SEM 1

 Pharyngeal constriction
- Circular and longitudinal muscles of the pharynx will contract
Dysphagia Assessment to make sure there is no residue left in the region
Normal Phases of Swallowing - Possible implications:
1. Oral Preparatory o Post-swallow coughing (even when the others are working
- Awareness (tiny aspect of cognition) functionally): because the residue can go down once the
- Senses larynx goes back to its resting phase
- Stimulate  Opening of upper esophageal sphincter
- Not a physical state of swallowing, but the perceptual or the - Initiates the esophageal phase by means of peristalsis
cognitive side of it 4. Esophageal Phase
- It is very important to look into the cognitive side of feeding - Once the esophageal phase is affected: refer to GI doctor
because it will entail the success of the proceeding phases - Peristalsis: movement of the smooth muscles to push down
 Feeding/eating is one of our primitive skills the bolus
 If patients with cognitive impairment react to food = food is a
o active in nature; purely involuntary
good material for cognitive therapy
o can only be facilitated when the body is moving
o You always need to try for feeding; do not be afraid
 If patients with cognitive impairment do not react to food = appropriately (the lesser the physical activity, the lesser the
there’s a risk of aspiration because they tend to keep the food in function of peristalsis)
their mouth for too long - Possible implications:
2. Oral Phase o Bad breath (may smell sour or like vomit): acidic-like smell
- Jaw grading, biting, latching due to reflux
- Bolus manipulation, mastication o Constipated
- Bolus formation o Case sample: A patient with nasogastric tube consumes milk
- Bolus cohesion (when the food is being prepared for and shows signs of white residue at the tongue are will only
propulsion) mean that the milk goes up due to reflux. A smell of rotten
Borderline: once food touches any of the trigger points for swallow milk will also be observed in this scenario.
------------------------ initiation of swallow reflex ------------------------------- - Advice:
3. Pharyngeal Phase o Changing bed-position from time to time
- Swallow reflex (1s – normal swallowing time) o Encourage physical activities
o Pharyngeal plexus work (work of both CN 9 and 10) *Talk to family/PT about these advices
 If there’s a problem at the pharyngeal level of swallowing,
it a problem of both CN 9 and 10 Cranial Nerve Assessment
o Swallow reflex is a dance (6) – in one second, there’s a lot - Connected to the physical aspect: the movement of our OPM
happening from top to bottom and everything has to be mechanism
coordinated. - The ones for swallowing:
 Velopharyngeal port closure o CN 5: trigeminal nerve (MIXED)
- Possible implications: **this is what triggers the anterior-posterior movement of hyoid
o nasal regurgitation Sensory
o lack of intraoral pressure: a positive pressure at the upper - Sensation of the face *focusing on the V3 (includes hard
area and a negative pressure at lower area of the body will palate)
help in pushing down the bolus; any issues with that - issues: drooling, pocketing, feeling hot/cold, sensation of
mechanism will disrupt the swallowing process tongue (anterior 2/3), feeling hot or cold, oral residue,
 Anterior-superior movement of hyoid anterior spillage
- Anterior movement: triggers the opening of the UES so that Motor
the food can be sucked in the esophagus; anterior digastric - Mastication (muscles: lateral pterygoid, masseter, temporalis)
muscle is involved - issues: jaw grading (e.g. if the patient is spastic/flaccid), poor
- Superior movement: help the food push down bolus formation, oral residue, open-mouth posture, fatigue*
- Possible implications: Assessment
o Vallecular residue: since the superior movement of the - different size of food cuts
laryngeal inlet closes the epiglottis (*the epiglottis does not  for jaw grading and ability to chew it
move by itself, it gets triggered) - introduce the food at the molar side
o Deflection  for tongue movement (especially if the patient has a
o Penetration (food particles above glottis) or aspiration (food flaccid tongue)
particles below glottis)  if they can’t swallow for the second/third try = dukutin mo
o If there is only the superior movement: post-swallow the yung food
patient will cough due to the pyriform sinus pooling o CN 7: facial nerve (MIXED)
 Epiglottic deflection Sensory
- Epiglottis is very important for the protection of your laryngeal - Taste (in the chorda tympani nerve)
inlet; first gatekeeper - issues: decreased taste levels
 Adduction of the vocal folds o increase taste input especially patients with dementia (aging
- Second gatekeeper affects taste) and/or patients with cognitive issues = to
