ANATOMY AND

PHYSIOLOGY OF
NORMAL DEGLUTITION
Anatomic Structures
Oral
Pharynx
Larynx
Esophagus

ORAL
Lips anteriorly
Teeth (24 Decidous, 32

Permenant)
Hard Palate
Soft Palate
Uvula
Mandible
Floor of Mouth
Tongue
Faucial Arches

Sulci
Natural Cavities/Spaces
Anterior Sulcus
Lateral Sulcus

Musculature of the Floor of Mouth

Mylohyoid
Geniohyoid
Anterior Belly of

Digastric

All of which attach to

the body of the madible
anteriorly and the body
of the hyoid bone
posteriorly

Hyoid
Forms foundation of the tongue
Larynx is supended from the
Hyoid Bone by the Thyrohyoid
Ligament and Thyrohyoid muscle
If the Hyoid elevates and moves
forward, the larynx will move
upward and forward unless it is
stabilized by other muscles

Tongue
Oral

Pharyngeal (Tongue base)

Tip
Blade
Front
Center
Back

Ends at Circumvallate Papillae

Active Under Cortical/Voluntary
Neural control

Begins at the Circumvallate

Papillae, ends at the Hyoid
bone
Active during pharyngeal
swallow
Involuntary neural control
brainstem
Can be placed under some
degree of voluntary control

Oral Cavity
Hard palate/Maxilla
Velum/soft palate
Uvula

Velopharyngeal closure
muscle pulls
Palatopharyngeus
Levator palatal muscle
Superior Pharyngeal

constrictor

Salivary Glands
Viscid mucus like
2. Serous watery
1.

Maintain oral moisture

Reduce tooth decay
Assist in digestion
Neutralize stomach acid

Pharyngeal Cavity
3 Pharyngeal constrictors
Superior
Medical
Inferior
Form posterior and lateral
pharyngeal walls

Pharyngeal cavity
Run laterally to attach to bony and soft tissue structures
located anteriorly: pterygoid plates, soft palate, BOT,
mandible, hyoid bone, thyroid and cricoid cartilages
Form the anterior wall of the pharynx
Inferior fibers of the superior constrictor attach to tongue
base/glossopharyngeus muscle. TBR and Anterior bulging
of the post pharyngeal wall at tongue base.

Pyriform Sinuses
Spaces formed between
fibers of inferior
constrictor and sides of
thyroid cartilage
Spaces end at
cricopharyngeal muscle

Cricopharyngeal muscle
Attach to cricoid lamina

Tonic when awake, loses

Cricoid
lamina/cricopharyngeus
forms valve into
esophagus called the
cricopharyngeal region
CP
UES
PE segment

tonic with sleep

Prevents air into
esophagus with respiration
Reduce material backflow
into pharynx
Sphincter 2-4 cm zone of
elevated pressure
greatest pressure
immediately prior to
swallow and during
inspiration

Esophagus
Collapsed muscular tube 23-25
cm long with sphincter at each
end UES/LES
Pharynx open vs. esophagus
closed
Sits behind trachea TE wall
(party wall)
LES (esophagus and stomach)
keep food and secretions in

2 layers of muscle:
inner circular and outer
longitudinal

Larynx
Base of tongue,
pharynx opens into
larynx
Topmost epiglottis
Attached into hyoid
bone by a ligament
Base attached to thyroid
notch

Larynx
Wedge-shaped space is the Valleculae
Open into larynx is Laryngeal Vestibule, which ends at
superior surface of false folds
Aryepiglottic folds form lateral walls
Arytenoids tilt anteriorly during swallowing, thought to be
form pull of the thyroarytenoid muscle fibers.
Tilt contributes to closure of airway
True cords form last level of airway protection

Larynx
3 levels of sphincter in
the larynx
1. Epiglottis and
aryepiglottic folds
2. Arytenoids
3. False Cords

Larynx
Larynx elevates
Pull anteriorly and

lowers for various

activities
Hyoid bone serves as
foundation for the
tongue
When one structure
moves, it often pulls on
and moves attached
structures

 [Link]
[Link]

Physiology
1. Oral prep: food manipulated/masticated
2. Oral phase of swallow: tongue propels food

post till pharyngeal swallow triggered

3. Pharyngeal Phase: bolus moved through
pharynx
4. Esophageal phase: cervical thoracic to
stomach
*duration and characteristics depend on volume and type
*580 swallows per day
*respiration and swallow are reciprocal halts w/ pharyngeal phase in all ages

1. Oral Prep
Needs sensory recognition
Movement varies w/ viscosity
Requires open nasal airway and nasal

breathing
Tippers and Dippers
Tippers food held midline w/ tip elevated and contact w/ alveolar ridge
Dippers 20%, food held floor of mouth in front of the tongue
Tongue thrust tongue moves anteriorly w/ the bolus pushing food from
the mouth. Seen w/ adults with frontal lobe damage and children w/ CP.

