Anatomy Of Articulation

*Adjustment of the shape, and therefore the acoustic properties of the vocal tract
*"the process of joining two elements together"
*articulators-Structures which come together or change shape of the vocal tract

*Bony framework
*22 Bones joined by sutures
*Divided into facial skeleton and cranium

*Mandible
*Maxilla
*Nasal bones
*Palatine bones
*Zygomatic bone
*Vomer bone
*Lacrimal bone
*Hyoid bone

*Unpaired, lower jaw
*Used for mastication
*Landmarks
-Mental symphsis: point of fusion for 2 halves of mandible
-Mental protuberence: runs up to mid line
-Mental tubercles (mental prominences): 2 paired separated by mental protruberance (part that sticks out at midline)
-Mental foramen: holes that are lateral to the tubericle for cranial nerve V
-Ramus: the rise, where the mandible goes up.

*Ramus-the rise
*Corpus-the body
*Angle-Corner between corpus and ramus.
*Condylar process-articulates with skull and allows for rotation of the mandible
*Coronoid process-point of attachment for lateral pterygoid muscle.
*Mandibular notch-separates the condoylar and coronoid process
*Dental Alveoli-small sacs that hold teeth on alveolar arch
*Alveolar Arch-see above
*Mental spines-point of attachment for muscles. bumps on the inside of the mandible.
*Mylohyoid line-line on the inside bottom of mandible. Point of attachment for mylohyoid muscle.

*Upper jaw, roof of mouth, floor of orbital cavity
*paired

*Frontal process-superior most part of bone
*Infraorbital margin-near the eye
*Infraorbital foramen-holes for cranial nerve V-trigeminal
*Zygomatic process-articulates with the zygomatic bones (cheek bones)
*Anterior nasal spine (anterior nasal crest) anterior of nasal crest
*Nasal crest-behind ant nasal spine
*Alveolar process-tooth bearing ridge on the top. Contain alveoli sacs for teeth
*Maxillary sinus-cavity
*Palatine process-roof of mouth
*Intermaxillary suture (median palatine suture) where two palatine bones articulate (where cleft pallate occurs)
*Premaxilla-separates lateral incisors and cuspids. hard to see in an adult. (where cleft lip occurs)

*Bridge of nose. most is cartilage. bone is at the top (bridge) of the nose

*Comprises posterior 1/4 of hard palate and extend superiorly.
Landmarks:
-posterior nasal spine: At midline of 2 bones and correlates w nasal spine of maxilla.
-Horizontal plate: Parallels the palatine process of the maxilla
-Perpendicular plate: Posterior wall of nasal cavity
-Orbital process: small portion of the orbital cavity.

It's big

*Cheek bones
*Zygomatic arch=
Zygomatic bone + temporal bone
Landmarks:
-Body & 4 processes
~Orbital process
~Maxillary process
~Temporal process
~Frontal process

*Unpaired, midline bone
*Makes up part of nasal septum (divides two cavities of nose)
*Looks like knife blade plowshar pointed anteriorly.

*Lacrimal: almost hidden in skull (near tear duct) constitute small part lateral nasal wall and medial orbit

Connected via musculature to mandible, plays role in articulation

*By sutures (non movable joints)
-Saggital
-Lamboidal
-Coronal

-Frontal bone
-Temporal bone
-Occipital bone
-Parietal bones
-Sphenoid bone
-Ethmoid bone

*Unpaired
*Anterior to coronal suture
*Landmarks
-Zygomatic
-Nasal portion
-Orbital portion-provides superior surface of the eye socket

*Houses the hearing mechanism
*Landmarks
-Mastoid portion=mastoid process
-Tympanic portion=styloid process
-Squamous portion=external auditiory meatus (ear canal) + zygomatic process + mandibular fossa
-Petrous portion=cochlea (inner ear) and semicircular canals

*Posterior skull
Landmarks
-Foramen magnum-the opening for the spinal cord and opening for medulla
-Condyle-point where skull articulates with C1
-Cerebellar fossa: marks the location of the cerebellum (on the inside) basically where cerebellum sits.

*Paired, overlie parietal lobes of cerebrum
-Just big. cover parietal lobes. Just two. That's all we need to know.

