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Understanding the Physiology of Impaired Pharyngeal Swallowing Nancy B. Swigert, M.A., CCC-SLP., BCS-S 1 Nancy B. Swigert, M.A.,CCC-SLP BCS-S Disclosures FINANCIAL Nancy B. Swigert received an honorarium for this presentation Some of this information is included in The Source for Dysphagia and Nancy receives royalties on the book NON-FINANCIAL Nothing to disclose 2 Nancy B. Swigert, M.A.,CCC-SLP BCS-S Goals for the presentation: Match cranial nerve to specific pharyngeal movements Describe relationship between specific muscles and pharyngeal movements. Explain specific exercises for improving pharyngeal movements Choose appropriate techniques to treat pharyngeal disorders Discuss evidence for specific techniques 3 Nancy B. Swigert, M.A.,CCC-SLP BCS-S Cranial nerves and muscles 4 Nancy B. Swigert, M.A.,CCC-SLP BCS-S Why is understanding neuro-physiology important? You might select the wrong treatment techniques for the problem A sign/symptom may have more than one possible physiologic cause You might select a treatment technique or method which doesn’t even make sense for the problem (e.g. treating a delay when the problem is reduced laryngeal elevation) 5 Nancy B. Swigert, M.A.,CCC-SLP BCS-S One “symptom” can have more than one cause Sign/symptom Different physiologic causes Functional short term goal Patient has residue in the pyriforms after the swallow Reduced laryngeal elevation Patient will increase laryngeal elevation to reduce the amount of food remaining in the pyriforms which could fall into the airway Reduced anterior Patient will increase movement of hyolaryngeal anterior movement of complex hyolaryngeal complex to reduce the amount of food remaining in the pyriforms which could fall into the airway 6 Nancy B. Swigert, M.A.,CCC-SLP BCS-S Let’s look at muscles and innervations for motor and sensory for: Tongue (we’ll focus on the movements related to pharyngeal phase) Pharynx Hyoid and Larynx Intrinsic larynx We’ll ignore the soft palate due to time constraints 7 Nancy B. Swigert, M.A.,CCC-SLP BCS-S Tongue Maintains seal with the soft palate Squeezes bolus posteriorly Helps initiate the pharyngeal phase 8 Nancy B. Swigert, M.A.,CCC-SLP BCS-S Tongue Muscle Function innervations - Motor Genioglossus Protrusion; press tongue to teeth or alveolar ridge (posterior fibers) CN XII Hypoglossal Retraction (anterior fibers) Styloglossus Draw tongue downward (all fibers) Pulls tongue up and back Palatoglossus Pulls tongue back to make the groove Hyoglossus Retracts or depresses tongue; elevates hyoid 9 innervations –Sensory CN V Trigeminal– anterior 2/3 general VII Facial -anterior 2/3 taste IX CN XII Hypoglossal Glossopharyngeal posterior 1/3 general and taste CN X Vagus (pharyngeal branch) X Vagus posterior general CN XII Hypoglossal Nancy B. Swigert, M.A.,CCC-SLP BCS-S IMPAIRED PHYSIOLOGY OF TONGUE – IMPACT ON SWALLOW What physiologic problem might you observe if impairments in tongue muscles Back of tongue to soft palate does not seal to keep bolus in mouth What symptoms might it cause What technique might you try? Do we have evidence? Premature loss of bolus over back of tongue. Can result in penetration or aspiration Hard k, g Base of tongue fails to pull back Residue in valleculae towards pharyngeal wall adequately Tongue retraction Effort swallow Pretend to gargle Pretend to yawn Increased stage transition Penetration duration (is this perhaps a Aspiration before the swallow sensory deficit in the back of the tongue? OR sensory deficit in the pharynx?) Sensory stim (cold, sour) Three second prep Super-supraglottic Mendelsohn We’ll discuss these mostly with the pharynx though this is a bit of an artificial separation 10 Nancy B. Swigert, M.A.,CCC-SLP BCS-S Efficacy: Three techniques on