Topics in Stroke Rehabilitation

ISSN: 1074-9357 (Print) 1945-5119 (Online) Journal homepage: http://www.tandfonline.com/loi/ytsr20

Neuroanatomy and Neurophysiology: Implications

for Swallowing

Adrienne L. Perlman

To cite this article: Adrienne L. Perlman (1996) Neuroanatomy and Neurophysiology: Implications
for Swallowing, Topics in Stroke Rehabilitation, 3:3, 1-13, DOI: 10.1080/10749357.1996.11754118

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 Neuroanatomy and Neurophysiology:
Implications for Swallowing

Deglutit~onis a complicated neuromuscular process that requires a complex level of communication

between the central and peripheral nervous systems, and which results in highly coordinated actions from
the muscles of mouth, pharynx, larynx, and esophagus. The actions of the individual muscles involved in
deglutition and their cranial nerve innervation for the oral and pharyngeal stages of the swallow are
presented. This is followed by a discussion of the research relating to potential areas of breakdown, and the
corresponding symptomology, associated with the oral and pharyngeal stages of swallowing following a
stroke. Key words: deglutition, dysphagia, neuroanatomy, neurophysiology, oral, pharyngeal, stroke
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Adrienne L. Perlman, PhD

Associate Professor
Department of Speech and Hearing
D EGLUTITION IS a complicated neuro-
muscular process that requires a com-
plex level of communication between the
Science central and peripheral nervous systems. This
University of Illinois at Urbana- results in highly coordinated actions from the
Champaign muscles of the mouth, pharynx, larynx, and
Urbana, Illinois esophagus. Although the principal center for
deglutition is in the brain stem, certain re-
gions rostra1 to the brain stem also contribute.
It has been reported that electrical stimula-
tion in the region of the primary motor cortex
does not elicit a swallow (Murry & Sessle,
1992). However, stimulation of the antero-
lateral region anterior to the precentral cortex
elicits swallowing with mastication (Car,
1977; Miller & Bowman, 1977; Sumi, 1970).
The pathway from the anterolateral cortex
descends through the internal capsule, sub-
thalamus, and mesencephalic reticular for-
mation to the reticular formation of the upper
brain stem (Miller, Bieger, & Conklin,
1996). This explains, at least in part, why
lesions to these areas can affect the process of
deglutition. Additionally, when stimulating
the frontal cortex, Martin and Sessle (1993)

Top Stroke Rehabil 1996:3(3):1-13

O 1996 Aspen Publishers, Inc.
 found at least four bilateral regions that elic-
ited swallowing. Furthermore, certain as-
pects of the swallow can be elicited by stimu-
lating the hypothalamus and midbrain
ventral tegmental field (Bieger, 199 1;
Bieger, Weerasuriya, & Hockman, 1978;
Hockman, Bieger, & Weerasuriya, 1959).
For an in-depth discussion of topics such as
the central swallowing pathway, pharmaco-
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logic studies of brain stem transmission, and
cortical responsibilities during swallowing,
the reader is referred to Miller and colleagues
(1996).
Two areas within the pons, the reticular
formation immediately dorsal to the motor
trigeminal nucleus and the region ventral to
the motor trigeminal nucleus, can elicit a
swallow but are not part of the core pathway
responsible for the sequence of muscle activ-
ity during swallowing. Rather, the core path-
way is at the level of the nucleus tractus
solitarius and the nucleus ambiguus of the
medulla. In a summary statement, Miller and
colleagues (1996) write that the brain stem
". . . is the region containing the interneurons
essential to the swallowing response. How-
ever, by adulthood, the cortex exercises sig-
nificant control over the initiation of swal-
lowing and the level of neuromuscular
activity during s\vallowing." Thus, it be-
comes apparent why dysphagia is a common
problem associated with stroke. Since dys-
phagia can lead to serious medical complica-
tions including pneumonia, sepsis, malnutri-
tion, and dehydration, it is important to
provide the stroke patient with appropriate
diagnostic examinations of swallowing
function and with treatment based on the
diagnostic findings.
Although the actions of the structures of
the mouth, pharynx, larynx, and esophagus
are not necessarily independent of one an-
other, the traditional classification of swal-
lowing into three stages-oral, pharyngeal,
and esophageal-provides a useful strategy
for discussing the swallow. Those muscles
that are responsible for the first two stages of
swallowing are innervated by Cranial Nerves
V, VII, IX, X, and XII. The actions of the
individual muscles involved in deglutition
and their cranial nerve innervation for the
oral and pharyngeal stages of the swallow are
presented in this article. For an in-depth
discussion of the peripheral controls for all
three stages of deglutition, the reader is re-
ferred to Perlman and Christensen (1996).
ORAL STAGE
The oral stage of the swallow can be di-
vided into an oral preparatory phase and an
oral transport phase. The oral preparatory
phase involves manipulation of the food bo-
lus and can employ the lips, tongue, jaw. soft
palate, muscles of mastication, and buccal
muscles. When the food bolus requires mas-
tication, the oral preparatory phase includes
tongue action to move the food posteriorly
and place it between the molars. It also in-
cludes a reduction phase during which the
bolus is chewed until it is broken into small
pieces and mixed with sufficient saliva to be
formed into a cohesive bolus ready to be
swallowed.
Great intra- and intersubject variability
can occur during the oral preparatory stage,
depending on such factors as the taste, tem-
perature. viscosity, and size of the bolus, as
well as individual anatomy, level of oral
sensitivity, rate of secretion and viscosity of
saliva, and cognitive and motor competence.
During the oral preparatory phase, the soft
palate is in contact with the pharyngeal as-
pect of the posterior tongue. On completion
of the oral preparatory phase, the oral trans-
port phase begins. During this phase, the lips

