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Getting Started

Multiple LessonsMultiple Lessons

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This selfThis self--study isstudy is offered foroffered for X.XX.X CEUsCEUs(Intermediate(Intermediate level,level, ProfessionalProfessional areaarea).).

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Clinical Swallowing Examination ofAdults with Dysphagia:Anatomy And Physiology Series

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Presenter

James L. Coyle, Ph.D., CCC-SLP, BRS-SCommunication Science and Disorders

University of Pittsburgh

Description

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Learning Outcomes

• identify sensorimotor structures innervated by thesix cranial nerves, and respiratory musculature thatare critical to oropharyngeal swallowing functionand speech production

• identify the actions of sensorimotor structurescritical to oropharyngeal swallowing function andspeech production

• identify clinical tactics that elicit sensorimotoractivity reflecting normal and abnormal function

• choose an appropriate instrumental investigationpath based on results of the clinical swallowingexam

Program Overview

1. Overview of Clinical Swallowing Exam and The Role ofAnatomy/Physiology

2. Overview of Oropharyngeal Swallow3. Assessment and Functions

a. Mandibularb. Facialc. Lingual/Tongued. Velar/Pharyngeale. Hylolaryngealf. Cricopharyngeal

4. CheckYour Knowledge!5. Summary

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SECTION 1

Overview of Clinical Swallowing Exam and TheRole of Anatomy/Physiology

Adverse Event(Stroke, e.g.)

Adverse Event(Pneumonia, e.g.)

SwallowingDisorder

Adverse Event(Stroke, e.g.)

CommunicationDisorder

SwallowingDisorder

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Clinical Swallow Examination

Examine structure and functionForm hypotheses regarding cause, effectPrepare trial interventionsEvaluate response to trial interventionsDetermine need for instrumental examination

Accurate evaluation ofthe upper aerodigestive

tract (UADT) is anessential, fundamentalskill that the SLP must

strive to keep sharp,accurate, and objective!

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SECTION 2:

Overview of Oropharyngeal Swallow

Overview of Oropharyngeal Swallow

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Structures

Understand how muscles contractUnderstand how structures move

How do muscles work?Muscles shorten (pull), never lengthen (push)Ends move toward center (concentric contraction)Example- an “unattached muscle”

Attachment 1 Attachment 1Attachment 1 Attachment 1

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1 TON1 lb.

insertionorigin

1 lb.insertion

Elbow

Biceps

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SECTION 3

Assessment and Functions

Functions and Assessment

MandibularFacialLingualVelarPharyngealHyolaryngeal

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3a: Mandible

MandibleMandible elevationPulls mandible to maxillae (+

dentition)Masseter

Pulls mandible toward craniumTemporalis

Pulls mandible toward sphenoid(center of head)Medial pterygoids

Pulls mandible toward opposite sidesphenoidLateral pterygoids

Mandible protrusion: lateralpterygoids

Mandible lateralization: temporaliswith contralateral pterygoids

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Prime mover is gravityPulls mandible toward hyoidMylohyoidAnterior digastricGeniohyoid

***Requires synergistic contraction ofINFRAHYOID strap muscles to prevent hyoidupward motion

Mandible Depression

Mandible-Anatomic Organization

Motor SupplyMandible elevatorsTrigeminal (V) -mandibular divisionMasseter, temporalis, medial pterygoid

Mandible depressorsTrigeminal (V) -mandibular division, C1 root (1

muscle)Mylohyoid, anterior belly of digastric (ABD)Geniohyoid (C1)

All innervations originate in both hemispheres

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Motor Supply (cont’d)Mandible lateralizationTrigeminal (V) -mandibular divisionMedial and lateral pterygoids,temporalis

ProtrusionLateral pterygoids

Innervations originate in both hemispheres

Mandible-Anatomic Organization

Trigeminal nerve

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MandibleElevationDepressionLateralizationRotary motions

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Mandible-Anatomic Organization

Adult mandible

Child mandible

Elderly edentulousmandible

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Mandible elevation

sphenoidsphenoid

Cranium

Maxillae

Mandible

Hyoid

Cranium

Maxillae

Hyoid

sphenoidsphenoidT

MMPLP

TM

LP

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Mandible elevation

sphenoidsphenoid

Cranium

Maxillae

Mandible

Hyoid

Cranium

Maxillae

Mandible

Hyoid

sphenoidsphenoidT

MMPLP

TM

LP

Normal Mandible

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Mandible depression

sphenoidsphenoid

Cranium

Maxillae

Mandible

Hyoid

Cranium

Maxillae

Hyoid

sphenoidsphenoid

MHGH

Gravity

GHABD

MH

Helddown

ABD

HelddownThyro-, sternohyoid

Mandible Lowering

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Motor examination

Elevationresistance

Depressionresistance

sphenoidsphenoid

Cranium

Maxillae

Mandible

Hyoid

T

MMPLPweak

Asymmetrical Mandible Test

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3b: Facial musculature

Motor SupplyFacial musculature (lips, buccal walls, etc.)Facial nerve (VII), various branches

