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©2010
WELCOME
Getting Started
Multiple LessonsMultiple Lessons
Interactive ExercisesInteractive Exercises
ReferencesReferences
Related ResourcesRelated Resources
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This selfThis self--study isstudy is offered foroffered for X.XX.X CEUsCEUs(Intermediate(Intermediate level,level, ProfessionalProfessional areaarea).).
ASHA-Approved CE Provider
Clinical Swallowing Examination ofAdults with Dysphagia:Anatomy And Physiology Series
4
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
16
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
19
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
25
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
33
C.N. X
Velum - Pharynx
Head Rotation
Is patient able to performExpose lesions
34
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)
36
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
40
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
41
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
43
Thyrohyoid Sternohyoid
Thyroid Cartilage
Arytenoid CartilageInferior Constrictor
44
conuselasticus
Arytenoid Thyroid
Cricoid
Vocal Fold
45
SECTION 4:
Check YourKnowledge
46
47
48
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
49
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
50
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
Parrish SwannInstructional Technology Manager
Matthew CutterManaging Editor
© 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