Download 2. Normal Physiology Rev HO.pptx

FEES®: Another Tool for Dysphagia Assessment
and Intervention
Idaho State University – Pocatello
March 4, 2016
Presenter: John R. Ashford, Ph.D. CCC-SLP
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1. Transport food from mouth to stomach
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2. Protect the airway
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Normal physiology –
◦  Safe
–  Low risk for aspiration
–  Supports nutrition/hydration
◦  Efficient
–  Task
(a)completion
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with
(b)minimum
effort
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Oral Phase
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Pharyngeal Phase
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Esophageal Phase
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Cortex
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Brainstem
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Mouth, pharynx, larynx
◦  Essential role in initiation of the swallow
◦  Motor fibers from primary motor cortex to brainstem
◦  Cranial nerves (Pons & Medulla)
◦  Motor fibers from cranial nerves & ansa cervicalis
◦  Sensory fibers go to the brainstem
–  Modify motor output
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Brainstem
◦  Sensory fibers go to the Cortex
–  Modify motor output
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Cranial Nerve
Location
Function
V
Pons
Jaw movement; sensation face,
mouth, & jaw; hyoid elevation
Pons
Face movement; hyoid elevation;
salivation; taste
- Trigeminal
VII - Facial*
IX - Glossopharyngeal* Medulla
Pharynx movement; pharynx &
tongue sensation
X - Vagus*
Medulla
Pharynx, palate, & Larynx movement
XII - Hypoglossal*
Medulla
Tongue movement
Ansa Cervicalis (C1-C2) Spinal Cord Larynx/hyoid elevating/descending
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I. Tongue Propulsion – Oral Phase
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II. Hyolaryngeal Elevation – Pharyngeal Phase
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◦  Posterior pharyngeal wall contact with tongue base
◦  Superior & anterior movement of hyoid/larynx
◦  Pharyngeal shortening/constriction
III. Upper Esophageal Opening- Cervical
Esophagus
◦  Relaxation of UES
◦  Directly associated with hyolaryngeal elevation
Langmore, 2001
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Oral Preparatory Phase
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Bolus Propulsion Phase
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◦  Initial Transport Subphase
◦  Bolus Reduction Subphase (Mastication &
Bolus Formation)
◦  Loading Subphase
◦  Bolus Propulsion Subphase
◦  Clearance Subphase
To quickly close off upper respiratory system
from lower respiratory system
To move food bolus quickly through pharynx
preventing food from entering airway
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Normal Sequence of Structural Movements
During Swallow
0 sec.
Langmore, 2001
Arytenoids medial, then forward
Arytenoids contact medially
Nasopharyngeal closure
Base of Tongue Movement
Hyoid Elevation/Epiglottic Inversion
UES Relaxation
Pharyngeal shortening/squeezing
Whiteout (pharynx closes)
TVF actively adduct
Arytenoids touch epiglottis
UES Opens
UES Closes
View Returns (pharynx reopens)
Epiglottis returns to rest
1.10 sec.
1.368 sec
1.424 sec.
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1. Swallow Onset
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2. Hyolaryngeal Elevation
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3. Pharyngeal Shortening
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4. Lateral Pharyngeal Wall Medialization
◦  Aka “Pharyngeal Squeezing”
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5. UES Opening
Langmore, 2001
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Arytenoid movement initiation to midline
(VF adduction)
◦  THE first action of the swallow event
◦  Can only be seen with endoscopy
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Arytenoids close approximation
◦  0.341 seconds BEFORE hyoid/larynx elevation begins.
◦  Arytenoids initiate movement before VF contraction
onset (0.63s)
◦  Fluoroscopically, swallow initiation seen as hyoid bone/
laryngeal elevation
Langmore, 2001
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Endoscopically…
◦  larynx moves upward toward the end of the
endoscope
◦  onset of epiglottic movement to invert signals onset
of hyolaryngeal elevation
◦  “whiteout” indicates timely epiglottic inversion
Langmore, 2001
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Occurs simultaneously with onset of hyolaryngeal
elevation
Lateral pharyngeal walls medialize
◦  Sequential contraction of pharyngeal constrictor
muscles: superior to medial to inferior constrictors
◦  Pharynx lumen shortens & narrows laterally to squeeze
the tail of the bolus
–  Large boli require tongue propulsion to move through
pharynx
–  Small boli require pharyngeal constrictors to clear through
pharynx
Langmore, 2001
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Pharyngeal Peristalsis
ì
ì
ì
ì
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Swallow Continues
“White-out”
Relaxation
ë
Relaxation
ì
ì
ì
ì
Relaxation
ì
ì
ì
Pharyngeal
Peristalsis or
“Squeeze’
ì
ì
ì
Swallow Onset
Pre-swallow
ì
Post Swallow - Rest
ì
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Three Primary Factors
◦  Relaxation of UES (Cricopharyngeus M.)
◦  Indirect traction via hyoid & larynx from suprahyoid
muscles during hyolaryngeal elevation
◦  Pressure from descending bolus
Massey 2006
}  Respiration
}  All
resumes
structures return to resting position
}  Normal
“clean-up” functions
◦  Response to sensory input
–  Secondary swallow to clear trace residue
–  Throat-clearing to remove secretions
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Yummy
Donut
Hyoid
Hyoid
Pharynx
Vomiting
PPW
Larynx
UES
At Rest
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PPW
UES
Max. Elevation/Expansion
During Swallow
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