Oral Prep
Soft palate is pulled down and forward, sealing off the oral

cavity from pharynx

Mastication involves a rotary lateral movement of
mandible and tongue. Tongue mixes food w/ saliva w/
peripheral feedback to position bolus on teeth and prevent
injury to tongue
Tension in buccal musculature closer of lateral sulcus
After chewing, tongue pulls food into semi-cohesive bolus
before oral stage of swallow initiated

Oral Prep
Active chewing, soft palate not pulled down, thus

premature spillage common, not normal during hold

phase of liquid/pudding
Volume of bolus swallowed varies w/ viscosity; this
downsizing w/ viscosity allows easier passage through
pharynx and UES. Larger volumes, the tongue will
subdivide
Larynx and pharynx are at rest during oral prep phase
Great deal of sensory info is processed from sensory
receptors throughout the oral cavity

2. Oral Phase
Initiated when tongue begins post movement of bolus
Sides and tip of tongue anchor against the alvelor ridge.

Central groove is formed and acts as a chute

Viscosity thickens, pressure of the oral tongue against
palate increases negative pressure of tension of buccal
musculature
1-1.5 seconds
Needs labial seal, intact lingual movement, intact buccal
musculature, normal palatal muscle, and ability to breath
through nose

Bolus propulsion

3. Triggering of Pharyngeal Swallow

As the tongue movement propels the bolus post,

sensory receptors in the oropharynx and tongue

are stimulated, sending sensory info to cortex and
brainstem
Bolus head passes faucial arches and tongue
base crosses the lower rim of the mandible, oral
stage is terminated and pharyngeal swallow is
triggered
If pharyngeal stage is not triggered by that time,
delayed
Humans cannot swallow unless there is
something in their mouth

Triggering Pharyngeal Swallow

Sensory portion of

pharyngeal swallow
cranial IX, X, XI.
Impulses travel to the
swallow center in
brainstem. Motor IX
and X
Cortical recognition of
bolus critical to
initiation of oral phase

4. Pharyngeal Swallow
1. Velopharyngeal closure: elevation and retraction of the
velum and complete closure of the velopharyngeal portion
to prevent material from entering nasal cavity. Enables
build up of pressure in the pharynx.

Pharyngeal Swallow
2. Elevation and anterior movement of the hyoid and
larynx: Elevate and move anteriorly by the pull of the floor
of mouth muscles (anterior belly of digastric, myolohyoid,
geniohyoid, laryngeal elevator-thyrohyoid). Average
elevation 2 cm. Elevation contributes to closure of the
airway, forward movement contributes to opening of the
UES.

Pharyngeal Swallow
3. Closure of the Larynx: all 3 sphincters true folds,
laryngeal entrance (false folds, anterior tilt arytenoids,
thickening of epiglottic base) and epiglottis. Airway closed
1/3-2/3 second and 5 seconds w/ sequential cup drinking.
TVC close when larynx has elevated approx 50% of max
elevation.

Pharyngeal Swallow
4. Cricopharyngeal opening: tension in the
cricopharyngeal muscle portion of the sphincter is released.
Laryngeal anterior-superior motion opens the sphincter,
sphincter is yanked open by the motion of the larynx
resulting from the upward and forward pull of the floor of
mouth muscles. Pressure w/in bolus widens the opening.
Once passed, larynx lowers and cricopharyngeal muscle
returns to level of contraction.

Pharyngeal Swallow
5. Tongue base and pharyngeal wall action: when bolus
reaches tongue base level, tongue base and pharyngeal
walls should make complete contact during the swallow.
Move towards each other, pressure builds. Pharyngeal wall
contracts and continues down pharynx to UES.

