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322 CLINICAL MANAGEMENT OF SWALLOWING DISORDERS
swallowing problems relate to muscle weakness
and muscle fatigue.
Positron emission tomography (PET): a method of
examining neural activity associated with specific motions such as speaking or swallowing.
Although it is noninvasive, it has the disadvantage
of exposure to radiation.
Postprandial: after eating.
Prader-Willi syndrome (PWS): a genetic disorder
that occurs in approximately 1 out of every 15,000
births. PWS affects males and females with equal
frequency and affects all races and ethnicities. PWS
is recognized as the most common genetic cause
of life-threatening childhood obesity. PWS was
first described by Swiss doctors Andrea Prader,
Alexis Labhart, and Heinrich Willi in 1956 based
on the clinical characteristics of 9 children they
examined. The common characteristics defined in
the initial report included small hands and feet,
abnormal growth and body composition (small
stature, very low lean body mass, and early-onset
childhood obesity), hypotonia (weak muscles)
at birth, insatiable hunger, extreme obesity, and
intellectual disability. PWS results from an abnormality of chromosome 15, and definitive diagnosis
is now based on genetic testing.
Prandial aspiration: the entry of material from the
oropharynx or gastrointestinal tract into the larynx and lower respiratory tract during food or
liquid intake. A person may either inhale the
material, or it may be delivered into the tracheobronchial tree during positive pressure ventilation. The aspirated material is often colloquially
referred to as “going down the wrong pipe.”
Presbyphagia: changes in swallowing functions
during healthy aging. Such changes are not severe
enough to cause dysphagia but may affect overall
swallowing efficiency and safety for older adults.
Primary lactation insufficiency: inability to produce
sufficient milk supply despite adequate stimulation with a baby or pump. Causes may be apparent, such as inadequate glandular tissue, or could
be unexplained.
Primary motor cortex: located in the frontal lobe
of the brain, the primary motor cortex generates neural impulses that control execution of
movement.
Primary peristalsis: the peristaltic wave triggered
by the swallowing center. The peristaltic contraction wave travels at a speed of 2 cm/s and correlates with manometry-recorded contractions.
The relationship of contraction and food bolus
is more complex because of intrabolus pressures
from above (contraction from above) and the
resistance from below (outflow resistance).
Progressive supranuclear palsy: a neurological dis-
order of unknown origin that gradually destroys
cells in many areas of the brain, leading to serious
and permanent problems with the control of gait
and balance. The most obvious sign of the disease
is an inability to aim the eyes properly, which
occurs because of damage in the area of the brain
that coordinates eye movements. Some patients
describe this effect as a blurring. Another common visual problem is an inability to maintain
eye contact during a conversation. This can give
the mistaken impression that the patient is hostile
or uninterested. Patients also often show alterations of mood and behavior, including depression
and apathy as well as progressive mild dementia, lack of appetite, or dysphagia for solids. The
disease is “progressive” because it worsens over
time; “supranuclear” because the main problem
is not in the nuclei (clusters of cells in the brainstem) that directly control eye movements, but in
higher centers that control the nuclei; and “palsy,”
which means weakness, in this case of eye movement. Progressive supranuclear palsy (PSP) characteristically begins with loss of balance. Nearly
all patients eventually develop the characteristic
difficulty in moving the eyes up and down, the
sign that often arouses a doctor’s suspicion of
the correct diagnosis. Although PSP gets progressively worse, no one dies from PSP itself. Difficulty swallowing can eventually permit aspiration
of food into the trachea (windpipe). PSP may also
be complicated by the effects of immobility, especially pneumonia, and by injuries from falls.
Prokinetic agents (or prokinetics): medications
that help control acid reflux. Prokinetics help
strengthen the lower esophageal sphincter (LES)
and cause the contents of the stomach to empty
faster. This allows less time for acid reflux to
occur.
GLOSSARY 323
Prosthodontist: a prosthodontist is a dentist with
advanced specialty training including the design
and fitting of prosthetic appliances, dental
implants, dentures, veneers, crowns, and teeth
whitening.
Proton therapy: a type of radiation therapy that uses
protons (positively charged particles) instead of
x-rays. Because it can be targeted specifically to
the tumor, it has fewer side effects.
Pseudobulbar palsy: bilateral corticobulbar tract
damage in which speech and swallowing disorders are common.
Ptosis: also known as drooping eyelid. This is
caused by weakness of the muscle responsible
for raising the eyelid, damage to the nerves that
control those muscles, or looseness of the skin of
the upper eyelids.