and buccal muscles contract, the posterior
tongue depresses, and the anterior portion of
the tongue presses against the hard palate as
it propels the bolus toward the oropharynx.
During this oral transport phase, the soft
palate elevates to separate the nasopharynx
from the oropharynx.
PHARYNGEAL STAGE
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Beginning with the contraction of the
muscles of the floor of the mouth, rapid,
coordinated motions assist in propelling the
bolus through the pharynx and into the
esophagus. This stage appears to be predomi-
nantly a pressure-driven event. As the bolus
enters the oropharynx, the arytenoids adduct,
and the lateral cricoarytenoid, false vocal
folds, and true vocal folds contract, thus
closing the glottis. Additionally, the epiglot-
tis covers the entrance to the larynx, provid-
ing further protection for the airway, reduc-
ing the irregularities of the anterior aspect of
the pharyngeal conduit, and diverting the
bolus into the pyriform sinuses.
The action of the lips, buccal muscles,
tongue, and velum, along with closure of the
glottis, contribute to the increase in pharyn-
geal pressure. This pressure is further in-
creased by the serial contractions of the pha-
ryngeal constrictor muscles. Additionally,
the smoothing of the anterior wall of the
pharynx and the contraction of the longitudi-
nal muscles of the pharynx, which shorten
and dilate the tube, assist in bolus transport.
In a combined manometric and videofluoro-
scopic study of pharyngeal clearance (Kah-
rilas, Logemann, Lin, & Ergun, 1992), it was
reported that the arytenoids and the upper
esophageal sphincter were elevated an aver-
age of 22 mm during the swallow. This
shortening occurred an average of 4 to 6 s
preceding the time of upper esophageal
Neuroanatomy and Neurophysiology 3
sphincter opening and lasted an average of
500 to 700 ms, depending on the size of the
bolus. The shortening was attributed, in a
large part, to the contraction of the stylopha-
ryngeus muscle. These results lend support
to the theory that bolus transit depends in part
on an intact pharyngeal contraction wave and
adequate shortening of the pharyngeal tube.
As a result of the muscle contraction in the
floor of the mouth, the hyoid bone is pulled into
a more anterior-superior position. In turn, the
motion of the hyoid along with the contraction
of the thyrohyoid muscle assist in elevating the
larynx to a position somewhat away from the
bolus flow. These two motions appear to be the
mechanisms that are primarily responsible for
epiglottic downfolding (VanDaele, Perlman,
& Cassell, 1995).
Simultaneous videofluoroscopy and ma-
nometry has led investigators to conclude
that there is a direct relationship between
anterior-superior movement of the hyoid
bone and the amount of opening of the
cricopharyngeus muscle during the swallow
(Kahrilas, Dodds, Dent, & Logemann,
1988). Thus, the opening of the upper esoph-
ageal sphincter is related to both muscle
relaxation and a passive mechanical action
resulting from the pull by the larynx as the
muscular and ligamentous connections
cause it to follow the hyoid in the anterior-
superior direction. One may wish to argue
that the contraction of the thyrohyoid
muscles also contribute to the opening of the
cricopharyngeal segment.
INNERVATION FOR THE ORAL
AND PHARYNGEAL STAGES OF
SWALLOWING
Four pairs of cranial nerves-V, VII, IX,
and X, are responsible for conveying afferent
information on taste and general sensation
 (pressure, light touch, pain, and temperature)
from the oral cavity, the pharynx, and the
larynx. Five pairs of cranial nerves-V, VII,
IX, X, and XII-are responsible for convey-
ing efferent information to the muscles of the
mouth, pharynx, and larynx during degluti-
tion. When the musculoskeletal system is
viewed as a simple mechanical system, then
by knowing the origin and the insertion of a
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The ability to predict how paralysis of a
muscle or group of muscles will affect
structural movement is important
information in the assessment of
disease or disorder.
veys sensory impulses from the mucosa of

