Determining What, When, Why and How Determining What, When, Why and How

What What are the clinical signs of aspiration and are the clinical signs of aspiration and what what consistencies consistencies
cause them to occur? cause them to occur?
When When are these signs occuring? are these signs occuring?
Why Why are these signs occuring? are these signs occuring?
How How can the SLP mitigate these signs of aspiration? can the SLP mitigate these signs of aspiration?
What What are the clinical signs of aspiration and/or dysphagia are the clinical signs of aspiration and/or dysphagia
Coughing Coughing
Throat clearing Throat clearing
wet phonation wet phonation
Feeling something stuc in the throat Feeling something stuc in the throat
!dynophagia !dynophagia
WH"T food#li$iud consistencies% WH"T food#li$iud consistencies%
Thin& nectar'thic& honey'thic li$uids Thin& nectar'thic& honey'thic li$uids
Pureed& (round& )echanical Soft or *egular foods Pureed& (round& )echanical Soft or *egular foods
When When are the signs occuring? are the signs occuring?
+,F!*, +,F!*, the swallow - .efore hyoid .egins anterior and superior the swallow - .efore hyoid .egins anterior and superior
mo/ement mo/ement
01*23( 01*23( the swallow - after the hyoid .egins anterior and the swallow - after the hyoid .egins anterior and
superior mo/ement to when it is at the height of its ascent4 superior mo/ement to when it is at the height of its ascent4
"FT,* "FT,* the swallow - after the point at which the hyoid has the swallow - after the point at which the hyoid has
reached its highest point reached its highest point

Why Why is the patient showing clinical signs of aspiratio is the patient showing clinical signs of aspiration n
Why Why the patient is dysphagic is addressed .y your e/aluation the patient is dysphagic is addressed .y your e/aluation
and analysis on and analysis on
Clinical e5amination Clinical e5amination
- - )+S )+S
- - F,,S F,,S
6nowing the normal swallow physiology is imperati/e& as that 6nowing the normal swallow physiology is imperati/e& as that
nowledge is used to determine the a.normal aspects of the nowledge is used to determine the a.normal aspects of the
patient7s swallowing4 patient7s swallowing4
How How to mitigate the dysphagic components of the swallow to mitigate the dysphagic components of the swallow

"ll treatment strategies& tass& e5ercises& postures and protocols "ll treatment strategies& tass& e5ercises& postures and protocols
used )1ST ha/e used )1ST ha/e appropriate rationale appropriate rationale .ased on the 8ndings of .ased on the 8ndings of
the clinical and#or instrumental swallow e5amination the clinical and#or instrumental swallow e5amination
The Abnormal Swallow The Abnormal Swallow
Reductions in labial and lingual strength and range of motion (ROM) can have affects on
the oral preparatory, oral transit and pharyngeal phases of the swallow.
Decreased Labial Strength and/or !" Decreased Labial Strength and/or !"
!ral Preparation is a9ected !ral Preparation is a9ected
- - 1na.le to open mouth to accept .olus 1na.le to open mouth to accept .olus
- - 1na.le to maintain la.ial seal resulting in anterior spillage 1na.le to maintain la.ial seal resulting in anterior spillage
- - 1na.le to suc through a straw or tae food from a spoon& for or 1na.le to suc through a straw or tae food from a spoon& for or
cup4 cup4
Decreased Lingual Strength, !" and/or #oordination Decreased Lingual Strength, !" and/or #oordination
!ral Preparation !ral Preparation
- - Cannot maintain a cohesi/e .olus .etween tongue and hard Cannot maintain a cohesi/e .olus .etween tongue and hard
palate palate
- - Cannot clear residue from lateral sulci& anterior sulci and :oor of Cannot clear residue from lateral sulci& anterior sulci and :oor of
mouth4 mouth4
- - 1na.le to place food .ac on teeth during mastication4 1na.le to place food .ac on teeth during mastication4
- - Fre$uently .iting tongue if sensation is a9ected Fre$uently .iting tongue if sensation is a9ected
!ral Transit !ral Transit
- - 1na.le to mo/e the .olus posteriorly for the swallow to .e 1na.le to mo/e the .olus posteriorly for the swallow to .e
triggered triggered
Pharyngeal phase Pharyngeal phase
- - Poor or reduced .ase of tongue retraction Poor or reduced .ase of tongue retraction
- - *esidue in the /alleculae is a symptom of reduce +!t retraction *esidue in the /alleculae is a symptom of reduce +!t retraction
- - "spiration +,F!*, the swallow due to reduced lingual control "spiration +,F!*, the swallow due to reduced lingual control
Ade$uate %s& 'oor !ral 'rep
'remature Spillage due to reduced lingual
coordination
Delayed or Absent 'haryngeal Swallow Delayed or Absent 'haryngeal Swallow
Pharyngeal swallow is not triggered promptly or at all Pharyngeal swallow is not triggered promptly or at all
The head of the .olus is .eyond the point where the angle of the The head of the .olus is .eyond the point where the angle of the
ramus of mandi.le and +!T tongue cross on )+S ramus of mandi.le and +!T tongue cross on )+S before before the hyoid the hyoid
.one .egins to mo/e anteriorly and superiorly4 .one .egins to mo/e anteriorly and superiorly4
Puree or li$uids enter the /alleculae and#or pyriform sinuses Puree or li$uids enter the /alleculae and#or pyriform sinuses
.efore the swallow is triggered ;n#a to foods re$uiring mastication< .efore the swallow is triggered ;n#a to foods re$uiring mastication<
Penetration or aspiration .efore the swallow Penetration or aspiration .efore the swallow
educed (ase !f Tongue etraction educed (ase !f Tongue etraction