Pulse oximetry: a technique to measure the oxygen
saturation of arterial blood by means of a photoelectric technique.
Pulsed-dye laser (PDL): the pulsed-dye laser uses a
beam of light at a specific wavelength; used for
conditions or spots on the skin that are made up
of blood and blood vessels.
Regurgitation: a backward flowing, for example,
of food, or the sloshing of blood back into the
heart (or between chambers of the heart) when
a heart valve is incompetent and does not close
effectively.
Reliability: a test’s ability to measure the same thing
consistently across multiple uses.
Respiratory distress syndrome: rapid shallow
breathing following injury or infection to the
lungs. In newborns, a breathing disorder caused
by immature lungs usually in premature infants.
Rett syndrome: a uniform and striking, progressive
neurological developmental disorder and one of
the most common causes of mental retardation
in females. It is an X-linked dominant neurological disorder that affects girls only and is one of
the most common causes of mental retardation
in females. Girls with the syndrome show normal development during the first 6 to 18 months
of life followed first by a period of stagnation
and then by rapid regression in motor and language skills. The hallmark of Rett syndrome is
the loss of purposeful hand use and its replace-
ment with stereotyped hand-wringing. Screaming fits and inconsolable crying are common.
Because of these autistic-like behaviors, feeding
is highly irregular. Other key features include
loss of speech, behavior reminiscent of autism,
panic-like attacks, bruxism (grinding of teeth),
and microcephaly (small head).
Rheumatoid arthritis: a chronic inflammatory disor-
der that can affect more than just joints. In some
people, the condition also can damage a wide
variety of body systems, including the skin, eyes,
lungs, heart, and blood vessels. An autoimmune
disorder, rheumatoid arthritis occurs when the
immune system mistakenly attacks the body’s tissues. Rheumatoid arthritis affects the lining of
joints, causing a painful swelling that can eventually result in bone erosion and joint deformity.
Sarcoidosis: an autoimmune disease of unknown
origin that causes small lumps (granulomas) due
to chronic inflammation to develop in a great
range of body tissues. Sarcoidosis can appear in
almost any body organ but most often starts in
the lungs or lymph nodes. It also affects the eyes,
liver, and skin; it less often affects the spleen,
bones, joints, skeletal muscles, heart, and central
nervous system (brain and spinal cord). In the
majority of cases, the granulomas clear up with
or without treatment. In cases where the granulomas do not heal and disappear, the tissues tend
to remain inflamed and become scarred (fibrotic).
Sarcopenia: a condition that occurs with aging or
immobility, characterized by progressive and generalized loss of skeletal muscle mass and strength
and/or physical performance.
Schatzki ring: described by Richard Schatzki, MD,
in 1953; a narrowing of the lower part of the
esophagus caused by changes in the esophageal
mucosa. In the majority of cases, Schatzki ring is
benign and asymptomatic; the condition is associated with hiatal hernias and can disrupt the
normal esophageal functions. It has been suggested that long-term gastroesophageal reflux
disease causes chronic inflammation and thus
chronic damage to the lower esophagus. The
damage will heal and form a scar that is the
Schatzki ring.
324 CLINICAL MANAGEMENT OF SWALLOWING DISORDERS
Scintigraphy: a procedure used to track movement
of the bolus and quantify the residual bolus in the
oropharynx, pharynx, larynx, and trachea using
a special camera (gamma camera). The patient
swallows a small amount of a radionuclide material such as technetium 99m combined with liquid
or food for this test.
Scleroderma: a disease of connective tissue with
the formation of scar tissue (fibrosis) in the skin
and sometimes also in other organs of the body.
Scleroderma is classified into diffuse and limited
forms. The CREST syndrome is a limited form
of scleroderma. CREST stands for calcinosis (the
formation of tiny deposits of calcium in the skin),
Raynaud phenomenon (spasm of the tiny artery
vessels supplying blood to the fingers, toes,
nose, tongue, or ears), esophagus (esophageal
involvement by the scleroderma), sclerodactyly
(localized thickening and tightness of the skin
of the fingers or toes), and telangiectasias (dilated capillaries that form tiny red areas, frequently
on the face, hands, and in the mouth behind the
lips).
Secondary peristalsis: the peristaltic wave that
is induced by esophageal distension from the
retained bolus, refluxed material, or swallowed
air. The primary role is to clear the esophagus of
retained food or any gastroesophageal refluxate.