muscle, to a first order, the effects of contrac-
tion can be inferred. The ability to predict
how paralysis of a muscle or group of
muscles will affect structural movement is
important information in the assessment of
disease or disorder as well as in the planning
of therapy techniques.
Cranial Nerve V
the anterior two thirds of the tongue, soft
palate, buccal region, floor of the mouth,
lower teeth and gums, temporomandibular
joint, and skin of the lower lip and jaw. The
maxillary division of Cranial Nerve V con-
veys sensory information from the mucosa of
the nasopharynx, soft palate, hard palate, and
upper teeth and gums.
Eferent controls
- -

Afferent controls The efferent controls from Cranial Nerve

Two divisions of the trigeminal nerve are V include innervation of the temporalis,
composed of fibers that transmit oral sensa- masseter, internal pterygoid, and external
tion (Figure 1).The mandibular division con- pterygoid muscles, as well as the mylohyoid

Afferent control

L, I

Sensation
I Efferent control

Mandibular ~emporaiism. ~ y l b h y o i d e u sm.

division Masseter m. Anterior belly of
Pterygoideus internalis m. digastricus m.
Pterygoideus medialis m.
Mucous mimbrane of:
anterior 2/3 of tongue
soft palate
cheek
floor of mouth Mucous Aembrane of:
Lower teeth and gums nasopharynx
Temporomandibular soft alate
joint
Skin of: hartpalate
lower lip Upper teeth and gums
jaw

Figure 1. Cranial Nerve V: innervation relevant to deglutition.

 Neuroanatorny and Neurophysiology 5

and anterior belly of the digastric muscles. Efferent controls

The temporalis muscle elevates and retracts
the mandible. The masseter and medial
pterygoid muscles also elevate the mandible,
and the lateral pterygoid depresses and pro-
trudes the mandible. These four paired
muscles are commonly called the muscles of
mastication. The mylohyoid muscle also
plays a major role in deglutition. On contrac-
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The facial motor nucleus is located in the
ventrolateral portion of the pontine tegmen-
tum. Fibers from this nerve innervate the sub-
mandibular and sublingual salivary glands and
mucous membranes of the nasal and oral cavi-
ties as well as the muscles of the face, the
platysma, stylohyoid,and posterior belly of the
digastric muscles. Although not related to de-

tion, this muscle contributes to the important glutition, the lacrimal glands and the stapedius
upward and forward movement of the hyoid muscle are also innervated by thls cranial nerve
bone. The muscle is also active during chew- and are mentioned here because of the role
ing and sucking. If the jaw is fixed, the these can play in the differential diagnosis of
anterior belly of the digastric muscle can Cranial Nerve VII damage.
contribute to the elevation of the hyoid; if the The muscles of facial expression have
hyoidis fixed, the muscle helps to depress the little relation to deglutition; consequently,
jaw. However, according to Hrycyshyn and they are not all discussed below or listed in
Basmajian (1972), electromyographic inves- Figure 2. Those muscles of the lower face
tigation revealed that the anterior belly of the
digastric is not consistently active during
human swallowing. In fact, they found that
about one fourth of the subjects they exam-
ined with electromyography had no activity
in that muscle during swallowing.
p2Z-l
branch
1
Chorda Posterior belly of
Cranial Nerve VII tympani dieastricus m.
Afferent controls I
Anterior 2/3 of tongue
Fibers from the facial nerve travel via the branch
chorda tympani nerve to terminate in the
nucleus tractus solitarius and are responsible
for taste sensation from the anterior two
thirds of the tongue. Most of the signals from
the taste fibers ascend unilaterally to the
I- I
Superior