Orbicularis oris, risorius, buccinator, et al.Innervation to lower face : contralateral hemisphereInnervation to upper face: both hemispheres

Face-Anatomic Organization

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Parts that move and what they do

Face-Anatomic Organization

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Right hemisphere Left hemisphere

(L) VIINerve

(R) VIINerve

Facial nerve distribution

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Salivary glands

IXVII

Facial nerve branches

Face-Anatomic Organization

Concentric closure (rounding)

Face-Anatomic Organization

Push with tonguedepressor

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Retraction

Face-Anatomic Organization

Sensory fieldsOphthalmicMaxillary

Mandibular

Trigeminal sensory fields

Face-Anatomic Organization

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C.N. X

C.N. V

Face-Anatomic Organization

3c:Tongue-Anatomic Organization

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Motor SupplyLingual motionProtrusion, retraction*, lateralization, elevation,

depression: Hypoglossal (XII)Genioglossus, styloglossus, intrinsic lingual

musculature, hyoglossusRetraction/elevation: Vagus (X) (pharyngeal plexus)Palatoglossus

Innervations originate in both hemispheres exceptGenioglossus (contralateral) in many humans

Tongue-Anatomic Organization

Tongue-Anatomic Organization

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C1

C2

C3hypoglossal n.

Tongue-Anatomic Organization

Coronal section oftongue

hyoglossus

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Superior longitudinaltransversus

inferiorlongitudinal

genioglossus

geniohyoid

mylohyoidAnterior digastric

© Patrick J. Lynch, medical illustrator; C. Carl Jaffe, MD,cardiologist. Creative Commons Attribution 2.5 License2006 http://commons.wikimedia.org Visible Human Project. Public Domain

genioglossus

Tongue-Anatomic Organization

geniohyoid

geniohyoid

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V

Tongue-Anatomic Organization

VIIIX

X

Tongue- Anatomic Organization

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3d: Velum-Anatomic Organization

Motor SupplyVelar elevation and depression: Vagus (X),

pharyngeal plexus)Levator veli palatini - elevationTensor veli palatini (trigeminal (V) assists(controversial)

Palatoglossus – depression*Linguavelar valve closure

Innervation originate in both hemispheres

Velum-Anatomic Organization

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Velum/soft palateElevationDepression

Velum-Anatomic Organization

Pharyngeal constriction, propulsionPharyngeal constrictors (sup., mid., inf.)

Contribution to VP closure“Squeeze” bolus downward

Pharyngeal elevators (stylo-, palato-,salpingo- pharyngeus.)pull pharynx toward bolus

Velum - Pharynx

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Motor SupplyPharyngeal constriction &

elevationGlossopharyngeal, vagus (X)

(pharyngeal plexus)Pharyngeal constrictors (X),

stylopharyngeus (IX),salpingopharyngeus (X).

Cortical input is of bilateralorigin*Not all of these muscles have

been shown to be corticallyrepresentedActivation initiated at lower

levels

Velum - Pharynx

Glossopharyngeal,Vagus N.

to stylopharyngeus

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C.N. X

Velum - Pharynx

Head Rotation

Is patient able to performExpose lesions

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Motor Supply Head rotationAccessory

branch of CN XI(sternocleidomastoid)

Head Rotation:AnatomicOrganization

3e: Hyolaryngeal excursion (HLE)

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Hyolaryngeal DisplacementA. Pulls hyoid toward mandibleMylohyoidAnterior digastricGeniohyoid

B. Pulls hyoid toward skull baseStylohyoidPosterior digastric

C. Pulls hyoid toward tongueHyoglossus

Mandible synergistically held “up” by masseter, et al.

A

B

Hyolaryngeal excursion (HLE)

Hyoid boneElevation +Depression+ Anterior

displacement+ Posterior

displacement

Larynx attached

Hyoid Body

Cricoid

Trachea

C-Tmembrane

T-Hmembrane

C-Tmuscle

Hyolaryngeal excursion (HLE)

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Hyolaryngeal excursion (HLE)

sphenoid

Cranium

Maxillae

Mandible

Hyoid

Cranium

Maxillae

Hyoid

sphenoid

MHGH

GHABDMH

ABD

SHPBD

HG

Hyolaryngeal excursion (HLE)

Mandibularelevator

Mandibularelevator

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sphenoidsphenoid

Cranium

Maxillae

Mandible

Cranium

Maxillaesphenoidsphenoid

GHABDMH

SHPBD

HG

Hyoid

MHGH ABD

Hyoid

Hyolaryngeal excursion (HLE)