*Form base of cranium
Landmarks
-Clivus: forms the union with foramen magnum of occipital bone.
-Lesser wings: arise from corpus (body) and partially cover the optic canal
-Greater wings: arise from the posterior corpus and articulate with the frontal and temporal bone.
-Lateral & medial pterygoid plates: points of attachment for muscles
-Hamulus: projects from each medial lamina and is a point of attachment for a tendon (tendon that attaches is called tensor villi palitini)

*Forms walls of orbital and nasal cavities. located behind nose. like core of an apple within brain.
Landmarks
-Crista galli: the superior surface that protrudes into cranial space. (part of nose that goes into brain if you get hit in the nose)
-Perpendicular plate: projects downward and makes up the superior nasal septum.
-Middle & superior nasal conchae: lateral to the perpendicular plate

*Taste
*Mastication (chewing)
*Degultition (swallowing)
It's essential for life, critical for swallowing. For total glossectomy (tongue removal) Need a feeding tube.

*Articulator
-Modifies shape of oral cavity
-Resonance
-High innervation ratio (lots of nerves to a relatively small muscle)

*Longitudinal medial sulcus: also called central sulcus (groove) divides tongue into left/right superficially.
*Sulcus terminalis: terminal sulcus marks the posterior palatine surface.
*Palatine surface: oral surface. Portion of the tongue within the oral cavity. Anterior 2/3rds.
*Pharyngeal surface: posterior 1/3rd of tongue within oropharynx.
*Papillae: Posterior 1/3 of tongue is lined with small irregular prominences (bumps) not tastebuds.
*Lingual frenulum: joins the inferior tongue with the mandible.
*Medial fibrous septum: Deep to the central sulcus. Divides the tongue left and right. Point of attachement for muscles and it originates at the body of the hyoid bone via the hyoglossal membrane. How tongue attaches to hyoid
*Sublingual folds: Transverse bands of tissue on either side of the inferior tongue. (runs laterally on both sides of tongue.

*Tip/Apex-anterior
*Base/root-posterior/back. root is bottom
*Dorsum-superior/top surface

*Provide fine modifications of tongue for precise articulation
-Superior longitudinal
-Inferior longitudinal
-Transverse
-Vertical

*In middle of tongue
*Shortens and turns tip up.
Superior, paired, and courses the length of the tongue. Forms the upper layer of the tongue. If contracted unilateraly, tongue will move toward the contracted side.

*Underside of tongue
*Draws tip down
Runs root to apex. Absent in the medial tongue because of genioglossus. Helps with lingual retraction if contracted with superior. Unilateral contraction moves tongue toward contraction and down.

*Courses laterally from median septum
*Narrows tongue
When contracted it pulls edges of tongue toward midline.

*Right angle to transverse
*Runs base of tongue to dorsum
Contraction pulls tongue into floor of mouth

*Move tongue as unit "sets general posture for articulation"
-Genioglossus
-Styloglossus
-Hyoglossus
-Palatoglossus

*Bulk of tongue
*Protrudes, retracts, depresses tongue
Primary mover of tongue, originates on inner mandibular surface. Fans out and inserts into the apex, dorsum, and hyoid. Different fibers of the muscle can be contracted independently facilitating different movements.

*Draws tongue up, back
*Antagonist to genioglossus
Originates at the styloid process, and inserts into the inferior margin of the tongue. When contracts, brings tongue up and back.

*Pulls sides of tongue down
*Antagonist to palatoglossus
-Arises from the hyoid bone courses up and inserts into the sides of tongue between styloglossus and interior longitudinal muscle. Contracts, pulls tongue sides down.

*Also muscle of soft palate
*Elevates posterior tongue
*=anterior faucial pillar
Muscle of tongue and soft palatte. Makes up part of the anterior faucial pillar. Has a dual purpose to depress velum and elevate back of tongue.

*Cupid's bow-the double curve of the upper lip.
*Vermillion zone-red part of the lip. rich in capillaries w/very thin epithelium.
*Philtrum=infranasal depression. The vertical groove over upper lip. No function. Just visual prominence.
*Columella (nasi)-the small column between nares (nostrils)
-note-there are no salivary glands on the lips, so we lick them.

