2. Normal Swallowing
• Complicated and intricate phenomenon
• Mixture of voluntary and reflex, or automatic, actions
• Total number of swallows per day is about 600:
– 200 while eating and drinking
– 350 while awake without food
– 50 while sleeping
'empty' swallows primarily to the clearance of saliva from
the mouth
3. Anatomy of swallowing
• 55 muscles of the oropharyngeal, laryngeal, and
esophageal regions
• Five cranial nerves – V, VII, IX, X, XII
• Two cervical nerve roots
• Centers within the central nervous system
4. Anatomy of swallowing
A. Oral cavity
– Separated from the
pharynx by the
faucial pillars
B. Pharynx
C. Esophagus
5. Anatomy of swallowing
• Laryngeal aditus (upper end
of the larynx) opens into the
lower portion of the pharynx
• Epiglottis
– Originates in the larynx
and is angled upward and
backward
– Attached to the hyoid bone
anteriorly
6. Anatomy of swallowing
Hyoid bone
• Mechanical connections to
the cranial base, mandible,
sternum, and thyroid cartilage
via the suprahyoid and
infrahyoid muscles
• Important role in controlling
the movements of the jaw and
tongue.
7. Anatomy of swallowing
Valleculae
• Space between the
pharyngeal surface of the
tongue and the epiglottis
Pyriform recesses
• Two spaces in the pharynx
lateral to the larynx
8. Anatomy of swallowing
Constrictor muscles
• Flattens and contracts the
pharynx in swallowing
Cricopharyngeus muscle
•Closes the UES by compressing it against the back of the
cricoid cartilage
9. Innervation of major muscles related to swallowing
Cranial nerves
Muscles
Masticatory muscles
Mylohyoid
Trigeminal Nerve (V)
Tensor veli palatini
Anterior belly of digastrics
Facial muscle
Facial nerve (VII)
Stylohyoid
Posterior belly of digastrics
10. Innervation of major muscles related to swallowing
Cranial nerves
Muscles
Glossopharyngeal Nerve (IX) Stylopharyngeus
Levator veli palatine
Palatopharyngeous
Salpingopharyngeous
Vagus nerve (X)
Intrinsic laryngeal muscles
Cricopharyngeus
Pharyngeal constrictors
11. Innervation of major muscles related to swallowing
Cranial nerves
Muscles
Intrinsic tongue muscles
Hyoglossus
Geniohyoid
Hypoglossal nerve (XII)
Genioglossus
Styloglossus
Thyrohyoid
12. Sensory afferents
I. Trigeminal
– Teeth and gums, palate and roof of the pharynx
II. Glossopharyngeal
– Posterior third of the tongue, pharynx, area of the
tonsil
III. Vagus
– Pharynx, larynx
13. Brainstem centers
• Central pattern generators – Dorsomedial &
Ventrolateral
• Mainly involves nucleus of the tractus solitarius and
the nucleus ambiguous
• Programs directing the sequential movements of the
various muscles involved
14. Brainstem centers
• Activated by
– Descending pathways from the motor cortex
(cortico bulbar tracts)
– Ascending pathways from sensory structures
within the oropharynx and esophagus
Nucleus of the tractus solitarius receives the descending
and peripheral afferent influences
15. Dorsomedial pattern generator
• Resides in the medial reticular formation of the
rostral medulla and the reticulum adjacent to the
nucleus tractus solitarius
• Initiation and organization of the swallowing
sequence
16. Ventrolateral pattern generator
• Lies near the nucleus ambiguous and its surrounding
reticular formation
• Serves primarily as a connecting pathway to motor
nuclei such as the nucleus ambiguus and the dorsal
motor nucleus of the vagus, which directly control
motor output to the pharyngeal musculature and
proximal esophagus
17. Cortical control to brainstem
structures
Inferior precentral gyrus
• Cortical representations of tongue and face
• Bilaterally symmetrical activation
18. Other cortical areas involved in
swallowing
Supplementary motor area
• Preparation for volitional swallowing
Anterior cingulate cortex
• Monitoring autonomic and vegetative functions.