Maximum Posterior Movement of Tongue Pull-back (tongue retraction): “Pull the back of your tongue to the back of your mouth and hold for a second” Yawn: “Pull your tongue back during a yawn and hold for a second” Gargle: “Pull your tongue back during a gargle and hold for a second” (Subjects were consecutively referred patients) (Veis, et al 2000) 11 Nancy B. Swigert, M.A.,CCC-SLP BCS-S Efficacy: Three techniques on Maximum Posterior Movement of Tongue Base Gargle task most successful in eliciting more tongue base retraction for the group of subjects (although not in every subject) Interesting finding: Number of repeat swallows on each bolus correlated significantly with approximate % of residue in valleculae 12 Should we pay more attention to repeat swallows on clinical exam? Nancy B. Swigert, M.A.,CCC-SLP BCS-S Effortful Swallow Multiple studies, done mostly with normals Results in effects in tongue pressures Also found changes in pharynx and PES Huckabee and Steele (2006, 2007) And changes in esophageal pressures Huckabee and Steele (2006, 2007) Lever et al 2007 Here are a few examples 13 Nancy B. Swigert, M.A.,CCC-SLP BCS-S Effortful swallow Instructions emphasized increased tongue to palate pressure “push hard with your tongue” Resulted in increased sEMG amplitudes, tonguepalate pressures and pharyngeal pressures Effortful swallow may be helpful in clearing the pharynx in some patients 14 Huckabee and Steele (2006, 2007) Nancy B. Swigert, M.A.,CCC-SLP BCS-S Effortful swallow possible impact on timing Compared timing of pharyngeal and PES pressure onsets across effortful and normal swallows Delayed onset of effortful swallows (defined by delayed increase in pharyngeal pressure or relaxation of PES) And overall increased duration of the swallows So.. Is effortful swallow contraindicated in patients with increased stage transition duration (i.e. delayed swallow)? 15 Hiss and Huckabee 2005 Nancy B. Swigert, M.A.,CCC-SLP BCS-S Effortful swallow in patients One study(6 stroke; 2 H&N) found no impact on: Frequency of penetration or aspiration Amount of pharyngeal residue Did reduce depth of penetration Bulow, Olsson & Ekberg 2001 A different study (3 H&N CA patients) Increased swallow pressure (base of tongue to posterior pharyngeal wall) Increased length of time base of tongue was in contact with pharyngeal wall 16 Lazarus, Logemann, Song et al 2002 Nancy B. Swigert, M.A.,CCC-SLP BCS-S Effects of sour on tongue movements 16 healthy adults Tongue movement data for tongue body and dorsum Water + four tastes used: Water, high intensity sour (2.7% citric acid), moderate intensity sour, moderate sweet, sweet-sour High intensity sour stimulus elicited significantly larger amplitude and higher peak velocity forward and backward tongue body movements than other stimuli Suggests Trigeminal irritation may be required to influence bolus transmit times during swallowing 17 Steele, Pelletier & van Lieshout (2007) Nancy B. Swigert, M.A.,CCC-SLP BCS-S Pharynx Muscles of pharynx surround the: Nasopharynx Oropharynx Laryngopharynx They squeeze the bolus into the esophagus 18 Nancy B. Swigert, M.A.,CCC-SLP BCS-S Pharynx Muscle innervations- Motor innervations – Sensory Superior and middle Contract on bolus to squeeze constrictors it down Lowest portion superior constrictor = glossopharyngeus Inferior constrictor Includes thryopharyngeus (superior) and cricopharyngeus(CP) (Inferior). CP is tonic until it relaxes during swallowing to open so bolus can pass Palatopharyngeus Elevates; contracts on bolus; some laryngeal elevation CN X Vagus (pharyngeal branch) CN IX and CN X (pharyngeal plexus) – general sensory CN X (pharyngeal branch) CN IX and CN X (pharyngeal plexus) – general sensory CN X (pharyngeal branch) CN IX and CN X (pharyngeal plexus) – general sensory