Selective serotonin reuptake inhibitors (SSRIs): a
class of medications used to treat depression.
Prozac, Zoloft, and Paxil are examples of SSRIs.
Besides dry mouth and nausea, there are many
side effects of these medications, and they must
be prescribed diligently after careful examination.
Sensitivity: a test’s accuracy in identifying true
cases of the target disorder.
Serology: the science of blood testing to identify
antibodies and antigens to determine immune
deficiencies in serum, plasma, and other body
fluids.
Sialorrhea: excessive drooling. This condition is
usually caused by nerve or muscle problems or a
breakdown in the skin around the mouth. Drooling is related to forward spillage. Posterior drooling may result in excessive spillage down into
the airway.
Silent aspiration: aspiration without any obvious
signs of swallowing difficulty, such as coughing
or breathing difficulty. Silent aspiration is related
to loss of sensation in the vagus nerve.
Sjögren syndrome: an autoimmune disease of sali-
vary and tear glands. Sjögren syndrome involves
inflammation of glands and other tissues of the
body. Most patients with Sjögren syndrome are
female. Sjögren syndrome can be complicated by
infections of the eyes, breathing passages, and
mouth. Sjögren syndrome is typically associated
with antibodies against a variety of body tissues
(autoantibodies).
Slough: to separate from surrounding living tissue.
Used of dead tissue.
Spasticity: stiff or rigid muscles with exaggerated,
deep tendon reflexes (eg, a knee-jerk reflex). The
condition can interfere with walking, movement,
or speech.
Specificity: a test’s accuracy in rejecting cases that
do not match the target disorder.
Squamous cell carcinoma: cancer that begins in
squamous cells — thin, flat cells that look under
the microscope like fish scales. Squamous cells
are found in the tissue that forms the surface of
the skin, the lining of hollow organs of the body,
and the passages of the respiratory and digestive
tracts. Squamous cell carcinomas may arise in any
of these tissues.
Stenosis: also known as a stricture. This is an
abnormal narrowing in a blood vessel or other
tubular organ or structure.
Stomatitis: inflammation of the mucosal lining of
any of the structures in the mouth, which may
involve the cheeks, gums, tongue, lips, and roof
or floor of the mouth. The word stomatitis literally means inflammation of the mouth.
Subluxation: partial dislocation of a joint. A com-
plete dislocation is a luxation.
Suckling: motion that requires the tongue to move
anterior to posterior. Usually the infant begins to
swallow using this pattern. Compare to sucking,
which is an inferior to superior motion of the
tongue that is acquired later in normal infancy.
Surrogate decision-maker: also known as a health
care proxy. This is a person who makes health
or personal care decisions for an incompetent
patient.
Swallow reflex: when masticated food passes be-
yond the facial arches into the hypopharynx, the
GLOSSARY 325
swallow becomes reflexive, meaning that it is
under involuntary control. In a normal swallow,
breath holding occurs, the vocal folds adduct, and
the bolus passes into the esophagus.
Systemic lupus erythematosus (SLE): an autoim-
mune disease. In this disease, the body’s immune
system mistakenly attacks healthy tissue. It can
affect the skin, joints, kidneys, brain, and other
organs.
Tardive dyskinesia: a disorder that involves invol-
untary movements, especially of the lower face.
Tardive means “delayed,” and dyskinesia means
“abnormal movement.”
Third-party disability (https://doi.org/10.3109/ 096
38280902927028): third-party disability is defined
as the disability of family members due to the
health condition of their significant other and was
identified as a direction for future development
by the World Health Organization in 2001.
Tonic contraction: continuous contraction of a
muscle.
Tracheostomy: a surgically created opening in the
neck leading directly to the trachea (the breathing tube). It is maintained open with a hollow
tube called a tracheostomy tube.
Tracheotomy: a surgical procedure that opens up
the windpipe (trachea). It is performed in emergency situations, in the operating room, or at bedside of critically ill patients.
Tractus solitarius: a tract composed of mostly sen-
sory fibers that convey information from stretch
receptors and chemoreceptors in the walls of the
cardiovascular respiratory and intestinal tracts.
Its fibers are distributed to the nucleus of the
solitary tract.
Transcutaneous: through the skin.
Transoral: by way of the mouth.
Treacher Collins syndrome: a condition that affects
the development of bones and other tissues of
the face. The signs and symptoms of this disorder
vary greatly, ranging from almost unnoticeable to
severe. Most affected individuals have underdeveloped facial bones, particularly the cheekbones,
and a very small jaw and chin (micrognathia).