Levator labii superioris
Levator labii aleque nasi superior
Levator anguli oris
Depressor labi inferioris
Depressor anguli oris
Risorus
Orbicularis oris
Metalis
Platysma
Buccinator
Zygomatic minor

*Superior/Inferior
*Drawstring contraction
*Pursing of lips
*Point of insertion for many other muscles

*Retracts corners of mouth
*Originates posterior face along masseter
*Inserts into orbicularis oris at corners of mouth

*Deep and parallel to risorius
*Retracts lips
*Mastication

*Originates infraorbital margin maxilla
*Inserts mid-lateral region of upper lip
*Elevates upper lip
(this and the next two muscles make up the levator triad. Share point of insertion, common function to elevate lip).

*Originates frontal portion of maxilla
*Courses vertically along lateral nose
*Inserts mid-lateral region upper lip
*Elevates upper lip
(sounds like labi alaquay nasi...by nose, part of levator triad)

*Originates facial process zygomatic bone
*Inserts mid-lateral region upper lip
*Elevates upper lip.
(third of levator triad)

*Obscured by levator labii superioris
*Draws corners of mouth up and medially

*Lateral to zygomatic minor, inserts into corner orbicularis oris
*Elevates and retracts angle of mouth
:) for smiling :)

*Counterpart for "levator triad"
*Originates from mandible
*Inserts into lower lip
*Pulls lips down and out

*AKA triangularis
*Fanlike projection from mandible to obicularis oris and corner of upper lip.
*Depresses corners of mouth. Helps compress upper lip against lower lip (Frown) :(

*Originates from mandible
*Courses down and inserts into chin
*Elevates and wrinkes chin, pulls lower lip out (pout) :<

*Often considered a neck muscle
*Originates from pec major/deltoid fascia
*Courses up, inserts into corner of mouth, lower mandible
*Depress mandible

Teeth
*Housed within alveoli of maxillae and mandible
*Used for mastication and articulation

*Crown: visible 1/3rd of tooth.
*Root: Hidden under gingiva (gumline)
*Neck: juncture of crown and root
*Enamel: Hard surface of the crown
*Dentin: ivory of tooth just deep to the enamel.
*Pulp: Houses the nerves
*Cementum: thin layer of bone that holds the tooth in the socket
*Peridontal Ligament: Attaches tooth to the alveolar bone and helps withstand the forces of chewing.

Midline is between two central incisors.
*Medial: part of tooth facing midline
*Distal: part of tooth facing away from midline
*Lingual: surface that comes in contact with the tongue
*Buccal: Surface that comes in contact with the cheeck
*Occlusal: contact between the upper and lower arches, where upper and lower teeth touch. There is thick enamel because of abrasion.

*Incisors: Central (middle two) and lateral
*Cuspids: aka canine
-1st bicuspis
-2nd bicuspid
1st molar
2nd molar
3rd molar (wisdom tooth)

Occlusion: process of bringing the upper and lower teeth into contact. Essential for mastication.
Class I occlusion-normal. 1st molar of mandibular arch is 1/2 tooth advanced of the maxillary molar. The upper incisors project over the lower incisors by a few mm, so they hide lower incisors naturally.
Class II malocclusion-overbite The first mandibular molars aer retracted at least one tooth from the first maxillary molars
Class III malocclusion-underbite The first mandibular molar is advanced farther than one tooth beyond the maxillary molar, so the mandible is protruded.

*Deciduous teeth (shedding): baby teeth
*Erupt 6 months-2 years
*10 Deciduous teeth
-4 incisors
-2 cuspids
-2 first molars
-2 second molars

*Oral
*Buccal
*Nasal
*Pharyngeal

*Extends from lips to faucial pillars-arches in back of mouth
Landmarks:
*Hard palate: roof of mouth
-Rugae: Creases that run laterally
*Velum: Soft palate posterior to hard palate and it's a movable mass separating nasal and oral cavities. Attached to the palatine bone, therefore it's a muscular extension of the hard palate.
*Uvula: Termination of the velum
*Anterior/Posterior faucial pillars: Prominate tissue bands on either side of the velum. They are continuous with the velum and mark the posterior margin of the oral cavity.
*Palatine tonsils: are tonsils. Lymphoid tissue masses situate between anterior and posterior faucial pillars.

Between dental arches and cheek

Nasal Sounds, also we care about this because you don't want nasal regurgitation of food in swallowing.

