Airway Closure

1
Airway Closure

• During the swallow, the pharynx is reconfigured
  from a respiratory tract to an alimentary tract
• Laryngeal airway can be compromised at any time
  before, during, or after this alimentary
  reconfiguration and return to respiration

2
Airway Protection

• Several components of the swallow that are
  related to airway protection
• Laryngeal elevation
• Glottic closure
• Supraglottic closure
• Epiglottic inversion over the airway

3
Glottic Closure

• Glottic closure is not well-visualized with
  fluoroscopy
• AP view gives fair impression of true vocal fold
  and ventricular fold movement toward the mesial
  plane
• Lateral projection
• Allows observation of anterior tilting of the
  arytenoid cartilages
• Contact of arytenoids to base of epiglottis base
  during laryngeal elevation

4
Shaker R, Dodds W, Dantas R, Hogan W, Arnrdorfer
R. (1990) Coordination of deglutitive glottic
closure with oropharyngeal swallowing.
Gastroenterology, 98 1478-84

• Glottal closure patterns associated with
  swallowing.
• Type 1 The vocal folds are observed to remain
  in contact along their entire length after
  laryngeal elevation is initiated. 58
• Type 2 The vocal folds are in contact in the
  anterior half of their length but slightly
  separated in the posterior portion, leaving a
  small gap. 7
• Type 3 The vocal folds are not in contact with
  each other, leaving a small, elongated
  triangular opening between the folds. 35

5
Martin, B.J.W., Logemann, J.A., Shaker, R.
Dodds, W.J. Normal laryngeal valving patterns
during three breath-holding maneuvers A pilot
investigation. Dysphagia, Vol. 1, 1993, pp. 11-20

• Patients instructed to hold your breath
• Optimum laryngeal valving obtained in only 17.
• When instructions were varied
• (i.e., hold your breath hard)
• percentage of successful vocal fold approximation
  increased significantly

6
Mendelsohn, M.S. Martin, R.E. Airway
protection during breath-holding. Annals of
Otology, Rhinology Laryngology, Vol. 102, 1993,
pp. 941-944.

• Normal Subjects
• Instruction to perform relaxed breath-holding
• resulted in vocal fold closure in only 57
• The high variability of laryngeal valving during
  breath-holding in normal subjects suggests that
  video nasolaryngoscopy should be undertaken in
  all patients who are taught the supraglottic
  swallow.

7
Hirst LJ, Sama A, Carding PN, Wilson JA.Is a
'safe swallow' really safe? Int J Lang Commun
Disord 199833 Suppl279-80

• Fiberoptic nasendoscopy was used to assess vocal
  cord adduction.
• 45 normal subjects asked to hold their breath
• 57.7 of normal subjects did not fully close
  their vocal cords for the complete duration of
  breath holding.
• implications for the efficacy of teaching methods
  of the supraglottic safe swallow technique.

8
Ohmae Y, Logemann JA, Kaiser P, Hanson DG,
Kahrilas PJ. Effects of two breath-holding
maneuvers on oropharyngeal swallow. Annals of
Otology Rhinology and Laryngology.
1996105123-131.

• Compared
• Supraglottic maneuver (SGM)
• Super supraglottic maneuver (SSGM)
• Simultaneous MBS and FEES
• Eight healthy volunteers
• SSGM resulted in
• Earlier cricopharyngeal opening
• Prolonged pharyngeal swallow
• Laryngeal valving before swallow
• Change in extent of vertical laryngeal position
  before swallow.

9
Donzelli, J., Brady, S. (2004) The Effects of
Breath-Holding on Vocal Fold Adduction
Implications for Safe Swallowing Archives of
Otolaryngology Head Neck Surgery. 130208-210.
Hard breath-hold instruction most effective
method to attain full laryngeal closure
10
Breath-Holding

• Request patient to hold his or her breath.
• If laryngeal breath-holding is not observed
• Ask the patient to
• Bear down, as if lifting something heavy.
• Bear down, as if having a bowel movement.

11
Case Study

• 50 year old veteran
• Exacerbation of Multiple Sclerosis
• Clinical signs of aspiration with thin liquids