Some people with this condition are also born
with a cleft palate. In severe cases, underdevelopment of the facial bones may restrict an
affected infant’s airway, causing potentially life-
threatening respiratory problems. People with
Treacher Collins syndrome often have eyes that
slant downward, sparse eyelashes, and a notch in
the lower eyelids called an eyelid coloboma. Some
affected individuals have additional eye abnormalities that can lead to vision loss. This condition is also characterized by absent, small, or
unusually formed ears. Hearing loss occurs in
about half of all affected individuals; hearing loss is
caused by defects of the 3 small bones in the middle ear or by underdevelopment of the ear canal.
Trigeminal nerve (CN V): responsible for sensation
in the face. Sensory information from the face
and body is processed by parallel pathways in
the central nervous system. CN V is primarily a
sensory nerve, but it also has certain motor functions (biting, chewing, and swallowing).
Trismus: inability to open the mouth fully. This may
be due to spasm of the jaw muscles and be a
symptom of tetanus (lockjaw), or it may be due to
abnormally short jaw muscles, as in the trismuspseudo-pamprodactyly syndrome.
Trisomy 21 syndrome: a common chromosomal
disorder, often called Down syndrome, due to
an extra chromosome number 21 (trisomy 21).
The chromosome abnormality affects both the
physical and intellectual development of the individual. Trisomy 21 syndrome is associated with a
major risk for heart malformations, a lesser risk
of duodenal atresia (part of the small intestines is
not developed), and a minor but still significant
risk of acute leukemia. Children born with Down
syndrome are often slow to acquire strong sucking ability; thus, they may be slow to thrive if
the swallowing problem is not detected early. In
Down syndrome, there are certain characteristic
features in the appearance that may individually
be quite subtle but together permit a clinical diagnosis of Down syndrome to be made at birth.
These signs of Down syndrome include slight
flattening of the face, minimal squaring off of
the top of the ear, a low bridge of the nose (lower
than the usually flat nasal bridge of the normal newborn), an epicanthic fold (a fold of skin
over top of the inner corner of the eye, which can
also be seen less frequently in normal babies), a
ring of tiny harmless white spots around the iris,
and a little narrowing of the palate.
326 CLINICAL MANAGEMENT OF SWALLOWING DISORDERS
Upper motor neuron: a neuron that starts in the
motor cortex of the brain and terminates within
the medulla (another part of the brain) or within
the spinal cord. Damage to upper motor neurons
can result in spasticity and exaggerated reflexes.
Vagal: a response when the vagus nerve is stimu-
lated. A vagal response may cause dizziness or
even cause one to pass out.
Vagus nerve (CN X): a nerve that supplies nerve
fibers to the pharynx (throat), larynx (voice box),
trachea (windpipe), lungs, heart, esophagus, and
intestinal tract as far as the transverse portion
of the colon. The vagus nerve also brings sensory information back to the brain from the ear,
tongue, pharynx, and larynx. It originates in the
medulla oblongata, a part of the brainstem, and
wanders all the way down from the brainstem to
the colon.
Validity: a test’s ability to measure what it is de-
signed to measure.
Vasospasm: blood vessel spasm, also known as
Raynaud’s. Lactation may provoke this condition
in the nipples and cause severe pain. It can occur
spontaneously without any prior systemic vasospasm or autoimmune condition.
Velocardiofacial syndrome (VCFS): a genetic con-
dition characterized by abnormal pharyngeal
arch development that results in defective development of the parathyroid glands, thymus, and
conotruncal region of the heart. Shprintzen and
colleagues first described the syndrome in 1978.
More than 180 different clinical features are associated with velocardiofacial syndrome, with no
single anomaly present in every patient. Some
abnormalities are more common than others.
Affected individuals may present with structural or functional palatal abnormalities, cardiac
defects, unique facial characteristics, hypernasal
speech, hypotonia, and defective thymic development. Palatal abnormalities predispose to speech
and feeding difficulties.
Velopharyngeal insufficiency: incomplete closure
of the velopharyngeal sphincter between the
oropharynx and the nasopharynx. Closure, normally achieved by the sphincteric action of the
soft palate and the superior constrictor muscle,
is impaired in patients with cleft palate, repaired
cleft palate, congenitally short palate, submucous
cleft palate, palatal paralysis, and sometimes,
enlarged tonsils. The condition may also result
when adenoidectomy or uvulopalatopharyngoplasty (UVP) is done in a patient with a congenital underdevelopment (submucous cleft) or
paralysis of the palate.