19. Other cortical areas involved in
swallowing
Anterior insula, particularly on the right
• Activation during volitional swallowing
• Allows gustatory and other intraoral sensations to
modulate swallowing.
• Lesions increase the swallowing threshold and delay
the pharyngeal phase of swallowing
20. Other higher centers in swallowing
Cerebellum
• Esp left-sided activation
• Coordination, timing, and sequencing of swallowing
• controls output for the motor nuclei of cranial nerves
V, VII, and XII
Putamen
• Activated during volitional swallowing
21. Stages of Swallowing
Initiated reflexly when food or liquid stimulates sensory
nerves in the oropharynx
Three distinct stages or phases:
• Oral
Horizontal subsystem
Volitional in character
• Pharyngeal
• Esophageal
Vertical subsystem
Primarily under reflex control
22. ORAL PHASE
• Oral preparatory and oral propulsive stages
• Food bolus is formed and pushed to pharynx
23. Oral preparatory stage
Chewing
• Cyclic movement of the jaw coordinated with the movements
of the tongue, cheek, soft palate and hyoid bone
• Food particles are reduced in size and softened by salivation
until the food consistency is optimal for swallowing
• Movements of the jaw and tongue pump air into the nasal
cavity through the pharynx, delivering the food's aroma to
chemoreceptors in the nose
24. Oral propulsive stage
Shallow midline gutter in tongue to
accommodate bolus
Styloglossi and genioglossi
Emptying of the longitudinal gutter posteriorly
Hyoglossus and some intrinsic lingual muscles
Elevation of anterior and mid tongue, hyoid bone and floor
of the mouth
Mylohyoid, geniohyoid and stylohyoid
Relaxation of the posterior oral seal and a forward movement
of the posterior tongue
Palatoglossi.
Overall effect is sweeps or squeezes the bolus
towards the fauces to pharynx
25. ORAL PHASE
• Transported food accumulates on the pharyngeal
surface of the tongue and in the valleculae
• Duration of bolus aggregation in the oropharynx
ranges from a fraction of a second to about ten
seconds in normal individuals eating solid food
26. PHARYNGEAL PHASE
• Rapid sequential activity, occurring within a second
• Pharynx changes from being an air channel to food
channel
Two crucial biological features:
1. Food passage
2. Airway protection
27. Airway protection
Closing the nasopharynx
• Superior Pharyngeal Constrictor + Palatopharyngeal
forming a variable, ridge-like, structure (Passavant's
Ridge) to which the soft palate is elevated.
• Occurs at same time the bolus head comes into the
pharynx
• Prevents bolus regurgitation into the nasal cavity
28. Airway protection
Closure at lower level
a) Vocal folds close to seal the glottis
b) hyoid bone and larynx are pulled upward and
forward
– Tucks the larynx under the base of the tongue
Suprahyoid and Thyrohyoid
c) Epiglottis tilts backward to seal the laryngeal
vestibule
29. Food passage
• Sequential contraction of three pharyngeal constrictor
muscles
• Driving force which propels the bolus towards the
oesophagus
31. Relaxation of
UES
3 factors
UES consists of the inferior
pharyngeal constrictor,
cricopharyngeous and most
proximal part of the esophagus
1) Relaxation of the cricopharyngeous muscle
– Precedes arrival of the bolus
2) Contraction of the suprahyoid and thyrohyoid muscles
– Pull the hyo-laryngeal complex forward, opening the
sphincter
– Active opening process
3) Pressure of the descending bolus
32. OESOPHAGEAL PHASE
Once in the oesophagus, the bolus is propelled by
peristaltic contractions down to the lower
oesophageal sphincter, which opens momentarily to
allow the bolus to enter the stomach
33. Synchronization of swallowing with
respiration
