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32 CLINICAL MANAGEMENT OF SWALLOWING DISORDERS
Temporalis
Levator labii
Zygomatic bone
Zygomaticus minor
Zygomaticus major
Depressor anguli oris
Depressor labii inferioris
Mentalis
Thyroid cartilage
A
Risorius
Levator anguli oris
Buccinator
Masseter
Orbicularis oris
Mandible
Omohyoid
Sternohyoid
Sternocleidomastoid
Sternothryoid
FIGURE 2–7. A. Anterior superficial view of the muscles of the head, face, and upper neck that produce facial expressions
and lip motions. continues
2. ANATOMY AND PHYSIOLOGY OF THE SWALLOWING MECHANISM 33
Zygomatic arch
Zygomatic major m.
Temporalis m.
Zygomatic minor m.
Orbicularis oculi m.
Occipito-frontalis m.
Mandible
Masseter m.
Sternocleidomastoid m.
Levator scapulae m.
B
Levator labii superioris m.
Levator anguli oris m.
Buccinator m.
Orbicularis oris m.
Depressor labii inferioris m.
Mentalis m.
Cervicis m.
Depressor anguli oris m.
Trapezius m.
Platysma m.
Middle scalene m.
Risorius m.
FIGURE 2–7. continued B. Lateral view of the muscles of the right side of the head, face, and upper neck.
34 CLINICAL MANAGEMENT OF SWALLOWING DISORDERS
TABLE 2–3. Muscles of the Face, Their Actions, and Innervations That
Contribute to Supporting Bolus in Oral Cavity and Also to Facial Expression
Muscles Action Innervation
Levator labii superioris Raises upper lip VII Facial nerve
Depressor labii inferioris Lowers lower lip VII Facial nerve
Depressor anguli oris Aids in opening the mouth VII Facial nerve
Buccinator Presses cheeks against
teeth (eg, sucking, blowing)
In mastication, keeps food
between teeth and away
from cheeks
Mentalis Acts to lift lower lip
Pulls chin upward
Platysma Depresses mandible
Helps to retract lower lip
For example, if there is damage to the hypoglossal
nerve on one side, the tongue is likely to direct the
bolus from the strong side to the weak side,
6
causing food to pocket in the cheek. Hypoglossal nerve
damage can be seen with tongue deviation during
protrusion.
The oral portion of the tongue is innervated
by the hypoglossal nerve (CN XII). This portion of
the tongue remains under voluntary control of the
CNS. The base of the tongue, sometimes thought of
as the back of the tongue, receives motor innervation by the pharyngeal plexus of the vagus nerve
(CNX), primarily through the palatoglossus muscle.
The palatoglossus is the only tongue muscle supplied by the vagus nerve.
VII Facial nerve
VII Facial nerve
VII Facial nerve
7
“zest.”
Smoking, age, and effects of radiation dete-
riorate taste.
Both gender and age likely influence the speed
and accuracy of swallowing. Inamoto et al found
that gender, height, and age each had effects on
swallowing.
8
They found that the volumes of the larynx and hypopharynx were significantly greater in
men than in women. Especially with age, they found
that the volumes of these cavities decreased. They
also found smaller spaces in the piriform sinuses
in the aging adult for both genders as they aged.
The volumes in these cavities should be considered
when adjusting for bolus size and texture during
swallowing assessments and treatments.
Hold the tip of the tongue down with a tongue
blade to see if the back of the tongue elevates.
See how detailed the tongue functions. You may
even note the muscle elevating.
The sensory nervous system of the tongue plays
a role in swallowing. Taste receptors are found on
the oral portion of the tongue and at the base of
the tongue. Five basic taste sensations exist: sweet,
sour, salty, bitter, and identified more recently,
Residuals in the vallecula and piriform are
normal in older adults. The importance of sensation becomes important as these residuals may
lead to aspiration after the swallow.
Figure 2–8A shows the extrinsic muscles of the
tongue. The genioglossus muscle is a fan-shaped
muscle that makes up the bulk of the tongue.
Actions of the genioglossus and hyoglossus muscles
lower the tongue and protract it anteriorly. Actions
of the styloglossus and palatoglossus muscles are
2. ANATOMY AND PHYSIOLOGY OF THE SWALLOWING MECHANISM 35
Styloglossus m.
Mastoid process
Superior pharyngeal
Diagastric
(cut)
Stylopharyngeus m.
Middle pharyngeal
constrictor m.
Hyoglossus m.
Thyrohyoid membrane
Inferior pharyngeal
constrictor m.
constrictor m.
Stylohyoid m.
Hyoid bone
Palatoglossus m.
Tongue
Intermediate tendon
of diagastric
Fibrous loop
for intermediate
tendon of diagastric
Hard palate
Genioglossus
m.
Mandible
Mylohyoid m.
Geniohyoid m.