Orbiculari; oris m.
Levator anguli oris m.
ventroposterior medial nucleus of the thala-
I
mus and ascend through the posterior portion
of the internal capsule to terminate in the Inferior
postcentral gyrus and possibly to the insula
and superior temporal gyrus (Norback & Orbicularis oris m.
Buccinator m.
Demarest, 1981). Taste fibers also travel to
the hypothalamus and probably influence Figure 2. Cranial Nerve VII: innervation rel-
autonomic function. evant to deglutition.
 that are known or suspected to have some
relationship to oral preparation or bolus
transport are listed.
The buccal branch of the facial nerve di-
vides into an inferior and a superior branch.
The superior branch innervates seven mus-
cles that are associated with facial expres-
sion. Of those, two muscles are important to
deglutition. The orbicularis oris muscle
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serves to open, close, protrude, invert, and
twist the lips. The levator anguli oris muscle
elevates the angle of the mouth and com-
presses the lips. The inferior portion of the
buccal branch of the facial nerve innervates
the lower lip, which performs the same move-
ments as the upper lip. Although one can chew
and swallow without tight lip closure, there is a
tendency to drool, and there is generally diffi-
culty with efficient bolus transport when the
seal is not tight. The buccal branch also
innervates the buccinator muscle. The bucci-
nator muscle flattens the cheeks and holds
r-
Sensation Muscular
branch
Mucous mdrnbrane of: ~ t ~ l o ~ h a r ) ; n g ern.
us
oropharynx
palatine tonsils
faucial pillars
Posterior lh of tongue
5-Taste
Posterior 11; of tongue
Figure 3. Cranial Nerve IX: innervationrelevant
to deglutition.
the food in contact with the teeth. Weakness
of the buccinatol- muscle secondary to a Cen-
tral VII weakness is fairly common among
stroke patients. Buccinator weakness results
in difficulty clearing the buccal area of food.
This food residue can fall into the airway
some time after the swallow, resulting in
coughing, choking, or aspiration. Thus, it is
important to clear a patient's mouth of food
residue during and after meals or snacks.
Contraction of the stylohyoid muscle and
the posterior belly of the digastric help to
elevate and retract the hyoid bone. The stylo-
hyoid also elevates the base of the tongue and
may be active during oral preparation. The
role of these two muscles, if any, has not been
assessed during deglutition.
Cranial Nerve IX
Afferent controls
The glossopharyngeal nerve conveys taste
sensation from the posterior one third of the
tongue. It also supplies the sensation of
touch, pain, and temperature from the mu-
cous membranes of the oropharynx, the pa-
latine tonsils, the faucial pillars, and the pos-
terior third of the tongue. All afferent fibers
enter the nucleus tractus solitarius, and nu-
merous projections travel from there to the
reticular formation. There are projections to
the thalamus and cortex, but little is known
about these secondary projections.
The areas innervated by this nerve are
considered very important to the successful
initiation of a swallow. Loss of sensation in
the posterior mouth and upper pharynx can
result in either an absence of a swallow or,
when sensation from the lower pharynx or
larynx is still intact (due to Cranial Nerve X
innervation), in a severely delayed initiation
of the swallow. (See Figure 3.)