• Breathing ceases briefly during swallowing
– Physical closure by elevation of the soft palate and
tilting of the epiglottis
– Neural suppression of respiration in the brainstem
• Respiratory pause continues for 0.5 to 1.5 s
• Expiration immediately follows a swallow, thus
reducing the risk of aspiration
34. Dysphagia
• Impaired swallowing can originate from disturbances
in the mouth, pharynx, or esophagus
• Can involve mechanical, musculoskeletal, or
neurogenic mechanisms
35. Consequences of dysphagia
• Inadequate nutrition
• Dehydration
• Recurrent upper respiratory infections
• Frank aspiration with consequent pneumonia and
even asphyxia
36. Approach to a case of Dysphagia
Good history will accurately identify the
location and cause of dysphagia in 80%
of cases
37. Approach to a case of Dysphagia
• Dysphagia for solid food but
not liquids
Mechanical
obstruction
• Equal dysphagia for both
solids and liquids
Esophageal
dysmotility
38. Mechanical Dysphagia
• Structural abnormalities, both within and adjacent to
the mouth, pharynx, and esophagus
Oral
Pharyngeal
Esophageal
Congenital abnormalities Cervical anterior
Esophageal carcinoma
Intraoral tumors
osteophytes
Esophageal diverticulum
Burns
Diphtheria
Esophageal infection:
Trauma
Thyromegaly
Esophageal stricture
Temporomandibular joint Retropharyngeal abscess
Esophageal webs or rings
dysfunction
Retropharyngeal tumor
GERD
Zenker diverticulum
Thoracic aortic aneurysm
40. Oropharyngeal source for the
dysphagia
• Difficulty initiating swallowing
• Need for repeated attempts to succeed at swallowing
• Presence of nasal regurgitation during swallowing
• Coughing or choking immediately after attempted
swallowing
42. Oral stage dysfunction
Clinical examination of CN V, VII, XII
Weakness of the buccal or labial muscles
• Food trapped in the buccal or labial sulci (between
the lower teeth and the cheeks or gums, respectively)
43. Oral stage dysfunction
Tongue dysfunction
• impaired mastication and bolus formation, and bolus
transport
Sensory impairments
• excessive retention of food in the oral cavity after
eating and swallowing
45. Cranial nerve IX
• Examine pain and touch sensation of the pharynx,
tonsilar region and soft palate
• Only muscle with innervation purely from CN IX is
stylopharyngeus
• Only deficit detectable is a slight lowering of the
palatal arch at rest on the involved side.
• Gag reflex
46. VAGUS NERVE
• With a contribution from the bulbar portion of CN
XI, supplies all the striated muscles of the soft palate,
pharynx, and larynx except for the stylopharyngeus
(CN IX) and tensor veli palatini (CN V)
• Sensory from the pharynx, larynx
47. CN X lesions
• Speech may have a nasal quality
• Dysphagia more marked for liquids than solids with a
tendency to nasal regurgitation
• Droop of the palate and flattening of the palatal arch
– Preserved tensor veli palatini (CN V) may prevent
marked drooping of the palate
• Gag reflex lost on the involved side
48. CN X lesions
Vernet's rideau phenomenon
• Due to unilateral weakness of the superior pharyngeal
constrictor
• “curtain movement”, with motion of the pharyngeal
wall toward the nonparalyzed side on testing the gag
reflex or at the beginning of phonation
49. Gag reflex
• Elicited by touching the lateral oropharynx in the
region of the anterior faucial pillar (pharyngeal
reflex)
• Or by touching one side of the soft palate or uvula
(palatal reflex)
Pharyngeal reflex is the more active of the two
50. Gag reflex
Three motor components
1) Elevation of the soft palate to seal off the
nasopharynx
2) Closure of the glottis to protect the airway
3) Constriction of the pharynx to prevent entry of the
substance.