Pharynx is 12 cm long tube between nose and vocal cords.
*Nasopharynx: above the soft palate
-Pharyngeal tonsils (adenoids): mass of lymphoid tissue that arises from the base of the posterior nasopharynx. May provide support for velum, so an adenoidectomy can cause hypernasality.
-Eustachian tubes: Maintain the pressure in the middle ear (goes from ear to nasopharynx, ear pop on plane)
*Oropharynx: Immidiately posterior to the facuial pillars. Bound by velum above & the hyoid below.
-Velopharengeal port: is the opening between the oropharynx and the nasopharynx. If you have velppharyngeal incompetence (velum doesn't hit wall)= nasal regurgitation of food and hypernasality.
*Laryngopharynx/hypopharynx: goes from hyoid bone to the vocal fold.

Origin: Zygomatic Arch
Course: Down
Insertion: Ramus of mandible and coronoid process
Function: Elevate mandible. BIG most superficial muscle of mastication.

Origin: Temporal and parietal bones
Course: down, forward through zygomatic arch
Insertion: coronoid process and ramus
Function: Elevate, retract mandible. Big too. Brings jaw up and back, like movement for chewing.

Origin: pterygoid plate of sphenoid
Course: down and back
Insertion: ramus of mandible
Function: Elevates mandible

Origin: Greater wing and lateral pterygoid plate of sphenoid
Course: Back
Insert: Condyloid process mandible
Function: protrudes mandible. Deep underneath jaw bone. moves jaw forward.

Origin: Symphsis of mandible, mastoid process of temporal bone
Course: Medially and down
Insert: Intermediate tendon to hyoid bone
Function: If hyoid bone is stable, depresses mandible (drop jaw bone once hyoid is as high as it can go)

Platysma, Geniohyoid, Mylohyoid. Elevate the hyoid and depress mandible.

Origin: Mental spine of mandible
Insert: hyoid bone
Function: depress mandible

Origin: Mylohyoid line inside mandible
Inserts: median raphe and hyoid bone
Function: Depress mandible if hyoid stable.

*Velum elevates for speech (non-nasal sounds) and swallowing (so food doesn't go up nose. nasal regurgitation)
*Palatal aponeurosis point of insertion. sheet for muscles to attach.
*Contains taste buds
*Elevates, tenses, depresses

Origin: temporal bone (petrous portion, Eustachian tube)
Course: Inferior and anterior
Insert: Palatal aponeurosis on either side of uvula. Attaches to arches on either side of uvula.
Function: Elevates and retracts soft palate from the back. Helps to close nasal port.

Origin: Posterior nasal spine of palatine bone and aponeurosis
Couse: Posteriorly on both sides of midline
Insert: Mucous membrane cover of velum
Function: Shortens velum (soft palate) When contracts, lifts up velum, close VP port.

Origin: sphenoid bone and eustachian tube
Course: Inferior to tendon
Insert: Tendon loops around hamulus and into palatal aponeurosis
Function: Tenses velum, dilates Eustachian tube. Next to evator veli palatini. All to close VP port.

*Anterior faucial pillar
*Also a muscle of tongue
Origin: sides of apoeurosis
Insert: sides of tongue at back
Function: depress velum, creates arch called palatoglossal arch.
*Important. aka anterior faucial pillar, the first arch.

*Posterior faucial pillar
*Pharyngeal muscle
Origin: hard and soft palates
Insert: posterior thyroid cartilage
Function: Elevates larynx, constricts pharynx, depresses velum. Second "rainbow" of the throat (2nd faucial pillar) Goes far down. posterior thyroid cartilage is deep.

*Used in swallowing
*Constricts pharynx to push bolus into esophagus
*Landmark: pharyngeal raphe=vertical midline. point of attachment to muscles.
Pharyngeal aponerosis=faucial sheet within walls liked with mucus membrane and covered by pharyngeal constrictors.

Origin: posterior to buccinator
Course: posteriorly
Insert: medial pharyngeal raphe
Function: helps close velopharyngeal port. Also forms lateral and posterior walls of oro and nasopharynx. This is very high up. makes walls of phayrnx.

Origin: Hyoid bone
Course: up and back
Inserts: medial pharyngeal raphe
Function: Constricts diameter of pharynx. Lower than previous. squeeze pharynx to propel bolus down.

aka Cricopharyngeus
Origin: cricoid cartilage
Course: Back
Inserts: orifice of esophagus
Function: Constrict superior orifice of esophagus. One of two parts (lower/inferior). Muscle forms a ring and constricts.

