Disorders of Swallowing

Oral Stage General Disorders

lip closure
jaw movement
tongue movement (c1)
tone in facial musculature
Oral Transit Time (seconds)
- Normal Rate: 1 - 1.25 sec
- Over 60: 1.25 sec

Pharyngeal Stage General Disorders

Motility Problem
- Slowed Pharyngeal Transit Time (normal: 1 second). Pharyngeal Transit Time is defined as the time it takes for the bolus to pass from the faucial arches over the base of the tongue and through the pyriform sinus into the esophagus.
- If Pharyngeal Transit Time is increased, motility problems are present.
Delayed/Absent Swallowing Response(transition between the oral and pharyngeal stages of swallow) occurs if the bolus rolls over the base of tongue before the swallowing response triggers. When material rolls into the pharynx without a response, the bolus may land in the valleculae, the pyriform sinuses , or airway, depending upon the amount of food given, consistency of the food, and patient's posture.
- If swallowing response is not triggered, tongue may compensate by propelling bolus posteriorly so that it falls over the base of the tongue and collect in the valleculae. Bolus may remain there until response is triggered. May take 1 second, or as long as 5 to 10 seconds.
- The delay is timed from the intial video frame showing the bolus head passing the point where the lower edge of the mandible corsses the tongue until the first frame where the pharyngeal swallow is initiated (where laryngeal and hyoid elevation begin as a part of the pharyngeal swallow).
  - Young Adults: 0 - .2 sec
  - Over 60: .5 sec

Neruomuscular and Anatomic Disorders of Swallowing

Decreased labial stength

Patient Description

Unable to keep food in mouth

Clinical Symptom

Food falling from the mouth.

Radiographic Symptom

Food falling from the mouth

Inability to lateralize material with tongue.

Patient Description

Cannot chew

Avoid foods requiring mastication

Clinical Symptom

Material remains midline on tongue or falls into sulcus.

Radiographic Symptom

Material remains midline on tongue or falls into sulcus.

Reduced buccal tension

Patient Description

Cannot chew

Avoid foods requiring mastication

Clinical Symptom

Materal falls into sulci

Radiographic Symptom

Materal falls into sulci

Reduced tongue coordination to form bolus (after mastication)

Patient Description

Material goes all over mouth

Food catches in mouth

Clinical Symptom

Material spreads around oral cavity.

Radiographic Symptom

Loss of bolus control (c4): material spreads around oral cavity.

Reduced oral sensation

Patient Description

Material goes all over mouth

Food catches in mouth

Clinical Symptom

Material spreads around oral cavity.

Radiographic Symptom

Loss of bolus control: material spreads around oral cavity.

Reduced tongue coordination to hold bolus (c5) (for liquids and paste materials).

Patient Description

Coughing, choking before the swallow

Food catches in mouth

Clinical Symptom

Coughing, choking before the swallow

Radiographic Symptom

Material falls (c2) over base of tongue into the valleculae or airway

Reduced tongue elevation

Patient Description

Food catches in mouth.

Slow eating, worse with solids.

Clinical Symptom

Slow oral transit times

Radiographic Symptoms

Slow oral transit times

Reduced tongue elevation

Collection of material on the hard palate

Reduced anterior to posterior tongue movement

Patient Description

Slow eating, worse with solids.

Clinical Symptom

Slow oral transit times

Radiographic Symptom

Slow oral transit times (c1)

delayed and prolonged oral bolus transport (c3)

Swallow apraxia (Disorganized anterior to posterior tongue movement. Repeated tongue pumping)

Patient Description

Slow eating

Clinical Symptom

Slow oral transit times

Radiographic Symptom

Slow oral transit times

Scarred tongue contour

Patient Description

Slow eating

Clinical Symptom

Slow oral transit times

Radiographic Symptoms

Slow oral transit times

Collection of material in tongue depression from scarring, worsened with tongue movement.

Delayed pharyngeal swallow (c6)

Patient Description

Food catches at base of tongue, high in throat

Food coughed up

Coughing, choking

Clinical Symptoms

Delayed elevation of hyoid bone and thyroid cartilage

Expectoration of material before the pharyngeal swallow

Radiographic Symptoms

Hesitation of material in the valleculae prior to initiation of pharyngeal swallow

Aspiration before swallow

Expectoration of material before the pharyngeal swallow

Video Sampel

Pt 17 (CVA, Delayed response, Reduced P contraction)

Paste Bolus

Mild reduction in tongue function with repeated tongue pumping

Residue in valleculae & along back & base of tongue after swallow

Dry swallows to clear residue

Residue still remains - indicative of reduced p. contraction.