51. Gag reflex
Afferent limb - CN IX
Reflex center - medulla
Efferent limb - CNs IX and X
• Constriction and elevation of the oropharynx
• Midline raphe of the palate and the uvula elevate
• Pharyngeal constrictors contract
52. Gag reflex
• Unilateral weakness
– Raphe will deviate away from the weak side and
toward the normal side
• May be bilaterally absent in some normal individuals
• Unilateral absence signifies a lower motor neuron
lesion
53. Significance of gag reflex
• Poor gag reflex in an awake patient with an acute
deficit may be a predictor of swallowing difficulties
Useful but limited in assessing airway protection
• Patients with an apparently intact gag reflex may still
aspirate
• Absent in ~ 37% of normals - low predictive value in
the assessment of aspiration risk
54. Cervical auscultation
• Assess coordination between respiration and
swallowing
• In the normal situation, swallowing occurs during
exhalation
• Discoordinated swallowing in the midst of inhalation
increases aspiration possibility
55. Standardized 3 oz water swallow test
• Simple bedside evaluation for oropharyngeal
dysphagia.
• Presence of cough on swallowing
– Positive predictive value of 84% with regard to the
presence of aspiration
– Negative predictive value of 78%.
• After the swallow, observe the patient for 1 minute or
more to see if a delayed cough response is present
56. Dysphagia limit
• Normal subjects can swallow a 20-ml bolus of water
in a single attempt
• With dysphagia must divide the bolus into two or
more parts in order to complete the swallow
57. Dysphagia limit
• Individuals are administered stepwise increases in
bolus volume, the volume of fluid at which the
division of the bolus first occurs is labeled the
dysphagia limit
Dysphagia limit of less than 20 ml as abnormal and
indicative of dysphagia
58. Modified barium swallow test
• Swallowing barium impregnated food of differing
consistencies (thin liquid, pudding, cookie)
• Observed via videofluoroscopy
59. Modified barium swallow test
• Oral and pharyngeal function can be characterized
• Presence of aspiration accurately documented
• Response to corrective measures such as positioning
techniques can also be evaluated
• Increasing bolus viscosity typically improves
swallowing function in individuals with neurogenic
dysphagia
60. Modified barium
swallow test
Laryngeal penetration
• passage of the food into the larynx but
above the vocal folds
• sometimes observed in normal
individuals
Aspiration
• passage of material through the vocal
folds
61. Videoendoscopy of the pharynx
• Via the nasal passageway
• Allows direct visualization of the pharyngeal
component of swallowing before and after passage of
the food bolus
• Primary value is to demonstrate the presence of
residual material in the pharynx after a swallow,
indicative of increased risk of aspiration
62. Swallowing Electromyography
• Mechanical upward-downward movement of the
larynx is detected by using a piezoelectric sensor
while submental integrated electromyography (EMG)
activity is recorded during dry and wet swallowing
• EMG activity of the cricopharyngeal muscle also can
be recorded.
63. Swallowing Electromyography
• In muscular disorders, laryngeal elevators are involved,
whereas the cricopharyngeal sphincter is intact
• In pyramidal lesions, discoordination between paretic
laryngeal elevators and the hyperreflexic cricopharyngeal
sphincter is present.
