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Identification of Swallowing Patterns Associated with Dysphagia

Brief Project Description

This project developed web pages utilizing QuickTime technology to create a tutorial that helps students learn to observe radiographic studies representing problems that are likely to occur when patients have swallowing dysfunction. This web site will be available for the students to supplement their classroom lectures.

General Project Description

This project deals with the diagnosis of disordered swallowing patterns commonly produced by dysphagic individuals. One of the greatest obstacles to learning movement patterns commonly produced by individuals with swallowing disorders is providing students with an adequate of amount of controlled observations. Students in communication disorders must evaluate swallowing disorders and determine their relationship, if any, to the anatomy and physiology of the swallowing mechanism. In order to perform this role successfully, the student must be skilled in evaluating the interpreting radiographic studies of patients with swallowing disorders. The trained eye remains the most valid instrument for determining whether or not the movement patterns indicative of swallowing incompetence are present. When these patterns are found, the student has responsibility for assessing their severity and the degree of swallowing dysfunction, and determining possible etiologies. The student must learn to be a reliable observer and to recognize, describe, and interpret evidence of anatomical and physiological conditions that are provided by the swallowing patterns. As the student learns about the different swallowing patterns, it is helpful to have visual tutorials that supplement classroom presentations in order train students to become proficient observers in determining the presence of specific swallowing problems.

The present project is designed to allow students to observe swallowing patterns (both normal and disordered) through the World Wide Web. This project utilized QuickTime technology to present these video segments as actual video segments.

Normal Swallow

In order for students in the field of Speech Pathology to understand, diagnose and provide treatment for persons with dysphagia, there must first be a thorough understanding of a "normal" swallow.

The act of deglutition is divided into four phases:

1. Oral Preparatory Phase - food is manipulated in the mouth and masticated (chewed) if necessary in order to reduce food to a consistency which can be swallowed.
2. Oral Phase - the tongue propels food posteriorly until the pharyngeal swallow is triggered.
3. Pharyngeal Phase - once the pharyngeal swallow is triggered, the bolus (cohesive ball of food) is transported through the pharynx.
4. Esophageal Phase - esophageal peristalsis carries the bolus from the cricopharyngeal juncture or upper esophageal sphincter (UES) through the esophagus to the Lower Esophageal Sphincter (LES).

This tutorial will allows the student to view the first three phases of swallowing via Videofluoroscopy.

Videofluoroscopy Segments:

Normal Studies

• 1/3 Teaspoon Honey Consistency - Lateral View
• 1/3 Teaspoon Ground Meat and 1/4 Cookie - Lateral View
• liquid gulp - Lateral View
• infant bottle feeding - Lateral View

Disordered Swallowing

• Child Dysphagia - Lateral View
• Adult Aspiration and Delayed Swallow - Lateral View
• Oral Incoordination - Lateral View

Disordered Swallow - Adult - Oral Incoordination

• This subject is attempting to swallow a piece of cookie coated in barium. Up and down tongue movement is noted, however, she is unable to move the bolus posteriorally with her tonuge and uses her finger to push the material backwards.
• She is unable to move the solid bolus posteriorly and instead begins to suck the barium off the cookie. The cookie remains in her mouth following 2 swallows of barium.

Special thanks to St.Mary's/Duluth Clinic (SMDC) Radiology and Speech Pathology departments for providing the videofluroscopy studies of the normal adult.

Normal Adult Swallow - Liquid Gulp from a glass (lateral view)

The subject is a 47 year old male with no history of swallowing problems. The videofluoroscopy segments include swallowing of a Liquid Gulp from a glass (lateral view) .

Notice that 2 swallows are needed to clear the liquid. This is considered normal .