Absent pharyngeal swallow

Patient Description

Food does not go down

Clinical Symptoms

No hyoid/thyroid elevation

Slow oral transist times

Radiographic Symptom

Hesitation of material in the valleculae, with potential spill over into pyriform sinus and/or airway

Reduced pharyngeal contraction (c2) /tongue base movement (c9)

Patient Description

Coughing, choking

Food coughed up

Clinical Symptom

Coughing, choking after the pharyngeal swallow

Radiographic Symptom

Residue of material in the valleculae (c1) after the swallow

Video Case

Pt 14 (CVA-Reduced contraction)

Cookie

Reduced pharyngeal contraction

After swallow residual food on tongue base and valleculae which collects in pyriform sinus.

Reduced laryngeal elevation (c7)

Patient Description

Coughing, choking

Food coughed up

Clinical Symptom

Expectoration of material after the pharyngeal swallow

Radiographic Symptom

Residue of material in the pyriform sinus after the swallow

Residue at top of airway

Video Sample

Pt 18 (CVA w/ tracheostomy tube, Reduced Laryngeal Elevation)

Reduced laryngeal elevation in presence of excellent airway closure

The vocal folds close, but epiglottis does not, due to reduced laryngeal elevation.

Has excellent vf closure during swallow, but aspirates after swallow when he opens airway to inhale.

Reduced laryngeal elevation results in residue in area of laryngeal vestibule because larynx is too low and collects food during swallow.

Because larynx is not elevating well, cricopharyngeal region does not open as widely and there is residue in pyriform sinuses.

Unilateral (c10) or bilateral pharyngeal paralysis. Reduced tongue base movement.

Patient Description

Food sticks high in throat

Clinical Symptom

NA

Radiographic Symptoms

Residue of material on one or both sides of valleculae or pyriform sinus

Aspiration after swallow

Cricopharyngeal dysfunction/Reduced laryngeal elevation (c1)

Patient Description

Coughing, choking

Material catching at bottom of throat

Clinical Symptoms

Coughingm choking after the swallow.

Gargly voice quality

Excessive secretions

Radiographic Symptoms

Aspiration after swallow

Collection of material in pyriform sinuses

Prominant pharyngoesophageal segment

Spillover form valleculae

Video Samples

Pt 16 (Spinal Cord Injury, Reduced P contraction, CP Dysfunction)

Liquid

Mild amount of residue in valleculae and posterior pharyngeal wall

Result of reduced pharyngeal contraction

Nasogastric tube in place

Mild cricopharyngeal dysfunction

Residual material lies on pharyngeal wall after paste swallow.

Residual gradually works its way toward the airway.

Dry swallows to clear residue

Delayed response

Pt 22 (CVA, Cricopharyngeal Dysfunction)

Cricopharyngeal dysfunction

Food does not penetrate upper esophageal sphincter into esophagus

Aspiration after swallow because food collected in pyriform sinuses is sucked into airway when pt inhales after swallow.

Pt 23 (CVA, Cricopharyngeal Dysfunction)

Oral and pharyngeal swallow normal

Residue in pyriform sinuses

Repeated dry swallows, pt drives residue into esophagus.

Head turned to left (damaged side) clears right pyriform sinus.

Reduced esophageal peristalsis or other esophageal disorder

Patient Description

Coughing, choking

Material catching at bottom of throat

Clinical Symptoms

Coughingm choking after the swallow.

Gargly voice quality

Excessive secretions

Radiographic Symptoms

Aspiration after swallow

Collection of material in pyriform sinuses

Prominant pharyngoesophageal segment

Reduced esophageal peristalsis or other esophageal disorder

Patient Description

Coughing, choking

Material catching at bottom of throat

Clinical Symptoms

Coughingm choking after the swallow.

Gargly voice quality

Excessive secretions

Radiographic Symptoms

Aspiration after swallow

Collection of material in pyriform sinuses

Prominant pharyngoesophageal segment

Esophageal diverticulum

Patient Description

Coughing, choking after the swallow

Regurgitation of food

Clinical Symptoms

Regurgitation of food

Coughing, choking after swallow

Radiographic Symptoms

Collection of material in side pocket in the pharynx or esophagus.

Partial or total obstruction in esophagus

Patient Description

Coughing, choking after the swallow

Regurgitation of food

Clinical Symptoms

Regurgitation of food

Coughing, choking after swallow

Radiographic Symptoms

Collection of material in side pocket in the pharynx or esophagus

Aspiration after the swallow from esophageal "overflow"

Tracheoesophageal fistula
- Patient Description
  - Coughing, choking after the swallow
- Clinical Symptoms
  - Coughing, choking after swallow
- Radiographic Symptoms
  - Material leaks through skin
- Video Sample
  - Pt 24 (Head Injury, TE Fistula)
    - Expectorates barium up airway tracheoesophageal fistula
Pharyngocutaneous fistula
- Patient Description
  - Material leaks out hole
- Clinical Symptoms
  - Material leaks out hole onto skin
- Radiographic Symptoms
  - Material leaks through skin