EMG can be used for muscle selection and for performing
injections of botulinum toxin in patients with dysphagia
64. Esophageal dysfunction
• Sensation of food “hanging up” in a retrosternal
location
• Main concern with esophageal dysphagia is to
exclude malignancy
65. Esophageal dysfunction
Malignancy is likely if there is:
• Short duration (< 4 months)
• Disease progression
• Dysphagia more for solids than for liquids
• Weight loss
67. Oculopharyngeal Muscular Dystrophy
• Rare autosomal dominant disorder
• GCG trinucleotide repeat on chromosome 14
• First appearing between ages 40 and 60
• Slowly progressive ptosis, dysphagia, and proximal
limb weakness
• Evolves slowly over many years
68. Oculopharyngeal Muscular Dystrophy
• Dysphagia due to impaired function of the
oropharyngeal musculature
• No specific treatment
• Cricopharyngeal myotomy affords relief in over 80%
• Botulinum toxin injections have been successfully
used
69. Myotonic Dystrophy
• autosomal dominant disorder
• cardiac, ophthalmological, and endocrinological
involvement
• Subjective dysphagia in 37% to 56% of patients
• Objective measures demonstrating disturbances in
swallowing in 70% to 80%
70. Myotonic Dystrophy
• Dysphagia due to
– Abnormal cricopharyngeal muscle activity is
present in 40%
– Impaired esophageal peristalsis
– incomplete relaxation of the UES and esophageal
hypotonia
Both muscle weakness and myotonia play a role in the
development of dysphagia
71. Inflammatory Myopathies
• Dysphagia more frequently is present in
dermatomyositis and when present is more severe
• Indicator of poor prognosis
Dysphagia in inclusion body myositis
• May even be the presenting symptom
• In late stages of the disorder, the frequency exceed
that seen in dermatomyositis and polymyositis
72. Inflammatory Myopathies
Treatment
• May respond to corticosteroids and other
immunosuppressive drugs
Unresponsive to steroids
• IVIG therapy has produced dramatic improvement
Inclusion-body myositis
• Typically responds poorly
• Myotomy is often necessary
73. Mitochondrial Disorders
Dysphagia due to
• Severe abnormalities of pharyngeal and upperesophageal peristalsis
• Cricopharyngeal dysfunction
• Impaired deglutitive coordination
74. Myasthenia Gravis
• In ~ 6% to 30%, bulbar involvement is evident from
the beginning
• with disease progression, most eventually develop
• major precipitant of myasthenic crisis in 56% of
patients
• Bedside speech pathology assessment is not a reliable
predictor of aspiration
75. Myasthenia Gravis
Dysphagia due to
Dysfunction at oral, pharyngeal, or even esophageal
levels
• Oral phase involvement due to fatigue and weakness
of the tongue or masticatory muscles
• Decreased amplitude and prolongation of the
peristaltic wave in esophagus
• Cricopharyngeal sphincter pressure reduced
76. Stroke
• Dysphagia in 45% to 57%
• Aspiration in
– 30% to 55% of stroke patients
– 36% of patients with unilateral cerebral stroke
– 46% with bilateral cerebral stroke
– brainstem strokes - more than 80%
Associated with increased likelihood of severe disability or
death
77. Warning signs of post-stroke
dysphagia
• Drooling
• Excessive tongue movement
• Spitting food out of the mouth
• Poor tongue control
• Pocketing of food in the mouth
• Facial weakness
• Slurred speech
• Coughing or choking when eating
78. Warning signs of post-stroke
dysphagia
• Regurgitation of food through the nose
• Wet or “gurgly” voice after eating
• Hoarse or breathy voice
• Complaints of food sticking in the throat
• Absence or delay of laryngeal elevation
• Prolonged chewing
• Prolonged time to eat or reluctance to eat
• Recurrent pneumonia
79. Dysphagia and site of stroke
Brainstem infarction
• Pharyngeal phase is primarily impaired
Hemispheric strokes
• Delay in initiation of voluntary swallowing
• Bilateral hemispheric damage is more likely to
produce dysphagia
80. Dysphagia and site of stroke
Can also occur in the setting of unilateral damage
Right hemisphere
• More impairment of pharyngeal motility
Left hemisphere
• Greater effect on oral stage function
81. Dysphagia and site of stroke
Subcortical strokes
• higher incidence of dysphagia and aspiration than
those with cortical damage
• delayed initiation of the pharyngeal stage of
swallowing
82. Dysphagia and site of stroke
Foix- Chavany-Marie syndrome (anterior operculum
syndrome)
• Bilateral infarction of the frontoparietal operculum
• inability to perform voluntary movements of the face,
jaw, tongue, and pharynx but fully preserved
involuntary movements of the same muscles
• Impairment of volitional swallowing
83. Tongue deviation & dysphagia
• Classically associated with medullary lesions
damaging the hypoglossal nucleus
• In almost 30% of persons with hemispheric
infarctions
• Dysphagia is present in 43% of affected patients
84. Stepwise assessment of swallowing in
stroke patients
• Modified swallowing assessment on the day of admission
• Clinical swallowing examination performed within 72
hours
• Performance of flexible transnasal swallowing endoscopy
within 5 days
• Appropriate diet and treatment determined after each step
• Significant reduction in the rate of pneumonia and in
antibiotic consumption (ickenstein et al., 2010)
85. Prognosis
• Swallowing often improves spontaneously in the days
and weeks after stroke
• more likely to occur after cortical strokes, compared
with those of brainstem origin
86. Dysphagia in other cerebrovascular
processes
• Carotid artery aneurysms
• Elongation and dilatation of the basilar artery
• Posterior inferior cerebellar artery aneurysm
• Intracranial vertebral artery dissections
• Giant dissecting vertebrobasilar aneurysms
87. Dysphagia in Multiple Sclerosis
• Frequent but often overlooked (24% to 34% )
• Prevalence rises with increasing disability
• Individuals with severe brainstem involvement as part of
their MS are especially likely to experience dysphagia.