Salpingopharyngeus Elevates and laterally draws walls up CN X (pharyngeal branch) CN IX and CN X (pharyngeal plexus) – general sensory Stylopharyngeus CN IX (Glossopharyngeal) CN IX and CN X (pharyngeal plexus) – general sensory 19 Function Elevates pharynx; some laryngeal elevation Nancy B. Swigert, M.A.,CCC-SLP BCS-S Impaired physiology of pharynx – Impact on Swallow What physiologic problem might you observe if impairments in tongue muscles What symptoms might it cause Increased stage transition Penetration duration (is this perhaps a Aspiration before the sensory deficit in the back of the swallow tongue? OR sensory deficit in the pharynx?) Reduced laryngeal Can contribute to elevation/pharyngeal shortening penetration during swallow Can result in residue in pyriforms Reduced constriction of Residue in pharynx, pharyngeal walls pyriforms 20 What technique might you try? Do we have evidence? Sensory stim (cold, sour) Three second prep Super-supraglottic * *For timing – we’ll discuss with larynx Mendelsohn * ** For timing – we’ll discuss with hyolaryngeal elevation Pitch glide (falsetto) Mendelsohn* We’ll discuss with hyolaryngeal elevation Tongue hold Effortful swallow We talked about this with the tongue. More evidence that tongue/pharynx is artificial Nancy B. Swigert, M.A.,CCC-SLP BCS-S separation Efficacy of Mechanical, Cold, Gustatory and Combined Stimulation Study broke the components down Normal healthy adults Only when all three components were presented was there statistically quicker average activity compared to no stimulation Used a different methodology: slowly introduced liquid bolus until patient felt capable of swallowing Supports explanation of temporary facilitative effect of this stimulus combination on swallow-specific activity Raised more questions than it answered Sciortino, et al 2003 21 Nancy B. Swigert, M.A.,CCC-SLP BCS-S Efficacy: Gustatory (Sour) 11 SNF residents 10 aspirated water (1 penetrator) Citric acid (2.7%) improved swallowing safety compared to water Eliminated aspiration in 8/10 22 Pelletier 2002 Nancy B. Swigert, M.A.,CCC-SLP BCS-S Efficacy: Gustatory (Sour) Taste stimuli increased the # of spontaneous swallows observed within 1 minute after initial swallow compared to water Gustatory stimuli might facilitate swallowing in some patients with neurogenic dysphagia Best response in patients without dementia 23 Nancy B. Swigert, M.A.,CCC-SLP BCS-S Sour bolus 6 healthy participants High Resolution Manometry, intramuscular EMG and surface EMG Magnitude and duration of swallow-related intrapharyngeal pressure and muscle activity increased with the lemon bolus Frequency of spontaneous swallows increased following ingestion of sour bolus Also had greater difficulty suppressing the swallow compared to water swallow 24 Hammer et al 2012 Nancy B. Swigert, M.A.,CCC-SLP BCS-S Lemon glycerin swabs When used for oral hygiene, considered ineffective Lemon reduces oral pH to 2-4 (below the normal 6-7) Acid conditions can irritate the mouth, cause pain and decalcify teeth and increase risk of dental caries Glycerin dehydrates the oral tissues 25 Trenter-Roth 1986 Nancy B. Swigert, M.A.,CCC-SLP BCS-S Effortful Pitch Glide (EPG) aka Falsetto + Pharyngeal Squeeze 11 healthy young taught the maneuver No statistical difference b/t EPG and swallowing for these kinematic measures: Performed it and repeated swallows during dynamic MRI Anterior hyoid, laryngeal elevation, pharyngeal shortening, lateral pharyngeal wall approximation Hyolaryngeal approximation is greater in EPG than swallowing Superior hyoid movement greater in swallowing than EPG…. 