Efferent controls
This nerve innervates only one muscle, the
stylopharyngeus. Neurons responsible for
innervation of the stylopharyngeus muscle
are located in the nucleus ambiguus. On
contraction, this muscle elevates and dilates
the pharynx. Although most clinicians rec-
ognize the importance of damage to the sen-
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sory branch of this nerve, they are inclined to
overlook the importance of damage to the
motor branch as well. As mentioned previ-
ously, shortening and widening of the phar-
ynx are important aspects of rapid, effective
bolus passage.
When performing a cranial nerve exarni-
nation, the clinician must be careful not to
place too much emphasis on the relationship
between the observation of the gag reflex and
the effectiveness of a swallow. That is to say,
the presence of a gag reflex does not mean
that the swallow is either intact or safe. Fur-
thermore, the absence of a gag does not
rzecessarily mean the absence or the ineffec-
tiveness of a swallow. If, however, it is
known that the patient had a normal gag
reflex and then lost it as a result of a stroke or
other insult, the examiner should view the
absent gag as a likely indicator of dysphagia.
The return of the gag reflex does not, in any
sense, imply the return of a safe swallow.
Cranial Nerve X
Afferent controls
Like the glossopharyngeal nerve, the va-
gus transmits information on taste and gen-
eral sensation to the nucleus tractus solitar-
ius. General sensation from the mucosa of the
pharynx is conveyed by the pharyngeal
plexus, which includes fibers from Cranial
Nerve IX.
Neui-oanatomy and Neztrophysiology 7
The internal branch of the superior laryn-
geal nerve conveys sensation from the mu-
cosa of the laryngopharynx, the epiglottis,
the laryngeal mucosa superior to the vocal
folds, joint receptors in the larynx, and a
small area on the posterior tongue. The recur-
rent laryngeal nerve conveys general sensa-
tion from the mucosa inferior to the vocal
folds and from the mucosa of the esophagus.
The esophageal branch of the vagus nerve
conveys general sensation from the mucosa
and the striated muscle portion of the esopha-
gus. Taste sensation from the vagus origi-
nates at the epiglottis, and taste fibers from
Cranial Nerve X travel with those of Cranial
Nerve IX. (See Figures 4-6.)
Efferent controls
Of the two medullary nuclei of the vagus
nerve, the nucleus ambiguus, which is lo-
cated in the reticular formation, is the site of
origin of the axons that convey motor im-
pulses to the pharynx, the larynx, and all
muscles of the soft palate except for the
tensor veli palatini muscle, which, although
not important to deglutition, does generally
assist in opening the eustacian tube during
swallowing (Leider, Hamlet, & Schwan,
1993). There are three branches of the vagus
that are important to the efferent controls of
the oral and pharyngeal stages of deglutition:
(1) the pharyngeal branch, (2) the recurrent
laryngeal branch, and (3) the external branch
of the superior laryngeal nerve.
Efferent fibers from the pharyngeal plexus
innervate oral and pharyngeal muscles. Of
the oral muscles, the palatoglossus muscle,
also known as the anterior faucial pillar, can
either lower the soft palate or raise the poste-
rior tongue. Although there have been no
reports from electromyographic studies of
this muscle during deglutition, the muscle is
 Sensation

Epiglottis
Pharyngeal Superior Recurrent Esopha eal
branch laryngeal laryngeal bran%
internal branch
branch

Mucous m'embrane of: Mucous membrane of: Mucous membrane of: Mucous Aembrane
Downloaded by [Australian Catholic University] at 01:56 17 September 2017

levator veli palatini m. laryngopharynx constrictor pharyngis and striated muscle

constrictor pharyngis epiglottis inferior m. of esophagus
superior m. aryepiglottic folds mucous below vocal
constrictor pharyngis laryngeal mucosa folds
medius m. above the vocal folds Esophagus
posterior tongue
(small area)
Joint receptors in larynx

Figure 4. Cranial Nerve X: innervation relevant to deglutition-afferent control.

most likely active during the oral stage of the walls upward. This would likely have an
swallow since this is the time when the palate elevating effect on the structures below.
is depressed, and it may be active during the Pharyngeal muscles innervated by the
pharyngeal stage as an aid in closing off the pharyngeal branch of this cranial nerve in-
oral cavity. The sensory input to this muscle clude the superior and middle pharyngeal
is from Cranial Nerve IX. During the swal- constrictor muscles. These muscles execute
low, there is also contraction of the palato- a circular squeezing action that is important
pharyngeus muscle, which is often referred for increasing the pharyngeal pressures nec-
to as theposteriorfaucialpillnr.The contrac- essary for efficient bolus transport. The
tion of the anterior and posterior faucial pil-
lars results in a narrowing that somewhat
separates the mouth from the oropharynx.
Contraction of the palatopharyngeus muscle
I Efferent controi /
also assists in shortening of the pharynx. The
levator veli palatini muscle elevates the soft Recurrent Superior laryngeal
branch external branch
palate. This action greatly reduces the oppor-
tunity for entrance of the bolus into the na-
Thyroarytenoideus m. Cricopharyngeus m.
sopharynx and likely aids in the development Arytenoideus obliquus rn.
of the increased pharyngeal pressure. Al- Arytenoideus transversus m.
Cricoarytenoideus lateral m.
though small, the uvular muscle can shorten Aryepiglotticus m.
and elevate the uvula. Such movement could Thyroepiglotticus m.
Cricoarytenoideus posterior m.
also assist in closure of the velopharyngeal
port. The salpingopharyngeus muscle el- Figure 5. Cranial Nerve X: innervation relevant
evates the nasopharynx and draws the lateral to deglutition-efferent control.