You may also view each stage:

1. Oral Preparatory and Oral Phases

• bolus held between the tongue and the anterior hard palate with the tongue cupping the liquid bolus with the sides of the tongue sealed against the lateral alveolus
• soft palate pulled down and forward, sealing off oral cavity from the pharynx if there is no active chewing
• tongue moves bolus posteriorly
• this stage takes less than 1 to 1.5 seconds to complete

2. Pharyngeal Phase

• elevation and retraction of the velum and complete closure of the velopharyngeal to prevent passage into the nasopharynx
• elevation and anterior movement of the hyoid and larynx
• closure of the larynx at the true vocal folds, the laryngeal entrance and the epiglottis to prevent material from entering the airway
• airway entrance is closed for approximately 5 seconds or more with sequential cup drinking

Normal Swallow - 1/3 Teaspoon Honey Consistency -Lateral View

In order for students in the field of Speech Pathology to understand, diagnose and provide treatment for persons with dysphagia, there must first be a thorough understanding of a "normal" swallow.

The act of deglutition is divided into four phases:

1. Oral Preparatory Phase - food is manipulated in the mouth and masticated (chewed) if necessary in order to reduce food to a consistency which can be swallowed.
2. Oral Phase - the tongue propels food posteriorly until the pharyngeal swallow is triggered.
3. Pharyngeal Phase - once the pharyngeal swallow is triggered, the bolus (cohesive ball of food) is transported through the pharynx.
4. Esophageal Phase - esophageal peristalsis carries the bolus from the cricopharyngeal juncture or upper esophageal sphincter (UES) through the esophagus to the Lower Esophageal Sphincter (LES).

This tutorial will allow the student to view the first three phases of swallowing via Videofluoroscopy.

The subject is a 47 year old male with no history of swallowing problems. The videofluoroscopy segments include swallowing of an 1/3 Teaspoon Honey Consistency Liquid (lateral view).

Videofluoroscopy Segment

Because this is a normal swallow, it happens very quickly. You will want to watch each segment repeatedly and look for one component at a time.

1/3 Teaspoon Honey Consistency -Lateral View

Watch the entire Honey Consistency segment , first.. Then, watch the Honey Consistency segment according to following components:

1. Posterior movement of the tongue to move the bolus back
2. Elevation and retraction of the velum and complete closure of the velopharyngeal port
3. Elevation and anterior movement of the hyoid and larynx
4. Bolus transported into valleculae
5. Backward movement of the epiglottis which protects the airway
   • Notice how there is virtually not residue of food in the pharynx after the swallows. 

Normal Adult Swallow -1/3 Teaspoon Ground Meat and 1/4 Cookie

The subject is a 47 year old male with no history of swallowing problems.

This segment may be watched in 3 parts:

1. Oral Preparatory Phase

• tongue positions material on the teeth
• rotary lateral movement of the mandible and tongue during mastication
• tongue moves the material back onto the teeth as the mandible opens
• after cycle is repeated numerous times, a bolus is formed
• during active chewing, the soft palate is not pulled down and forward and premature spillage is common and entirely normal

2. Pharyngeal Phase

• elevation and retraction of the velum and complete closure of the velopharyngeal to prevent passage into the nasopharynx
• elevation and anterior movement of the hyoid and larynx
• closure of the larynx at the true vocal folds, the laryngeal entrance and the epiglottis to prevent material from entering the airway

3. A second swallow was needed to clear all the material

1/3 Teaspoon Ground Meat and 1/4 Cookie In this segment, please note:

• The rotary lateral movement of the mandible and tongue
• The formation of the bolus
• During chewing, the soft palate is not pulled down and forward and material falls into the pharynx partially before the pharyngeal phase is triggered
• Bolus size decrease with the viscosity of food; J.P. swallowed twice on the ground meat material

Normal Infant Bottle Feeding

• The anatomic relationship between structures in the oral cavity and pharynx is different than that in adults. The tongue fills the oral cavity, the fat pads in the cheeks narrow the oral cavity laterally, and the hyoid bone and larynx are much higher than in adults, which provides more protection of the airway. The velum usually hangs lower, with the uvula often resting inside the epiglottis.
• When sucking from a nipple, the infant repeatedly pumps the tongue to express milk from the nipple with each pump collecting liquid at the faucial arches or in the valleculae. Each infant tends to use a pattern of specific number of tongue pumps. Normal infants use from 2 to 7 tongue pumps.
• When a bolus of adequate size has been formed, the pharyngeal swallow triggers, which is similar to that of an adult.
• The subject in this segment is a 6 month old male infant. The videofluoroscopy was done due to a suspected swallowing disorder. The infant's swallowing was in fact normal. Because swallowing was normal, it was recommended that the child be assessed for a possible reflux disorder.