26 Miloro et al 2012 Nancy B. Swigert, M.A.,CCC-SLP BCS-S Effortful Pitch Glide (EPG) aka Falsetto + Pharyngeal Squeeze The EPF recruits several muscle groups also used in swallowing May be beneficial exercise to strengthen hyolaryngeal approximation, anterior hyoid movement, laryngeal elevation, pharyngeal shortening and lateral pharyngeal wall approximation 27 Nancy B. Swigert, M.A.,CCC-SLP BCS-S Efficacy: tongue hold maneuver effect on pharyngeal wall (Masako) CA patients with tongue resection Noted increased anterior bulging of PPW 3 months after surgery More bulging with greater tongue resection Suggested PPW could compensate for tongue base not retracting 28 Fujiu, Logemann & Pauloski 1995 Nancy B. Swigert, M.A.,CCC-SLP BCS-S Efficacy: Tongue hold (Masako) 10 normal adults Swallows of 3 ml barium without and with tongue hold “Protrude tongue maximally but comfortably” Increased PPW bulging at mid and inferior levels of second cervical vertebra on the swallows with tongue hold See next slide for example 29 Fujiu & Logemann, 1996 Nancy B. Swigert, M.A.,CCC-SLP BCS-S Tongue hold (Masako) Do NOT use with food The move impairs some of the natural movements of swallowing (inhibits tongue base retraction) 30 Three negative findings: Increased pharyngeal residue, particularly in valleculae Shortened duration of airway closure Increased pharyngeal delay time in triggering the pharyngeal swallow Nancy B. Swigert, M.A.,CCC-SLP BCS-S More evidence that tongue hold is rehabilitative only 20 healthy participants Tongue hold swallows created significantly lower pressures in upper pharynx than noneffortful saliva swallows The increased anterior bulge cannot compensate for decreased pressure generation at level of upper pharynx This might impede bolus flow through the pharynx 31 Doeltgen et al 2007 Nancy B. Swigert, M.A.,CCC-SLP BCS-S Hyolaryngeal complex Hyoid bone is attached to thyroid cartilage below and tongue above Can be pulled in many different directions Supra-hyoid muscles Infra-hyoid muscles Moves up and forward as larynx elevates 32 Protects the airway Pulls open the PES Nancy B. Swigert, M.A.,CCC-SLP BCS-S Hyolaryngeal complex (Hyoid and Larynx) Muscle Mylohyoid Function CN innervations-motor Upward movement of hyoid Upward and forward of hyoid Jaw opener Moves hyoid upward Posterior, upward movement hyoid Posterior, upward movement hyoid Upward hyoid CN V Trigeminal (mylohyoid branch) Cervical plexus C1 Cervical plexus C1 Sternothyroid Moves hyoid and larynx together Pulls larynx down Sternohyoid Pulls hyoid down Ansa cervicalis Omohyoid Pulls hyoid down Ansa cervicalis Geniohyoid Anterior belly digastrics Posterior belly digastrics Stylohyoid Hyoglossus Thyrohyoid 33 CN V CN VII (Facial) CN VII CN XII Hypoglossal Ansa cervicalis Nancy B. Swigert, M.A.,CCC-SLP BCS-S Sensory Cervical spinal, cervical plexus Cervical spinal, cervical plexus Cervical spinal, cervical plexus Cervical spinal, cervical plexus Cervical spinal, cervical plexus Cervical spinal, cervical plexus Cervical spinal, cervical plexus Cervical spinal, cervical plexus Cervical spinal, cervical plexus Cervical spinal, cervical plexus Impaired physiology of hyolaryngeal complex – Impact on Swallow What physiologic problem might you observe if impairments in tongue muscles What symptoms might it cause What technique might you try? Do we have evidence? Reduced anterior and superior movement of hyolaryngeal complex Decreased PES opening Residue in pyriforms Epiglottis does not fully invert, allowing penetration Reduced closure at entrance to airway 34 Head Lift EMST Jaw Opening Mendelsohn Effortful *Discussed with tongue- specifics here on effects of hyoid m’ment Super-supraglottic swallow *Will discuss with larynx Allows penetration into vestibule May allow aspiration during the swallow Nancy B. Swigert, M.A.,CCC-SLP BCS-S Efficacy of specific treatment technique 14 healthy elderly and 14 healthy young Head Lift in healthy elderly Increase in: magnitude of anterior excursion