Efferent control
L,
Constrictor phar))ngis superior m.
Constrictor pharyngis medius m.
Constrictor pharyngis inferior m.
Levator veli palatini m.
Palatopharyngeus m.
Salpingopharyngeus m.
Palato lossus m.
~ u s c u q u suvulae m.
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Figure 6. Pharyngeal plexus: innervation rel-
evant to deglutition.
lower pharyngeal muscles have different in-
nervation. The external branch of the supe-
rior laryngeal nerve shares with the recurrent
nerve in the innervation of the inferior pha-
ryngeal constrictor muscle and the crico-
pharyngeus muscle.
The recurrent laryngeal nerve innervates
all but one intrinsic laryngeal muscle. That
muscle, the cricothyroid is innervated by the
external branch of the superior laryngeal
nerve and is important for pitch control dur-
ing phonation but appears to have little or no
importance for swallowing. The posterior
cricoarytenoid muscle is the only muscle that
abducts the vocal folds; thus, it is activated at
the completion of a swallow. All other intrin-
sic muscles contribute to vocal-fold adduc-
tion and have an important role in airway
protection. The intrinsic muscles that close
the glottis include the transverse (an un-
paired muscle) and oblique arytenoid, lateral
cricoarytenoid, lateral thyroarytenoid, and
medial thyroarytenoid (also known as the
vocalis muscle). The first three muscles
bring the vocal folds to a more medial posi-
tion, but contraction of these does not result
in complete glottal closure. It is the contrac-
tion of the medial and lateral thyroarytenoid
muscles that shortens, thickens, and fully
adducts the vocal folds. Although the aryepi-
Neuroanatomy and Neurophysiolog~l 9
glottic muscle has previously been described
in the literature as contributing to laryngeal
closure, VanDaele et al. (1995) reported that
aryepiglottic ~nuscletissue often was not
present in otherwise normal human aryepi-
glottic tissue specimens they studied.
Cranial Nerve XI1
Afferent controls
Cranial Nerve XI1 is a motor nerve, and,
therefore, there is no sensory component.
(See Figure 7.)
Efferent controls
This nerve innervates all of the intrinsic
and extrinsic muscles of the tongue. Fibers
from this nerve originate in the hypoglossal
nucleus of the medulla, and voluntary tongue
movement is innervated by fibers that are
derived from the corticobulbar tract. Addi-
tionally, fibers from the primary sensory
nucleus of Cranial Nerve V and from the
nucleus tractus solitarius enter the hypoglos-
sal nucleus to activate reflexive actions.
Of the intrinsic tongue muscles, the supe-
rior longitudinal muscle shortens the tongue
and turns the tip and lateral margins upward,
the inferior longitudinal shortens the tongue
and pulls the tip downward, the transverse
1 Efferent control 1
Su erior longitudinalis linguae r
n
InRrior longitudinalis linguae m.
Transversus rn.
Hyoglossus m.
Genio lossus m
Sty~ogksrusm. .
Geniohyoideus m.
Thyrohyoideus m.
Figure 7. Cranial Nerve XII: innervation rel-
evant to deglutition.
 muscle narrows and elongates the tongue,
and the verticalis muscle flattens and widens
the tongue. Certain extrinsic tongue muscles
that are very important to deglutition are also
innervated by this cranial nerve. As men-
tioned earlier, the thyrohyoid muscle is the
primary muscle of laryngeal elevation. On
contraction, it brings the thyroid cartilage
upward into close approximation with the hy-
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oid bone. The geniohyoid muscle helps draw
the hyoid bone in an anterior and superior
direction. Other muscles that are innervated by
this cranial nerve and that contribute to a safe
swallow are the hyoglossus and the genioglos-
sus muscles. If the tongue is fixed (which
occurs at the end of the bolus transport phase),
the hyoglossus muscle assists in hyoid eleva-
tion. If the hyoid is fixed, the tongue is retracted
and depressed by this muscle. The genioglos-
sus muscle assists in forming a channel for
bolus transport by making the tongue concave,
and the styloglossus muscle draws the tongue
upward and backward.
Ansa cervicalis
The ansa cervicalis is formed from the
anterior division of cervical spinal nerves
C1-C4. Three infrahyoid muscles that serve
to depress the hyoid are innervated by fibers
from this plexus: the sternohyoid, sternothy-
roid, and omohyoid muscles. Little is known
about their actions during or at the comple-
tion of the swallow. (See Figure 8.)
RESEARCH RELATING TO
POTENTIAL AREAS OF
BREAKDOWN AS A RESULT OF
STROKE: CORRESPONDING
DYSPHAGIC SYMPTOMATOLOGY
Many important concerns for the stroke
patient who has dysphagia are related to the
1 Efferent control 1
I
Sternohyoid m.
Omohyoid m.
Sternothyroid m.
Figure 8. Ansa cervicalis: innervation relevant
to deglutition.
risks associated with aspiration, malnutri-
tion, and dehydration. Aspiration is a fre-
quently observed phenomenon following
stroke and has been reported by various in-
vestigators. For example, when videofluoro-
graphic examinations were performed on 47
patients who had been referred for swallow-
ing evaluations poststroke, 51% (24) of the
patients were found to aspirate (Horner,
Massey, Riski, Lathrop, & Chase, 1988).
Aspiration was found among patients with
unilateral cortical and unilateral brain stem
strokes as well as among those with bilateral
signs of stroke. Additionally, silent aspira-
tion (no overt signs of discomfort, no cough-
ing) was observed in 13 of the 24 patients
who had been observed to aspirate on
videofluorography. In that report, no differ-
ences in aspiration were noted between right
and left hemisphere strokes. Teasell, Bach,
and McRae (1994) also found no differences
among 54 right and left hemisphere stroke
patients who had been admitted to a stroke
rehabilitation facility. However, other inves-
tigators have found differences between the
two populations (Robbins & Levine, 1988;
Robbins, Levine, Maser, Rosenbek, &
Kempster, 1993).
An investigation of patients who had ex-
perienced brain stem strokes (Horner,
Buoyer, Alberts, & Helms, 1991) reported
that 15 of the 23 patients they studied exhib-
ited aspiration; pontine lesions were present