Mild disability
• Abnormalities in the oral phase of swallowing
More severe disability
• Additional pharyngeal phase abnormalities develop
88. Dysphagia in Parkinson Disease
• Frequent phenomenon - 30% to 82%
• More likely to swallow during inspiration and also to
inhale post swallow
• Both increase the risk of aspiration
Oral phase
• Difficulty with bolus formation
• Delayed initiation of swallowing
• Repeated tongue pumping, and other abnormalities
89. Dysphagia in Parkinson Disease
Pharyngeal phase
• Pharyngeal dysmotility and impaired relaxation of the
cricopharyngeal muscle
Esophageal phase
• Slowed esophageal transit
• Both segmental and diffuse esophageal spasm
• Ineffective or tertiary contractions, and even aperistalsis
• Lower-esophageal sphincter dysfunction - reflux as well
as dysphagia.
90. Dysphagia in Parkinson Disease
Management
• Inconsistent response to levodopa or dopamine
agonist therapy
• Cricopharyngeal muscle dysfunction cricopharyngeal myotomy and botulinum toxin
injections
• Behavioral swallowing therapy
• PEG tube placement rarely necessary
91. Other Basal Ganglia Disorders
Parkinsonism-plus syndromes- PSP, MSA, CBD,
DLB
• Dysphagia is a frequent problem
• Develops relatively early in the course of the illness
Appearance of dysphagia within 1 year of symptom
onset virtually eliminates PD as a diagnostic
possibility
92. Amyotrophic Lateral Sclerosis
• Dysphagia eventually develops in most individuals
• Presenting feature in approximately 25%
• Sensation of solid food sticking in the esophagus may
provide the initial clue to emerging dysphagia
93. Amyotrophic Lateral Sclerosis
• Impaired function of the lips and tongue (particularly the
posterior portion of the tongue) due to evolving muscle
weakness typically appears first
• Next involvement of jaw and suprahyoid musculature
• Finally weakness of pharyngeal and laryngeal muscles
• Delay in, and eventual abolishment of, triggering of the
swallowing reflex for voluntarily initiated swallows, with
relative preservation of spontaneous reflexive swallows
until the terminal stages of the disease
94. Cranial Neuropathies
• Extramedullary, intracranial involvement in processes
involving the meninges, extramedullary tumors, aneurysms,
and skull fractures
• Lesions at the jugular foramen or in the retroparotid space some combination of IX, X, XI, XII, and the cervical
sympathetic
• Prominent in the miller fisher variant of AIDP
• Herpes zoster infection - attributed to cranial ganglionic
involvement
• Charcot-marie-tooth disease
95. Nuclear lesions
• Brain stem stroke and MS
• Brainstem tumors, both primary and metastatic,
• Central pontine myelinolysis
• Progressive multifocal leukoencephalopathy
• Leukoencephalopathy due to cyclosporin toxicity
• Brainstem encephalitis – Listeria and Epstein-barr
Virus
96. Cervical Spinal Cord lesions
• Especially if associated with respiratory insufficiency
• With higher spinal cord injury
• With treatment and time, most patients demonstrate
improvement
98. Dietary Modification
• Difficulties with the oral preparatory phase
– Diet of pureed foods
• As patients' swallowing function improves
– Soft and semisolid foods with regular consistencies
• Recommend to patients that they alternate bites with
sips, bite or sip size, and the number of swallows per
size
• Good oral hygiene and dental care
99. Viscosity and texture of food
Oropharyngeal neurogenic dysphagia
• Thickened liquids
– Liquids can be thickened with starch-based food