 boost the appetite for pleasure feeding (kahit bawal - Volitional cough – motor reflex
sakanila) **pre-swallow: vocal quality is breathy
Motor peri-swallow: coughs; di talaga nagsasara = paralyzed
- Controlling the face (lips, cheeks) **pre-swallow: harsh
- issues: drooling (due to: decreased lip seal, decreased tone – post-swallow: gurgly without coughing = sensory issues – it is
cheeks), decreased intraoral pressure (due to orifice 1 and above the vocal folds
chamber 1), decreased bolus formation, decreased tone – what is your first gatekeeper?  epiglottis, so you have a problem
cheeks: help contracts with that if the bolus is stuck above the vocal folds; and vocal fold
o CN 9: glossopharyngeal nerve (MIXED) closure; and cough reflex
- @ nasopharynx to laryngopharynx o CN 11: accessory nerve (MOTOR)
Sensory - It controls all your neck muscles
- Gag reflex: protective reflex and it is not primitive (it is with  Even though they are extrinsic, it helps the swallowing
you for the rest of your life) mechanism by providing stability
- Swallow reflex - Principle of recruitment: changing the posture can actually
**If the gag reflex is a problem (due to hyposensitivity) but the change the posture of the vocal being at the midline; gravity
swallow reflex is functional = NOT A PROBLEM also pulls it down
**If the gag reflex is a problem and the swallow reflex is a problem =  Spasticity: that is why stretching is a good thing for these
problem with CN 9 patients; also prior to feeding
- Taste of the posterior 1/3 of the tongue  Basic stretch: North South East West: maximum range of
- *sensation of the pharynx – when the food gets stuck: lump of motion, add 10% pressure; have to make sure that the
food above the palate, soft palate, kanin sa PPW torso is stable  SW, NW, SE, NE (“ask the patient to turn
Motor to this side, then ask them to look up, and you stretch the
*Things that we cannot see: shoulder part – have to elongate the muscle”)
-- you can only check this post-swallow by seeing: residue, coughing
or aspiration
--can only be assessed through instrumental means (e.g. FEES, MBS)
- Posterior pharyngeal wall movement
 issues: post-swallow nasal regurgitation
- Pharyngeal constriction/elongation o CN 12: hypoglossal nerve (MOTOR)
 issues: post-swallow coughing, pharyngeal residue, “di nag - All functions of your tongue (e.g. sweep, scrape, cupping,
elevate si something” manipulation, propulsion)
- Velum elevation NOTES:
 issues: nasal regurgitation, food stuck at velum - Primary goal of swallowing/dysphagia assessment:
TRIGGER POINTS OF GAG REFLEX nourishment/nutrition  achieved through volume
- Base of tongue (@ sublingual parotid) o Regardless of what consistency, as long as the patient is
- Faucial pillars (1st or 2nd - actual point) well-nourished then you stick with that.
- Posterior pharyngeal wall o X: “ah kaya na niya mag tubig, ngayon mag mashed potato
**To open the mouth forcefully ka naman.”
Using the cotton applicator… - If you see your patient gets easily tired, then you do OPM
1. Insert into the weak sides of the lips (side area joining the before swallowing  can’t swallow anymore; so if the patient
upper and lower lip) “Achilles’ heel of the lips” gets easily tired and your order is to do a swallowing
2. Reach the molar = automatically opens mouth assessment then you proceed with that (before OPM) with the
3. Reach the faucial pillar – sweep and check bilaterally; keep cranial nerves in mind.
it in the area for 5s (touching or tapping) - In prioritizing, it doesn’t have to be in an ascending order (CN
4. If the cotton applicator cannot go further, you are most 5, 7, 9, 10, 11, 12), it still depends on the needs and
likely at the PPW area background information of your patient
o CN 10: vagus nerve (MIXED) - TASTE:
- Not so far away from 9 (different region lang) o Anterior 2/3: CN 5
- @ laryngeal mechanism/inlet o Posterior 1/3: CN 9 or 10 (?)
Sensory - Gag reflex: protective; swallow reflex: taking/nutritive
- Swallow reflex - In a formal report, separate CN testing for swallowing from
- Cough reflex – sensory reflex the food trials
- General sensation of larynx CONSISTENCY
Level 0
FOOD
Thin water
AMOUNT
**cc/mL/# of
PRESENTATION
Cup/spoon/
MANIFESTATION
Anterior spillage
IMPRESSION
Poor self-
**FEES: before starting the swallowing process, they tap each spoon straw monitoring
Level 2 Corn soup Buccal Post-swallow
structure with the strobe (e.g. vocal folds, arytenoids) and see if they pocketing residue
(valleculae)
can trigger the cough reflex = to know if the larynx is functioning Level 4 Mashed Coughed for 2
potato with mins post-
relatively okay. gravy swallow

Motor *Manifestation: can be observed

*Impression: cannot be observed; inference
- Vocal fold adduction ~ reflection: decreased vocal quality (i.e.
breathy)