Thyroid cartilage
A
FIGURE 2–8. A. Extrinsic muscles of the tongue.. continues
of larynx
responsible for elevating the tongue. Figure 2–8B
shows the intrinsic tongue muscles, namely, the
tongue with its transverse, longitudinal, and vertical fibers, and the geniohyoid muscle, a thin muscle
at the base of the tongue. The vertical, transverse,
and longitudinal fibers allow the tongue to form a
“pocket” to hold the bolus in place and prevent it
from falling into the cheek or prematurely spilling
into the oropharynx.
The intrinsic muscles of the tongue shape the
tongue for management of various types of food and
liquid. The geniohyoid muscle moves the tongue
upward during deglutition by pulling on the hyoid
bone. This action also results in elevation of the
entire larynx. Table 2–4 shows the actions of the
extrinsic and intrinsic muscles of the tongue.
The tongue is also partially responsible for sensation that we get from foods and other odors. The
sensory branch of the trigeminal nerve (CN V) is
responsible for sensation to the face and anterior
mouth (teeth). The glossopharyngeal nerve (CN IX)
is responsible for sensation to the major portions of
the tongue. Sensation is also mediated through the
nose via the olfactory nerve (CN I).
The tongue directs the bolus and provides the
driving force for swallowing.
36 CLINICAL MANAGEMENT OF SWALLOWING DISORDERS
Lower lip
Mandible
Lingual mucosa
Superior longitudinal
muscle of tongue
Vertical and transverse
lingual muscles
Septum of the tongue
Foramen cecum
Lingual tonsil
Vallecula of
epiglottis
Epiglottis
Genioglossus
muscle
Geniohyoid
muscle
Mylohyoid
muscle
Hyoid bone
B
FIGURE 2–8. continued B. Intrinsic muscles of the tongue.
This driving force of the tongue can be
measured by a number of strategies. Devices
such as the Iowa Oral Performance Instrument
(IOPI)9 or the Tongueometer provide measurements of tongue maximum strength.
The tongue is highly mobile and rests on a sling
of muscles attached to the mandible (as shown in
Figure 2–8A), the maxilla, and tongue base. Because
Thyroid
cartilage
Vocal folds
of its mobility, it can control and move food rapidly
when there are no injuries to the muscles or nerves
of the tongue. The intrinsic muscles of the tongue
further guide the bolus and help move particles of
food into position for swallowing. These muscles
also help form distinctions in the vowels and consonants of languages.
The tongue requires moisture to aid in the
grinding and chewing processes. Natural saliva
provides that moisture. Six paired major exocrine
glands, parotid, submandibular, and sublingual,
2. ANATOMY AND PHYSIOLOGY OF THE SWALLOWING MECHANISM 37
TABLE 2–4. Muscles of the Tongue, Their Actions and Innervations
Extrinsic Muscles Action Innervation
Genioglossus Depresses tongue
Moves tongue anteriorly
Hyoglossus Depresses tongue
Decreases sides of tongue
Styloglossus Elevates tongue
Retracts tongue
Palatoglossus Elevates posterior tongue
Lowers soft palate
Intrinsic Muscles Action Innervation
Transverse Elongates and narrows tongue Hypoglossal CN XII
Vertical Flattens and widens tongue Hypoglossal CN XII
Longitudinal Elevates tip of tongue
Depresses apex and sides of
tongue
Geniohyoid Elevates hyoid bone and
tongue
Lowers mandible
Hypoglossal CN XII
Hypoglossal CN XII
Hypoglossal CN XII
Pharyngeal plexus axons
from CN X
Hypoglossal CN XII
Cervical spinal C 1
secrete saliva and open via ducts into the oral cavity.
As many as 300 minor salivary glands also provide
discharge of saliva fluids into the oral cavity. Normal salivary flow requires good hydration (water)
to maintain ideal function of the tongue.
Mandible
The muscles of the jaw consist of bones that form
the lower portion of the anterior face and provide
the framework of the mouth. The maxilla is the fixed
portion of the jaw, and the mandible is the moving
portion of the jaw to which many of the muscles
responsible for safe bolus transport attach. Figure2–9 shows an anterior view of the muscles of the
neck with the muscles of the jaw and their attachments to the sternum. The figure shows how the
muscles are layered. Table 2–5 describes the major
muscles of chewing and the muscles that support
the actions of the jaw.
Did you know that the masseter muscle is
considered the strongest muscle in the body?
Based on its weight, it is capable of holding
extremely heavy objects between the teeth.
The suprahyoid muscles are responsible for
elevating the hyoid bone. When that happens, the
larynx is elevated, it moves forward and allows a
more direct path for the bolus of food to pass. The
geniohyoid muscle, located at the inferior portion
of the tongue (see Figure 2–7B), is often considered
a part of the suprahyoid muscles since it also helps
to raise the hyoid bone.