thickeners
Difficulties with mastication
• Chopped or pureed foods
Uniform and viscous bolus of food or beverage - less
risk of aspirating
100. Exercises
Indirect
– Strengthen swallowing muscles
Direct
– Performed while swallowing
• Designed to facilitate oral motor strength, range of
motion (ROM), and coordination
• Usually are performed 5-10 times per day
101. Exercises
Lip exercises
• facilitate the patient's ability to prevent food or liquid
from leaking out of the oral cavity
Tongue exercises
• facilitate manipulation of the bolus and its propulsion
through the oral cavity or to facilitate retraction of the
tongue base
Jaw exercises
• facilitate the rotatory movements of mastication
103. Exercises
Head-lift (Shaker) exercise
• to increase anterior movement of the hyolaryngeal
complex and opening of the upper esophageal
sphincter
• lie flat and with shoulders on the floor and raise their
head high enough to see their toes, maintaining this
position for 1 minute
104. Facilitation techniques
Somatosensory stimulation (electrical current
)applied to the pharynx
• Change the excitability of the corticobulbar projection
• Induce cortical reorganization in patients with
poststroke dysphagia
Repetitive transcranial magnetic stimulation (RTMS)
105. Facilitation techniques
Deep pharyngeal neuromuscular stimulation (DPNS)
• To improve pharyngeal swallow
• On stimulating 3 reflex sites
1) Bitter taste buds and tongue base -improve tongue-base
retraction
2) Soft palate - improve palatal elevation
3) Superior and medial pharyngeal constrictor - improve
pharyngeal peristalsis and cricopharyngeal opening
106. Compensatory Techniques
Chin-tuck position
• decreases the space between the base of the tongue
and the posterior pharyngeal wall
• creating increased pharyngeal pressure to move the
bolus through the pharyngeal region
107. Compensatory Techniques
Rotation of the head to the affected side
• closes the pyriform sinus on the affected side and
directs food down the opposite or stronger side
• also adds external pressure on the damaged vocal
cord and moves it toward the midline, improving
airway closure.
108. Compensatory Techniques
Tilting the head to the strong side
• bolus tends to be directed down the stronger side in
the oral cavity and in the pharynx
• effective for patients who have unilateral tongue
dysfunction or a unilateral pharyngeal disorder.
109. Compensatory Techniques
Supraglottic swallow
• Close the airway voluntarily before and during the
swallow
• Take a deep breath and hold your breath
• Keep holding your breath while you swallow
• Cough immediately after the swallow
111. Enteral Feeding
• Unable to achieve adequate alimentation and
hydration by mouth
• Impaired level of consciousness, massive aspiration,
silent aspiration, esophageal obstruction, or recurrent
respiratory infections
112. Enteral Feeding
Nasogastric tube feeding
• In post stroke dysphagia temporarily provide
adequate nutrition and buy time until swallowing
improves
• prolonged use can lead to lesions to the nasal wing,
chronic sinusitis, gastroesophageal reflux, and
aspiration pneumonia
113. Enteral Feeding
Percutaneous endoscopic gastrostomy
Oroesophageal tube feeding
• patient is taught to insert the 14F urethral tube into
the mouth and past the side of the tongue, pushing
slowly until the catheter end reaches the lips
• Food supplements and liquid are administered by
means of a 500-mL syringe at a rate of approximately
50 mL/min