Bottle feeding - breast milk

• Note the different anatomic relationship between structures in the oral cavity and pharynx as described above.
• Two discreet segments can be viewed:
  • Oral Phase
    • 3 tongue pumps prior to initiation of the pharyngeal stage movie
  • Pharyngeal Phase

Disordered Swallow - Adult

The subject in these videofluoroscopy segments is an adult male, who was over 60 at the time of this study and had suffered a cerebrovascular accident (CVA).

Aspiration - thin liquids

• The subject is presented with a small amount of liquid barium.
• During the oral stage of the swallow, please observe the limited control with barium falling over the base of the tongue, without a pharyngeal swallow being triggered.
• Because material falls over the base of the tongue, a small amount of liquid barium is aspirated before the pharyngeal swallow is triggered. The patient did demonstrate a cough reflex following the aspiration indicating good sensation.

Delayed Pharyngeal Swallow and Pharyngeal Pooling (movie "Adult delayed swallow")

• The subject is presented with a small amount of thickened barium.
• The same difficulty of poor bolus control can be seen with this material.
• During this study, the material is not controlled and slides or trickles into the pharynx. Triggering of the pharyngeal response differs based on the age of the individual. For those over 60, the pharyngeal swallow is not triggered until the bolus head reaches approximately the middle of the tongue base. This video segment ends when the bolus reaches this point.
• The amount of delay can be measured by timing the point at which the bolus head reached the middle of the tongue base until the pharyngeal swallow is triggered. In this example, there is a delay of approximately 2 seconds, which would be considered a mild delay. Because of the increased viscosity of the bolus, material pools in the valleculae prior to the initiation of the pharyngeal swallow and no aspiration occurs.

Once the pharyngeal response is triggered, good laryngeal elevation is seen. Following the swallow, there is significant pooling in the valleculae and pyriform sinuses, indicating reduced pharyngeal sensation. The subject did not spontaneously swallow a second time and had significant difficulty swallowing a second time when asked to do so.

Disordered Swallow - Child

The anatomic relationship between structures in the oral cavity and pharynx is different than that in adults. The tongue fills the oral cavity, the fat pads in the cheeks narrow the oral cavity laterally, and the hyoid bone and larynx are much higher than in adults, which provides more protection of the airway. The velum usually hangs lower, with the uvula often resting inside the epiglottis.

When sucking from a nipple, the infant repeatedly pumps the tongue to express milk from the nipple with each pump collecting liquid at the faucial arches or in the valleculae. Each infant tends to use a pattern of specific number of tongue pumps. Normal infants use from 2 to 7 tongue pumps.

When a bolus of adequate size has been formed, the pharyngeal swallow triggers, which is similar to that of an adult.

These two videofluroscopic segments are of a child with dysphagia. The child is a 3 year, 6 month old male with a diagnosis of seizure disorder - infantile spasms. He was referred for a modified barium swallow because questions had arisen regarding the safety of oral feeding due to possible aspiration. His mother reports episodes of raspiness and coughing during feeding.

Bottle Feeding

The first segment is of bottle feeding. The child was positioned in his wheelchair with all his support straps in place. Neck hyperextension was evident throughout the evaluation. In this segment, note the overall uncoordinated, arrhythmical oral motor movements and the uncoordinated suck/swallow/breathe pattern.

Note that this child used an up and down suckling movement of the jaw and tongue as a unit. This is normal in younger children, however, eventually children use the tongue independent of the jaw to suck from a nipple.

The pharyngeal phase is delayed with material tending to pool in the valleculae and pyriform sinuses. Because of the hyperextended neck position, gravity assisted in moving the bolus backwards into the pharynx. Coating of the pharynx can also be observed.

Cracker softened with gravy

In this segment, the child had been given a piece of cracker which had been softened with gravy. Food remained in the pharynx and in the larynx. He attempted to cough, but when he inhaled to gain pressure for a cough , he aspirated the material .