38 CLINICAL MANAGEMENT OF SWALLOWING DISORDERS
Mandible
Masseter m.
Digastric m:
Anterior belly
Posterior belly
Hyoid bone
Stylohyoid m.
Sternohyoid m.
Omohyoid m.
Sternocleidomastoid m.
Thyroid cartilage
Sternothyroid m.
Cricothyroid m.
FIGURE 2–9. Muscles of the anterior neck that assist in swallowing and speech.
Inferior constrictor m.
Levatorscapulae m.
Thyrohyoid m.
Scalene muscles
2. ANATOMY AND PHYSIOLOGY OF THE SWALLOWING MECHANISM 39
TABLE 2–5. Muscles of the Mandible and Neck and Their Actions and Innervations
Muscles of the
Mandible Action Innervation
Masseter Elevates mandible Trigeminal CN V
Temporalis Retracts mandible
Aids in mouth closing
Lateral pterygoid Lateral motion of mandible
Depresses mandible
Opens mouth
Medial pterygoid Lateral motion of mandible
Pushes mandible forward
Suprahyoid Muscles
Mylohyoid Elevates hyoid bone
Aids in depressing mandible
Stylohyoid Moves hyoid bone posteriorly
Elevates hyoid bone
Digastric Elevates hyoid bone
Depresses mandible
Infrahyoid Muscles
Omohyoid Lowers hyoid bone Branches of spinal nerves C 1–3
Sternohyoid Aids in lowering hyoid bone Branches of spinal nerves C 1–3
Sternothyroid Lowers thyroid cartilage Branches of spinal nerves C 1–3
Trigeminal CN V
Trigeminal CN V
Trigeminal CN V
Trigeminal CN V
Facial CN VII
Trigeminal CN V
Facial CN VII
Thyrohyoid Lowers hyoid bone
Aids in elevating thyroid
Pharynx
The pharynx is a muscular tube that begins at the
posterior portion of the oral and nasal cavities and
extends to the esophagus. As shown in Figure 2–10A,
it is divided roughly into 3 sections: nasopharynx,
oropharynx, and laryngopharynx. This division can
be seen more clearly in Figure 2–10B. It lies behind
the larynx and trachea and provides passage of food
and liquids to the stomach. The normal pharynx consists of a series of circular constrictor muscles that
sequentially drive the food inferiorly to the stomach.
It is not the goal of this chapter to review all of the
actions of the pharyngeal muscles. These are aided
by the longitudinal muscles that elevate the pharynx
Branches of spinal nerves C 1–3
Hypoglossal CN XII
and larynx to increase the opening to the esophagus as shown in Figure 2–10B. Specific attention to
the constrictor muscles related to swallowing is considered. The cricopharyngeus muscle, which is part
of the inferior constrictor, forms the entrance to the
esophagus. When this muscle is damaged, the incidence of dysphagia is highly increased. This muscle
maintains contraction during respiration but relaxes
during swallowing. This action allows the larynx to
elevate and the food to pass into the esophagus. Scarring, fibrosis, or nerve injury can lead to cricopharyngeal dysfunction that may result in lack of action or
proper speed of action leading to aspiration despite
other normal oral and laryngeal functions. Table 2–6
describes the muscles of the pharynx.
40 CLINICAL MANAGEMENT OF SWALLOWING DISORDERS
Nasal septum
Soft palate
Uvula
Superior constrictor muscle
Posterior one third of tongue
Pharyngoepiglottic
fold
Aryepiglottic fold
Piriform fossa (recess)
Thyroid gland
A
Posterior View
Epiglottis
Inferior constrictor m.
(cut open)
Mucous membrane
covering cricoid cartilage
Pharyngoesophageal junction
(narrowest part of esophagus)
Esophagus
FIGURE 2–10. A. Posterior view of the muscles of the nasopharynx, oropharynx, and laryngopharynx. continues
2. ANATOMY AND PHYSIOLOGY OF THE SWALLOWING MECHANISM 41
Salpingo-pharyngeus m.
Palato-pharyngeus m.
Stylopharyngeus m.
Cervical spine
2nd vertebra
B
FIGURE 2–10. continued B. Sagittal view of the longitudinal muscles of the pharynx
responsible for elevating the pharynx and larynx to create a larger opening to the
esophagus.
TABLE 2–6. Muscles of the Pharynx and Their Actions and Innervations
Muscle Action Innervation
Superior constrictor Constricts upper pharynx Pharyngeal plexus CN X
Middle constrictor Constricts upper pharynx Pharyngeal plexus CN X
Inferior constrictor Part of the esophageal
sphincter (UES) constricts
Pharyngeal plexus CN X
Salpingopharyngeus Elevates pharynx Pharyngeal plexus CN X
Stylopharyngeus Elevates pharynx Glossopharyngeal CN IX
Palatopharyngeus Elevates pharynx and larynx Pharyngeal plexus CN X