Peristalsis
Progressive contraction
down a muscular tube
Pressure generated by
TBR and pharyngeal
wall constriction
increases w/ bolus
viscosity. Pressure
applied to the tail of the
bolus.

Movement
Velopharyngeal closure and hyolaryngeal excursion

occurs simultaneously
Open UES and airway closure
Pressure on bolus
1. oral tongue pushes tail
2. tongue base reaches pharyngeal wall and apply
pressure to bolus.

Always Remember This

Pharyngeal swallow must trigger for physiological

activities (Velar, pharyngeal, tongue base, laryngeal) to

occur. These activities occur ONLY as a result of
triggering pharyngeal swallow! There is no way to
voluntary initiate or modify pharyngeal contraction!

Movement
Pharyngeal transit time time bolus to move from point

pharyngeal swallow is triggered through the

cricopharyngeal juncture into esophagus. 1 second or
less.
Divides at the valleculae w/ flowing down each side of
pharynx through pyriform sinuses
Epiglottis directs food around the airway
Joins again at UES

Esophageal Phase
Time from UES to LES/stomach varies 8-20 seconds.

Bolus pulled through w/ peristaltic wave

Mechanism as a Set of Tubes & Valves

Oral cavity horizontal
Pharynx verticle

UES musculoskeletal
valve (cricopharyngeal
muscle & cricoid cartilage)
LES muscular sphincter.
Keep food/stomach acid in
stomach

Changes with Age

Infant: tongue fills the
oral cavity. Hyoid bone
and larynx are up, velum
hangs lower, uvula rests
inside epiglottis and
forms pocket in
valleculae. Greatest
elongation of the
pharynx and downward
displacement of larynx
occurs during puberty

Infant
Swallow begins in the fetus. Sucking nipple, infant

repeatedly pumps the tongue expressing milk. Normal

infants 2-7 pumps. Bolus of adequate size has been
formed, triggers pharyngeal swallow. 1ml liquid produces
oral then pharyngeal swallow (similar to adult).
Bite achieved approx 7 months
Chewing 10-12 months
Normal adult pattern 3-4 years

Older Adult
Number of chewing strokes related to age and dental

status. Increased strokes w/ poor dentition or dentures.

Physiological changes occur 70+. Ossification of thyroid
and cricoid cartilages and hyoid bone, appear more
prominent.
Larynx may begin to lower. Cervical arthritis, impinge on
pharyngeal wall decreases flexibility, decrease strength of
pharyngeal contraction.

Age and Swallowing

Dipper
longer oral stage
Pharyngeal residue
Increased penetration

w/out aspiration
Longer esophageal
transit

Age and Swallowing

Decreased max

laryngeal and hyoid

anterior and vertical
movement indicating
reduced
neuromuscular reserve
(difference between
necessary movement
and actual motion)

Age and Swallowing

Decreased flexibility

cricopharyngeal
opening less change
as volume increased,
exacerbates w/
weakness
Taste intensity of
taste & smell are
reduced

Coordination of respiration & swallowing

Apneic period fraction of second. Corresponds w/

closure of airway during pharyngeal stage. Duration

increases bolus volumes
Airway opens w/ oral prep, oral, and esophageal stages
Interrupting exhalation and returning to exhalation and
returning to exhalation
Slight airflow through the larynx and pharynx after the
swallow
May clear any residue from around the airway entrance
Dysphagia patients may more often interrupt inhalation to
swallow

Variations in normal swallowing

1.

2.
3.
4.
5.
6.

Volume effects bolus volume creates greatest

systematic changes in oropharyngeal swallow. Small
volume each phase, whereas large (10-20ml)
simultaneous oral & pharyngeal activity
Increased viscosity increased pressure. Valve
functions all increase slightly in duration
Cup drinking early airway closure, duration 5-10
seconds
Straw drinking suction
chug-a-lug pull larynx forward & hold breath
Pharyngeal swallow w/ no oral swallow

 [Link]
[Link]

Components of All Swallows

1.
2.
3.
4.

Components that must be present

Oral propulsion bolus into pharynx
Airway closure
UES opening
Tongue base pharyngeal wall propulsion to carry the
bolus through the pharynx and into the esophagus

.Variations on normal swallow generally involve

changing the timing of these elements, but all

must be present and normal for bolus to clear
safely and efficiently!