+ase of tongue does not mae contact or posterior pharyngeal +ase of tongue does not mae contact or posterior pharyngeal
wall& or does so wealy4 wall& or does so wealy4
"de$uate strength and full range of motion of the .ase of tongue "de$uate strength and full range of motion of the .ase of tongue
gi/es the .olus the initial propulsion to descend through the pharyn5 gi/es the .olus the initial propulsion to descend through the pharyn5
2f +!T retraction is poor& the swallow will .e poor 2f +!T retraction is poor& the swallow will .e poor
*esidue in the /alleculae after the swallow *esidue in the /alleculae after the swallow
Penetration and#or aspiration from the residue after the swallow Penetration and#or aspiration from the residue after the swallow
from the residue from the residue
educed )elar *le%ation educed )elar *le%ation
The /elum does not close o9 the nasopharyngeal port during the The /elum does not close o9 the nasopharyngeal port during the
swallow swallow
3asal regurgitation during the swallow 3asal regurgitation during the swallow
educed *piglottis etro+e,ion educed *piglottis etro+e,ion
,piglottis retro:e5ion is P"SS2=,
The epiglottis does not completely in/ert to co/er the airway4 The epiglottis does not completely in/ert to co/er the airway4
The residual material in the /alleculae after the swallow The residual material in the /alleculae after the swallow
*is of penetration or aspiration "FT,* the swallow from the *is of penetration or aspiration "FT,* the swallow from the
residue in the /alleculae residue in the /alleculae
Solids usually cause more of a pro.lem then li$uids ;especially Solids usually cause more of a pro.lem then li$uids ;especially
pills< pills<
Details of -ormal *piglottis etro+e,ion Details of -ormal *piglottis etro+e,ion
"s the hyolaryngeal comple5 ele/ates& the epiglottis is folded to "s the hyolaryngeal comple5 ele/ates& the epiglottis is folded to
a hori>ontal position4 a hori>ontal position4
Tongue .ase retraction .rings the tip of the epiglottis .ac to Tongue .ase retraction .rings the tip of the epiglottis .ac to
mae contact with the posterior pharyngeal wall and continues to mae contact with the posterior pharyngeal wall and continues to
s$uee>e down against the posterior pharyngeal wall .ringing it to its s$uee>e down against the posterior pharyngeal wall .ringing it to its
most inferior position4 most inferior position4
"s the .olus en/elops the epiglottis& the downward pressure of "s the .olus en/elops the epiglottis& the downward pressure of
the .olus contri.utes to epiglottal descent4 the .olus contri.utes to epiglottal descent4
??Se/eral factors can a9ect normal epiglottis retro:e5ion@ ??Se/eral factors can a9ect normal epiglottis retro:e5ion@
educed Laryngeal *le%ation educed Laryngeal *le%ation
The laryngeal /esti.ule is not completely o.literated from /iew The laryngeal /esti.ule is not completely o.literated from /iew
on the )+S on the )+S
Penetration and#or aspiration 01*23( the swallow may occur Penetration and#or aspiration 01*23( the swallow may occur
when airway closure is inade$uate during the swallow4 when airway closure is inade$uate during the swallow4
)ay o.ser/e residual material in the /alleculae and pyriform )ay o.ser/e residual material in the /alleculae and pyriform
sinuses from other aspects that are related to the reduced laryngeal sinuses from other aspects that are related to the reduced laryngeal
ele/ation4 ele/ation4
Laryngeal #losure Laryngeal #losure
True and false cords adducting and the anterior tilting of the True and false cords adducting and the anterior tilting of the
arytenoids to the .ase of the epiglottis comprise laryngeal closure4 arytenoids to the .ase of the epiglottis comprise laryngeal closure4
Laryngeal closure is .est seen using F,,S4 2t is diAcult to /iew
on )+S& .ut
anterior tilting helps o.literate the laryngeal /esti.ule on lateral /iew
of )+S4
True cord adduction can .e seen on "P /iew4
educed 'haryngeal Wall #ontraction educed 'haryngeal Wall #ontraction
!ccurs when the pharyngeal constrictors are wea or not !ccurs when the pharyngeal constrictors are wea or not
contracting at all contracting at all
*esidual material in the pyriform sinuses& .ilaterally or *esidual material in the pyriform sinuses& .ilaterally or
unilaterally4 unilaterally4
*esidue on the posterior pharyngeal wall4 *esidue on the posterior pharyngeal wall4
"spiration "FT,* the swallow from residue "spiration "FT,* the swallow from residue
0iAcult to directly o.ser/ed pharyngeal wall contraction& .ut 0iAcult to directly o.ser/ed pharyngeal wall contraction& .ut
inferences can .e made depending on the other parameters of the inferences can .e made depending on the other parameters of the
pharyngeal swallow4 pharyngeal swallow4
educed #ricopharyngeal !pening educed #ricopharyngeal !pening
Cricopharyngeal .ar may .e o.ser/ed if the pro.lem is chronic Cricopharyngeal .ar may .e o.ser/ed if the pro.lem is chronic
or no .ar is tycally seen if the tight CP is acute or no .ar is tycally seen if the tight CP is acute
*esidual seen in the pyriform sinuses only after the swallow *esidual seen in the pyriform sinuses only after the swallow
+ac:ow of material from the esophagus +ac:ow of material from the esophagus
Penetration and#or aspiration "FT,* the swallow from the residue Penetration and#or aspiration "FT,* the swallow from the residue
in the pyriform sinuses in the pyriform sinuses
Penetration-Aspiration Scale - Rosenbeck, et al (1996)
1. Material does not enter the airway
. Material enters the airway, remains above the vocal folds
and is e!ected from the airway.