in 13 of the patients. According to the inves-
tigators, all the brain stem stroke patients
with vocal-fold weakness and with dysar-
thria were found to aspirate. Of those patients
who were examined, 83% resumed oral feed-
ing. Another investigation of brain stem in-
volvement studied patients who had been
diagnosed with Wallenberg's lateral medul-
lary syndrome (Sacco et al., 1993). In this
study, 52% of the patients were found to be
Downloaded by [Australian Catholic University] at 01:56 17 September 2017
dysphagic. The investigators speculated that
the number of patients with documented dys-
phagia was low because many of their sub-
jects had only mild or partial strokes. Eight
stroke patients who were diagnosed as hav-
ing a left basal ganglionlinternal capsule
stroke were reported to demonstrate longer
oral transit time, longer pharyngeal transit
time, and a longer pharyngeal delay with
more viscous bolus materials than did nor-
mal subjects (Logemann, Shanahan, Rade-
maker, & Kahrilas, 1993).
Among stroke patients, aspiration of
nongastric material has been found to be a
significant indicator of respiratory complica-
tions or death. In a study of 26 stroke patients
with videofluorographic evidence of aspira-
tion and 33 dysphagic stroke patients with no
videofluorographic evidence of aspiration, it
was found that the odds ratio for developing
pneumonia was 7.6 times greater for those
patients who had aspirated than for those
who did not. Also, the odds ratio for death
was 9.2 times greater for patients who aspi-
rated thickened viscosities than for those
who aspirated only thin liquids (Schmidt,
Holas, Halvorson, & Reding, 1994).
In an attempt to determine the relationship
between aspiration and a set of variables that
can be identified on videofluorographic ex-
amination of oral pharyngeal swallowing
function, Perlman, Booth, and Grayhack
Neuroanatomy and Neurophysiology 11
(1994) studied 330 dysphagic patients in an
acute care hospital. Of those patients, 101
were referred as a result of a stroke and were
examined generally within a few days post-
episode. Table 1 shows the breakdown by
site of lesion and the variables that were
studied. These variables are defined in an
earlier article (Perlman, Grayhack, & Booth,
1992). Additional studies of this type should
include more of the variables examined dur-
ing videofluorography. The investigators
state that the percentage of brain stem pa-
tients who were observed aspirating was low
because patients with no evidence of a pha-
ryngeal swallow were not investigated by
videofluorography and therefore were not
included in the database. That is to say, only
brain stem stroke patients who had a swallow
were included in the study. Although the
incidence of oral stage dysphagiais still quite
high, there is a lower incidence of oral stage
dysphagia among patients diagnosed with
brain stem strokes than with all other types.
This is compatible with the information pre-
viously reported (Miller, 1993; Miller et al.,
1996). Also of interest is the high level of
aspiration noted among subcortical stroke
patients. The breakdown in deglutition in the
subcortical population occurred as a result of
insult at various sites, including the thalamus
or internal capsule.
Pharyngeal transit time was not one of the
variables studied in the report of Perlman and
colleagues (1994). However, another inves-
tigation (Johnson, McKenzie, & Sievers,
1993) found a significant correlation with the
eventual development of aspiration pneumo-
nia. Of 304 patients admitted with acute
stroke, 60 patients were referred for video-
fluorographic assessment. Johnson et al. re-
port that of those 60 patients, 29 developed
aspiration pneumonia within 1 year post-
 Table 1. Percentage of stroke patients who exhibited certain variables associated with dysphagia