Thyropharyngeus
*Origin: thyroid
*Course: up and back
*Insert: median pharyngeal raphe
Function: reduce diameter of lower pharynx.

Origin: Eustachian tube
Course: Down
Insert: Converges with palatopharyngeus
*Function: elevates lateral pharyngeal wall.

Origin: Styloid process
Course: Down
Insert: Into pharyngeal constrictors and posterior thyroid cartilage.
Function: Elevates and opens pharynx.

Oral Prepatory
Oral
Pharyngeal
Esophageal

Mastication: receipt of bolus-spoon or straw, to see if mouth has suction/labial seal.
Molars, tongue, saliva: all voluntary actions.
Facial muscles: velar, tongue, mandible. Press food against hard and soft palate to make a bolus. Voluntary control.
Tight labial seal: w/o can't suck. respiratory problems. palate/muscle weakness. need muscles controlled and raised. If VP port falls prematurely, can choke.

Deglutition=swallow. moving bolus posteriorly.
Tongue pumps, acts as a piston
Volitional control
Swallow should trigger when bolus passes faucial pillars/base of tongue, BOT.

*Not under volitional control. Involuntary!
*Soft palate elevates
*Hyoid elevates
*FVF and TVF close in case food escapes and epiglottis doesn't deflect.
*Epiglottis inverts
*Respiration stops
*UES relaxes: Upper esphageal sphincter relaxes so food can go down.
*Pharyngeal constrictors propel bolus. Problems? VP nasal regurgitation. Muscle weakness=lots of residue. Like drinking thick milk, residue doesn't go away. Biggest risk is aspiration.
Penitration: When bolus is in laryngeal vestibule but does not go through vocal cords. Aspiration when passes through VC. Problem when you have a paralyzed chord, but if epiglottis still works, your ok. Look out for pulmonary problems-aspiration & pneumonia.
So much happens in this phase!

*Bolus moves from UES to LES by peristalic contractions.
*GERD: Gastro esophogeal reflux disorder. Gravity helps with GERD.
-Bit controvercial. CP = cricopharyngeus and upper esophageal spincter is the same thing.

Difficulty moving food from mouth to stomach

*Decreased attention to eating/drinking
*Pocketing/holding food in mouth
*Coughing or throat clearing before, during, and after swallow
*Loss of food in mouth
*Change in vocal quality or breathing sounds after eating/drinking
*Patients body language/complaints.

*ASPIRATION: Food or liquid enters the airway/lungs (goes down the wrong pipe)
*Pneumonia
*Respiratory distress
*Weight loss/malnutrition
*Dehydration
*Loss of pleasure with eating/drinking
*Death

Subjective: Bedside/clinical evaluation precedes all other assessments. done in patients room
Objective:
-Modified Barium Swallow (MBS): x-ray aka, videofloroscopic swallow assessment
-Fiberoptic Endoscopic Evaluation of Swallowing (FEES): invasive test, scope through nose.

*Oral Prep
*Oral Phase
*Pharyngeal Phase
*Esophageal Phase

Look for strength, symmetry, good range of motion, sensation from:
-lips
-tongue
-jaw
-cheeks
-gag (controversial to impose)
-teeth/dentures?
-oral hygiene
-Cough
-Voice

1. Thin liquids (water/juice)
2. Nectar thick liquid
3. Honey thick liquid
4. Puree (applesauce, pudding)
5. Mechanical soft: Stew, pasta
6. Solids (normal: dry crackers & meat)
*typically start w/ice chips or puree

*Coughing
*Throat clearing
*Wet breath sounds
*Wet vocal quality.

Get objective test:
Modified barium swallow study: "the GOLD standard"

Modified barium swallow: A real time x ray of the swallow and transit of food/liquid from the mouth to the upper espohagus. Where is the food going and why?

Fiberoptic Endoscopic Evaluation of Swallowing:
-Alternative objective test:
*Invasive scope w/camera through nose to just above the vocal folds
*Watch swallow function from above
*Right pipe, wrong pipe, both?

SLP Makes Reccomondations
*What is safe to eat
*Feeding modifications
*Positioning
*Manuvers (chin tuck, head turn, etc)
*Level of supervision
*When to reassess?
*Followup with diet checks
*Advance as appropriate