Mandibularelevator

Mandibularelevator

HLE

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Hyolaryngeal Excursion responsible for:Epiglottic inversionAirway closureEmptying of valleculaeSuperior closureRelated to epiglottic inversion

Together with intrabolus pressure/tongue motionUES traction forces

Hyolaryngeal Excursion (HLE)

Hyolaryngeal Excursion (HLE)

Epiglottis is acted upon by HLE andintrabolus pressure/tongueAnterior attachment: thyroid cartilagePosterior portion: free edge of epiglottis

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Hyolaryngeal Excursion (HLE)

Hyoepiglottic ligament Vocal ligament attaches here

Epiglottis attaches here

larynx

tongue

mandible

Thyrohyoid

valleculae

“Base of epiglottis”

“Tip” of epiglottis

C4

C7

C6

C5Post. Phar.

wall

UES

Hyolaryngeal excursion and airway protection,vallecular emptying, UES opening

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tongue

mandible

larynx

T. H.

valleculae

“Base of epiglottis” displaced bysubmental muscles (anterior,

superior)UES

C4

C7

C6

C5Post. Phar.

wall

“Tip” of epiglottis

Hyolaryngeal excursion and airway protection,vallecular emptying, UES opening

Tongue& bolus

mandible

larynx

Protected Airway

T. H.

Hyolaryngeal excursion and airway protection,vallecular emptying, UES opening

Valleculae empty

“Tip of epiglottis” displaced bytongue, intrabolus pressure

UESC7

C6

C5Post. Phar.

wall

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Normal Swallowing

3f: Cricopharyngeal function

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Motor SupplyCricopharyngeal segment of inferior constrictorClosed at rest with high resting pressureRecurrent laryngeal branch of vagus (X)

Resting tone reduces during pharyngeal phaseSuprahyoid traction forces “pull UES open”

Laryngeal functionVocal fold adduction, abduction: vagus (X)

Cricopharyngeal function

Cricopharyngealsegment

Middleconstrictor

Superiorconstrictor

Stylo-pharyngeus

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Thyrohyoid Sternohyoid

Thyroid Cartilage

Arytenoid CartilageInferior Constrictor

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conuselasticus

Arytenoid Thyroid

Cricoid

Vocal Fold

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SECTION 4:

Check YourKnowledge

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47

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SECTION 5: Summary

Summary: Motor Examination

Anatomy and PhysiologyLingual intrinsics: bolus formation,

containmentSmall contribution to propulsion

Lingual extrinsics: bolus propulsionMasseter/pterygoids: mandibular elevation-

bolus containment, lingual stabilization

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Summary: Motor Examination

Facial-buccinator, orbicularis oris, etc.Bolus containmentLateral sulci, drooling

Soft palate elevatorsvelopharyngeal closure

Soft palate depressors (or tongue baseelevators (i.e. palatoglossus)

Suprahyoids: elevation and (net) anteriordisplacement of HLC (HLE), UES distensionMylo-, geniohyoid, digastrics,Mandibular depression

Infrahyoid strap mm: laryngeal stabilization

Summary: Motor Examination

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Pharyngeal constrictors: pharyngealperistalsis (wavelike top to bottomcontraction-bolus propulsion)

Pharyngeal elevators: “bolus propulsion”Cricopharyngeal segment of inferior

constrictor: UES closure

Summary: Motor Examination

Trigeminal nerve innervationAll tactile sensation of face, most of mouth

Facial nerve innervationTaste to anterior 2/3 tongueSmall region behind outer ear

Glossopharyngeal, vagus nerve innervationSoft palate, pharynx

Hypoglossal: none!(Proprioception not discussed)

Summary: Sensory Examination

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Important Points

CSE is part of a larger process and rarelystands as an independent examination

Knowledge of anatomy and physiology ofupper aerodigestive track is required

Working understanding of the diseaseprocess causing the disorders is necessary

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The DysphagiaEvaluation: Consultationto Instrumental Exam

(Master Clinician Series)

FEES: FiberopticEndoscopic Evaluation

of Swallowing

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Michele Lash, MAInstructional Designer/Program Manager

Janet Brown, MS, CCC-SLPDirector, Health Care Services in SLP

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© 2010 American Speech-Language-Hearing Association

Thank You!

Image attributions

All images displayed are either public domain withoutcopyright, or are licensed to any and all users undercommon use copyrights. © Patrick J. Lynch, medical illustrator; C. Carl Jaffe, MD, cardiologist.

Creative Commons Attribution 2.5 License 2006http://commons.wikimedia.org

Public Domain (also obtained from http://commons.wikimedia.org.)Gray’s Anatomy original plates (copyright expired)The Visible Human Project (U.S. Government funded work, public domain)SEER’s training web site (National Cancer Institute), U.S. Government funded

work, public domain