Site of lesion ASP DPS VS PSS HPS RHE DEF ORAL

Brain stem (12) 25.0 50.0 41.7 41.7 25.0 8.3 25.0 41.7
Left (39) 35.9 56.4 59.0 41.0 18.0 7.7 59.0 69.2
Right (26) 38.5 38.5 53.9 30.8 38.5 11.5 46.2 57.7
Subcortical (8) 75.0 87.5 75.0 37.5 62.5 0.0 62.5 62.5
Other or
unknown (16) 43.8 68.8 62.5 50.0 50.0 12.5 56.3 62.5
All strokes (101) 39.6 44.0 57.4 39.6 32.6 8.9 51.5 61.4
Downloaded by [Australian Catholic University] at 01:56 17 September 2017

Note. ASP = aspiration; DPS =delayedinitiationof pharyngeal stage of the swallow; VS = vallecular stasis; PSS = pyriform sinus
stasis; HPS =diffuse hypopharyngeal stasis; RHE =reduced hyoid elevation; DEF = deviant epiglottic function; ORAL = oral
involvement. Source: Adapted with permission from Perlman, A.L., Booth, B.M., & Grayhack. J.P. (1994). Videofluoroscopic
predictors of aspiration in patients with oropharyngeal dysphagia. Dysphagia, 9, 90-95, O 1994, Springer-Verlag.

stroke. The diagnosis of aspiration pneumo- issue is in need of investigation. Meanwhile,

nia was made using the scale described by
DePaso (1991).
Although much of the literature relating to
stroke and dysphagia has been directed to-
ward determining the likelihood of aspira-
tion, aspiration is only one of many symp-
toms of dysphagia observed in stroke
patients; this is evidenced by the data pre-
sented in Table 1. Those observations that
contribute to decreased oral intake with the
possible result of compromised nutritional
levels must also be considered when deter-
mining treatment options for the patient. This
clinicians responsible for patient rehabilita-
tion following stroke must pay close atten-
tion to the laboratory values indicating a
potential for malnutrition, results of the cra-
nial nerve examination, the perceptual char-
acteristics of the patient's speech and voice
production, and other indicators suggestive
of dysphagia (Perlman et al., 1991). When
dysphagia is suspected, it is important to
follow up with a videofluorographic exami-
nation and other appropriate instrumental
techniques (Perlman, in press) because,
without observational assessment, appropri-
ate treatment decisions generally cannot be
determined.

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