". Material enters the airway, remains above the vocal folds and
is not e!ected from the airway.
#. Material enters the airway, contacts the vocal folds and is
e!ected from the airway.
$. Material enters the airway, contacts the vocal folds and is
not e!ected from the airway.
%. Material enters the airway, passes below the vocal folds and
is e!ected into the laryn& or out of the airway.
'. Material enters the airway, passes below the vocal folds and
is not e!ected from the trachea despite effort.
(. Material enters the airway, passes below the vocal folds and
no effort is made to e!ect.
educed *sophageal Transit educed *sophageal Transit
Stasis of material in the esophagus Stasis of material in the esophagus
Tertiary contractions Tertiary contractions
Patient feels something stuc at the le/el of the sternal notch4 Patient feels something stuc at the le/el of the sternal notch4
*etrograde mo/ement of the .olus or re:u5 of material .ac into *etrograde mo/ement of the .olus or re:u5 of material .ac into
the pharyn5 the pharyn5
"spiration of re:u5ed material "spiration of re:u5ed material
.en/er0s Di%erticulum .en/er0s Di%erticulum
"n a.normal muscular out'pouching that forms either a.o/e the "n a.normal muscular out'pouching that forms either a.o/e the
cricopharyngeus muscle ;through 6illian7s dehiscence< or Bust .elow it cricopharyngeus muscle ;through 6illian7s dehiscence< or Bust .elow it
;through Laimer7s triangle< ;through Laimer7s triangle<
)ore common in men ages CD7s and ED7s )ore common in men ages CD7s and ED7s
They can collect food#li$uid and pills& producing dysphagic They can collect food#li$uid and pills& producing dysphagic
symptoms as it impinges on the esophagus symptoms as it impinges on the esophagus
Patients report undigested food#pills returning to mouth Patients report undigested food#pills returning to mouth
sometimes hours after ingestion sometimes hours after ingestion
Foul mouth odor from putri8ed content of the Feners Foul mouth odor from putri8ed content of the Feners
di/erticula4 di/erticula4
.en/er0s Di%erticulum .en/er0s Di%erticulum
2t is thought that patients with Fener7s di/erticulum ha/e 2t is thought that patients with Fener7s di/erticulum ha/e
improperly timed rela5ation of the cricopharyngeus muscle during improperly timed rela5ation of the cricopharyngeus muscle during
swallowing4 !/er time& the increased pressure causes herniation of the swallowing4 !/er time& the increased pressure causes herniation of the
esophageal mucosa posteriorly& .etween the inferior pharyngeal esophageal mucosa posteriorly& .etween the inferior pharyngeal
constrictor and the cricopharyngeus muscle4 Whether these patients constrictor and the cricopharyngeus muscle4 Whether these patients
ha/e an anatomical predisposition to di/erticulum formation is ha/e an anatomical predisposition to di/erticulum formation is
unnown4 unnown4
#er%ical !steophytes #er%ical !steophytes
"nterior cer/ical osteophytes are common .ony growths on the "nterior cer/ical osteophytes are common .ony growths on the
front of the spine front of the spine
"ppear as .ony proBections from .etween the cer/ical /erte.rae "ppear as .ony proBections from .etween the cer/ical /erte.rae
with displacement of the posterior pharyngeal or esophageal wall with displacement of the posterior pharyngeal or esophageal wall
Some patients complain of pain at the le/el of the CP Some patients complain of pain at the le/el of the CP
"ll patients report solids .eing more diAcult than li$uids "ll patients report solids .eing more diAcult than li$uids