Verbal apraxia: a motor speech disorder. It is caused
by damage to the parts of the brain related to
speaking. Other terms include apraxia of speech,
acquired speech apraxia, verbal apraxia, and
dyspraxia.
Videofluoroscopy: using a video-recording system
to examine the activity during an x-ray procedure.
Vocal fold paresis: a condition of the vocal fold
when it has lost partial neural innervation. Mobility of adduction and abduction is reduced and
slower compared to normal function.
Wallenberg syndrome: also known as lateral med-
ullary syndrome. This is a neurological condition
caused by a stroke in the vertebral or posterior inferior cerebellar artery of the brainstem.
Symptoms include difficulties with swallowing,
hoarseness, dizziness, nausea and vomiting, rapid
involuntary movements of the eyes (nystagmus),
and problems with balance and gait coordination.
Some individuals will experience a lack of pain
and temperature sensation on only one side of
the face, or a pattern of symptoms on opposite
sides of the body, such as paralysis or numbness
in the right side of the face, with weak or numb
limbs on the left side. Uncontrollable hiccups may
also occur, and some individuals will lose their
sense of taste on one side of the tongue, while
preserving taste sensations on the other side.
Wegener granulomatosis: characterized by a gran-
ulomatous arteritis involving the upper and lower
respiratory tracts, a progressive glomerulonephritis, and extra respiratory symptoms attributable
to systemic small-vessel arteritis. Wegener granulomatosis often affects the hard and soft palate
and may lead to extensive ulceration, oronasal
fistulas, and velopharyngeal insufficiency.
Whiteout phase: the time of airway closure during
which the swallow cannot be visualized, as the
pharyngeal walls contract over the bolus, collapsing the lumen over the endoscope.
World Health Organization (WHO): an agency of the
United Nations that is concerned with world pub-
GLOSSARY 327
lic health. Established in 1948 and headquartered
in Geneva, Switzerland.
Xanthan gum: a polysaccharide that is used as a
food additive and liquid thickener; an addition
or alternative to starch-based liquid thickeners.
Xerophonia: a dry-sounding or strange sounding
voice caused by various medications including
diabetes medications. In psychiatry, xenophonia
relates to a strange sounding voice.
Xerostomia: more commonly known as dry mouth,
is not a disease in itself. Rather, it is a symptom
of many other diseases and conditions. These
conditions cause saliva production to decrease
or stop.
Zenker diverticulum: also known as pharyngo-
esophageal diverticulum or pulsion diverticulum of the esophagus; named in 1877 by German
pathologist Friedrich Albert von Zenker. This is a
diverticulum of the mucosa of the pharynx, just
above the cricopharyngeal muscle.
Appendix
1
Reflux Symptom Index (RSI)
A score of greater than 10 strongly suggests that the patient has laryngopharyngeal reflux.
Within the last MONTH, how did the following
problems affect you? 0 = No problem; 5 = Severe problem
1. Hoarseness or problem with voice 0 1 2 3 4 5
2. Clearing your throat 0 1 2 3 4 5
3. Excess throat mucus or postnasal drip 0 1 2 3 4 5
4. Difficulty swallowing foods, liquids, or pills 0 1 2 3 4 5
5. Coughing after you ate or after lying down 0 1 2 3 4 5
6. Breathing difficulties or choking episodes 0 1 2 3 4 5
7. Troublesome or annoying cough 0 1 2 3 4 5
8. Something sticking in throat or lump in throat 0 1 2 3 4 5
9. Heartburn, chest pain, indigestion 0 1 2 3 4 5
Total RSI:
329
Appendix
2
Reflux Finding Score (RFS)
A score of greater than 5 strongly suggests laryngopharyngeal reflux disease.
Findings Scoring
Subglottic edema (pseudosulcus vocalis) 2 If present
Ventricular obliteration 2 If partial 4 If complete
Erythema/hyperemia 2 If arytenoid
only
Vocal fold edema 1 Mild 2 Moderate 3 Severe 4 Polyp
Arytenoid/interarytenoid edema 1 Mild 2 Moderate 3 Severe 4 Obstruction
Posterior commissure hypertrophy 1 Mild 2 Moderate 3 Severe 4 Obstruction
Granuloma/granulation 2 If present
Thick endolaryngeal mucus 2 If present
Total RFS:
4 If diffuse
331