of the larynx maximum A-P diameter cross-sectional area of UES decrease in hypopharyngeal intrabolus pressure (decrease in pharyngeal outflow resistance) Strengthens suprahyoid muscles 35 Shaker et al 1997 Nancy B. Swigert, M.A.,CCC-SLP BCS-S Studies with head lift – interesting finding AP deglutitive UES opening and hyoid bone and thyroid cartilage anterior excursion were noted to be reduced in the elderly Reduced excursion is associated with higher intrabolus pressure Suggests higher pharyngeal resistance 36 Kern et al 1999 Nancy B. Swigert, M.A.,CCC-SLP BCS-S Efficacy: Head lift 27 patients (hemispheric CVA, brainstem CVA, pharyngeal radiation) Six weeks of exercise vs. sham Improvement in: UES opening Anterior laryngeal excursion Post-deglutitive aspiration resolved Returned to PO 37 Shaker et al 2002 Nancy B. Swigert, M.A.,CCC-SLP BCS-S Efficacy: Head lift (patients) 11 patients with UES dysfunction Compared traditional therapy to head lift In addition to strengthening suprahyoid muscles… Augments thyrohyoid muscle shortening 38 Mepani et al 2009 Nancy B. Swigert, M.A.,CCC-SLP BCS-S Shaker compared to traditional Pre and post MBS Traditional: Super-supraglottic; Mendelsohn; Tongue base; yawning; gargle; tongue pull back 39 Logemann et al 1999 Nancy B. Swigert, M.A.,CCC-SLP BCS-S Shaker vs. traditional Shaker: reduced post swallow aspiration to greater degree than traditional Traditional: superior hyoid and laryngeal better (uses greater muscle effort than Shaker) Both: significant increase in width of UES opening on paste Aspiration after: Shaker Reduced range of movement in structures of pharynx: traditional therapy 40 Nancy B. Swigert, M.A.,CCC-SLP BCS-S EMST The EMST device is a calibrated instrument consisting of a mouthpiece with a one-way springloaded valve and it is referred to as an expiratory pressure threshold trainer. The valve blocks airflow produced by the user until a sufficient “threshold” pressure is produced to overcome the force. 41 (Baker et al., 2005), Nancy B. Swigert, M.A.,CCC-SLP BCS-S SEMG of submental muscles with EMST Patterns of activation in the submental muscles while training on EMST had longer duration of activation with higher amplitude compared to swallowing Increases motor unit recruitment 42 Wheeler, Chiara & Sapienza 2007 Nancy B. Swigert, M.A.,CCC-SLP BCS-S EMST compared to other techniques 25 healthy male subjects Compared normal swallow, effortful swallow, Mendelsohn and EMST Videofluorographic measurements and SEMG The target threshold was defined as 75% of each participant’s MEP. 43 Wheeler-Hegland, et al 2008 Nancy B. Swigert, M.A.,CCC-SLP BCS-S EMST Compared to normal swallow, Mendelsohn and Effortful swallow, there was less hyoid displacement with EMST Speaks to specificity of the task EMST achieved higher maximum and average submental sEMG activity versus normal swallowing. 44 Nancy B. Swigert, M.A.,CCC-SLP BCS-S EMST With the Mendelsohn maneuver and effortful swallow, the load imposed was volitional. That is, the submental muscle activity found to increase on sEMG resulted from the intention of the participant to “squeeze” those muscles, or to “swallow hard.” Conversely, the load imposed by EMST results from an externally imposed threshold that must be overcome in order to break the spring-loaded valve and allow air to flow through the device. 45 Nancy B. Swigert, M.A.,CCC-SLP BCS-S EMST EMST has potential to induce strength gains in the submental muscles secondary to the externally imposed load. Expiratory muscle strength training (EMST) increases motor unit recruitment of the submental muscle complex. 