

continuous”

Appliedanatomy

Sphincters:

• Velopharyngeal

• Laryngeal

• UES

13-Mar-17 SwallowingCourse/AnatomyandPhysiology 29

Appliedanatomy

Sphincters:

• Velopharyngeal

• Laryngeal

• UES

13-Mar-17 SwallowingCourse/AnatomyandPhysiology 30

Appliedphysiology

Temporalmeasures:

• OralTransitTime(OTT)

• PharyngealDelayTime(PDT)

• PharyngealTransitTime(PTT)

• OropharyngealSwallowingEfficiencyScore(OPSE

score)

13-Mar-17 SwallowingCourse/AnatomyandPhysiology 31