46 Nancy B. Swigert, M.A.,CCC-SLP BCS-S Jaw Opening Premise: Suprahyoid muscles used not only for elevating larynx, but for opening jaw 11 Healthy elderly Open jaw to maximum and hold for 10 s. 2x day for 4 weeks Concluded that jaw opening exercise significantly increased suprahyoid muscle strength 47 Wada et al 2012 Nancy B. Swigert, M.A.,CCC-SLP BCS-S Efficacy- particular treatment method Mendelsohn maneuver 48 Use of maneuver increased the duration of the anteriorsuperior excursion of the larynx and hyoid and delayed sphincter closure by maintaining traction on anterior sphincter wall (Kahrilas, et al 1991) Improved extent of UES opening and bolus head velocity (Logemann & Kahrilas, 1990) Nancy B. Swigert, M.A.,CCC-SLP BCS-S Efficacy of specific method Mendelsohn with SEMG Changes in swallow physiology Improved coordination, longer duration, and increased effort The sustained oral and pharyngeal postures inhibited some of the transient movements noted as part of incomplete swallow (e.g. lingual pumping, repetitive pharyngeal contraction) 49 (Crary, 1995) Nancy B. Swigert, M.A.,CCC-SLP BCS-S Mendelsohn with sEMG SEMG biofeedback 50 Chronic dysphagia secondary to brainstem stroke Physiologic change in swallowing as measured by severity ratings on VFSS 8 of 10 able to return to full oral intake with elimination of G-tube Average of 5.3 months Huckabee & Cannito, 1999 Bryant & Bryant, 1991 Crary, 1995 Nancy B. Swigert, M.A.,CCC-SLP BCS-S Efficacy of specific treatment techniques SEMG biofeedback Patients after stroke and head/neck cancer Patients had reduced hyolaryngeal elevation, reduced pharyngoesophageal segment opening & residue Daily 50 minute sessions and portable biofeedback to practice at home Average # sessions 12/stroke and 9/head & neck 87% of patients increased functional oral intake by at least one scale score on FOIS Stroke had more functional gains 51 Crary, et al 2004 Nancy B. Swigert, M.A.,CCC-SLP BCS-S Mendelsohn and Swallowing Duration Pilot study: Does intensive intervention using Mendelsohn maneuver result in lasting changes in swallowing physiology Hyoid bone excursion, UES opening, bolus flow characteristics (i.e. pharyngeal residue, laryngeal penetration, aspiration) 18 patients post stroke Prospective crossover design 2 weeks treatment; 2 weeks no treatment…. 52 McCullough et al 2012 Nancy B. Swigert, M.A.,CCC-SLP BCS-S Mendesohn Treatment: two sessions per day of Mendelsohn with sEMG biofeedback Changes measured on VFSS Significant changes in: Duration of superior and anterior hyoid movement after two weeks of treatment UES opening increased (but not significantly) No significant differences in penetration, aspiration, residue, dysphagia severity ratings 53 Nancy B. Swigert, M.A.,CCC-SLP BCS-S Effortful and hyoid movement Effortful swallow increased hyoid elevation before swallowing, but decreased overall movement during swallowing in healthy (Bulow et al 1999) Huckabee and Winkleman wondered if it would also result in decreased anterior movement of the hyoid….. 54 Huckabee & Winkelman 2012 Nancy B. Swigert, M.A.,CCC-SLP BCS-S Effortful and hyoid movement 24 healthy adults Non-effortful swallow Effortful swallow Tongue hold Measured with ultrasound…. Anterior hyoid movement relatively stable across swallowing conditions 55 Nancy B. Swigert, M.A.,CCC-SLP BCS-S Larynx Protects airway by closing and moving up and forward See previous slides on hyolaryngeal complex As larynx lifts, epiglottis flips down to send bolus on either side of larynx True and false folds adduct to close the glottis 56 Nancy B. Swigert, M.A.,CCC-SLP BCS-S Larynx Muscle Function CN innervationsmotor Thyroarytenoid Includes vocalis Adductor, tensor or relaxer Cricothyroid (pars oblique and recta) Lengthen and tense vf, C N X(external alters distance b/t laryngeal) thyroid and arytenoids Posterior cricoarytenoids Abduct and internally rotate arytenoids CN X (left recurrent laryngeal) Lateral cricoarytenoids Adduct and internally rotate arytenoids CN X (left recurrent laryngeal) Transverse arytenoids Adduct arytenoids CN X (left recurrent laryngeal) Oblique arytenoids Adducts arytenoids CN X (left recurrent laryngeal) 57 CN X (left recurrent laryngeal) Nancy B. Swigert, M.A.,CCC-SLP BCS-S Sensory CN X(internal laryngeal) mucous membrane at valleculae, epiglottis, aryepiglottic folds and most of larynx CN X (recurrent laryngeal) – mucous membrance below VF CN X special sensory to epiglottis Impaired physiology of larynx – Impact on Swallow What physiologic problem might you observe if impairments in tongue muscles What symptoms might it cause What technique might you try? Do we have evidence? Reduced closure at entrance to airway Allows penetration into vestibule May allow aspiration during the swallow Allows aspiration of material Reduced closure of airway at glottis 58 Super-supraglottic swallow Supra-glottic Valsalva Nancy B. Swigert, M.A.,CCC-SLP BCS-S Efficacy studies - particular approach Laryngeal closure: Valsalva, Supraglottic and Supersupraglottic 59 Some subjects close glottis during breath hold, and others did not (Mendelsohn & Martin, 1993) Arytenoid approximation and true vocal fold closure were produced consistently by the majority of subjects on all breath hold maneuvers, but false vocal fold approximation and anterior arytenoid tilting accomplished by majority of subjects only during effortful breath-hold conditions (Martin, et al 1993) Nancy B. Swigert, M.A.,CCC-SLP BCS-S Efficacy studies - particular approach Laryngeal closure: Valsalva, Supraglottic and Supersupraglottic Normal subjects produced earlier cricopharyngeal opening, prolonged pharyngeal swallow, some degree of laryngeal valving before swallow, and change in extent of vertical laryngeal position before the swallow Changes more successful and maintained longer with SSG than SG Breath-holding maneuvers alter not only airway conditions before swallow but also temporal relationships and biomechanical events during (Ohmae, et al 1996) 60 Nancy B. Swigert, M.A.,CCC-SLP BCS-S How you give Breath Hold instructions matters Brady 2004 Easy Breath Hold (supra-glottic) “Hold your breath while I count out loud to 5" Inhale/Easy Breath Hold “Take a deep breath, then hold your breath while I count out loud to 5" Hard Breath Hold (super-supraglottic) “Hold your breath very tightly, bearing down, while I count out loud to 5" 61 Nancy B. Swigert, M.A.,CCC-SLP BCS-S Efficacy studies: Breath-hold Effortful breath hold instruction most effective method to obtain TVC closure Inhale/easy breath hold least effective Easy breath hold better than inhale/easy Instructions for supraglottic to take a deep breath and then hold may be counterproductive 62 (Brady, 2004) Nancy B. Swigert, M.A.,CCC-SLP BCS-S Caution: Supraglottic and supersupraglottic Prolonged voluntary closure of glottis may create Valsalva maneuver, which has been associated with sudden cardiac death and cardiac arrhythmias Subjects: recent stroke, dysphagia and/or CAD 86% demonstrated abnormal cardiac findings(supraventricular tachycardia, premature atrial and ventricular contractions) SG and SSG contraindicated for patients with history of stroke or CAD (Chaudhuri et al 2002) 63 Nancy B. Swigert, M.A.,CCC-SLP BCS-S Closure at level of larynx Rarely is it just failure of true and/or false vocal folds to close The coordinated movements of closure of the larynx are intricately related to the elevation and forward movement of the larynx Some of the techniques for closure also address timing (e.g. supraglottic) and elevation (Mendelsohn) 64 Nancy B. Swigert, M.A.,CCC-SLP BCS-S Information on specific exercises National Foundation on Swallowing Disorders www.swallowingdisorderfoundation.com has patient handout and videos of some exercises 65 Nancy B. Swigert, M.A.,CCC-SLP BCS-S