How many times does a human swallow in 24 hours?


It is my understanding from an Orofacial Myofunctional Therapist that human beings swallow approximately 2000 times a day with a pressure of 4 pounds on the palate.

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Swallowing, known scientifically as deglutition, is the process in the human or animal body that makes something pass from the mouth, to the pharynx, and into the esophagus, while shutting the epiglottis. If this fails and the object goes through the trachea, then choking or pulmonary aspiration can occur. In the human body it is controlled by the swallowing reflex. Eating and swallowing are complex neuromuscular activities consisting essentially of three phases, an oral, pharyngeal and esophageal phase. Each phase is controlled by a different neurological mechanism. The oral phase, which is entirely voluntary, is mainly controlled by the medial temporal lobes and limbic system of the cerebral cortex with contributions from the motor cortex and other cortical areas. The pharyngeal swallow is started by the oral phase and subsequently is co-ordinated by the swallowing center in the medulla oblongata and pons. The reflex is initiated by touch receptors in the pharynx as a bolus of food is pushed to the back of the mouth by the tongue. Swallowing is a complex mechanism using both skeletal muscle (tongue) and smooth muscles of the pharynx and esophagus. The autonomic nervous system (ANS) coordinates this process in the pharyngeal and esophageal phases. Prior to the following stages of the oral phase, the mandible depresses and the lips abduct to allow food or liquid to enter the oral cavity. Upon entering the oral cavity, the mandible elevates and the lips adduct to assist in oral containment of the food and liquid. The following stages describe the normal and necessary actions to form the bolus, which is defined as the state of the food in which it is ready to be swallowed. 1) Moistening Food is moistened by saliva from the salivary glands (parasympathetic). 2) Mastication Food is mechanically broken down by the action of the teeth controlled by the muscles of mastication (Vc) acting on the temporomandibular joint. This results in a bolus which is moved from one side of the oral cavity to the other by the tongue. Buccinator (VII) helps to contain the food against the occlusal surfaces of the teeth. The bolus is ready for swallowing when it is held together by (largely mucus) saliva (VII—chorda tympani and IX—lesser petrosal), sensed by the lingual nerve of the tongue (Vc). Any food that is too dry to form a bolus will not be swallowed. 3) Trough formation A trough is then formed at the back of the tongue by the intrinsic muscles (XII). The trough obliterates against the hard palate from front to back, forcing the bolus to the back of the tongue. The intrinsic muscles of the tongue (XII) contract to make a trough (a longitudinal concave fold) at the back of the tongue. The tongue is then elevated to the roof of the mouth (by the mylohyoid (mylohyoid nerve—Vc), genioglossus, styloglossus and hyoglossus (the rest XII)) such that the tongue slopes downwards posteriorly. The contraction of the genioglossus and styloglossus (both XII) also contributes to the formation of the central trough. 4) Movement of the bolus posteriorly At the end of the oral preparatory phase, the food bolus has been formed and is ready to be propelled posteriorly into the pharynx. In order for anterior to posterior transit of the bolus to occur, orbicularis oris contracts and adducts the lips to form a tight seal of the oral cavity. Next, the superior longitudinal muscle elevates the apex of the tongue to make contact with the hard palate and the bolus is propelled to the posterior portion of the oral cavity. Once the bolus reaches the palatoglossal arch of the oropharynx, the pharyngeal phase, which is reflex and involuntary, then begins. Receptors initiating this reflex are proprioceptive (afferent limb of reflex is IX and efferent limb is the pharyngeal plexus- IX and X). They are scattered over the base of the tongue, the palatoglossal and palatopharyngeal arches, the tonsillar fossa, uvula and posterior pharyngeal wall. Stimuli from the receptors of this phase then provoke the pharyngeal phase. In fact, it has been shown that the swallowing reflex can be initiated entirely by peripheral stimulation of the internal branch of the superior laryngeal nerve. This phase is voluntary and involves important cranial nerves: V (trigeminal), VII (facial) and XII (hypoglossal). For the pharyngeal phase to work properly all other egress from the pharynx must be occluded—this includes the nasopharynx and the larynx. When the pharyngeal phase begins, other activities such as chewing, breathing, coughing and vomiting are concomitantly inhibited. 5) Closure of the nasopharynx The soft palate is tensed by tensor palatini (Vc), and then elevated by levator palatini (pharyngeal plexus—IX, X) to close the nasopharynx. There is also the simultaneous approximation of the walls of the pharynx to the posterior free border of the soft palate, which is carried out by the palatopharyngeus (pharyngeal plexus—IX, X) and the upper part of the superior constrictor (pharyngeal plexus—IX, X). 6) The pharynx prepares to receive the bolus The pharynx is pulled upwards and forwards by the suprahyoid and longitudinal pharyngeal muscles – stylopharyngeus (IX), salpingopharyngeus (pharyngeal plexus—IX, X) and palatopharyngeus (pharyngeal plexus—IX, X) to receive the bolus. The palatopharyngeal folds on each side of the pharynx are brought close together through the superior constrictor muscles, so that only a small bolus can pass. 7) Opening of the auditory tube The actions of the levator palatini (pharyngeal plexus—IX, X), tensor palatini (Vc) and salpingopharyngeus (pharyngeal plexus—IX, X) in the closure of the nasopharynx and elevation of the pharynx opens the auditory tube, which equalises the pressure between the nasopharynx and the middle ear. This does not contribute to swallowing, but happens as a consequence of it. 8) Closure of the oropharynx The oropharynx is kept closed by palatoglossus (pharyngeal plexus—IX, X), the intrinsic muscles of tongue (XII) and styloglossus (XII). 9) Laryngeal closure It is true vocal fold closure that is the primary laryngopharyngeal protective mechanism to prevent aspiration during swallowing. The adduction of the vocal cords are effected by the contraction of the lateral cricoarytenoids and the oblique and transverse arytenoids (all recurrent laryngeal nerve of vagus). Since the true vocal folds adduct during the swallow, a finite period of apnea (swallowing apnea) must necessarily take place with each swallow. When relating swallowing to respiration, it has been demonstrated that swallowing occurs most often during expiration, even at full expiration a fine air jet is expired probably to clear the upper larynx from food remnants or liquid. The clinical significance of this finding is that patients with a baseline of compromised lung function will, over a period of time, develop respiratory distress as a meal progresses. Subsequently, false vocal fold adduction, adduction of the aryepiglottic folds and retroversion of the epiglottis take place. The aryepiglotticus (recurrent laryngeal nerve of vagus) contracts, causing the arytenoids to appose each other (closes the laryngeal aditus by bringing the aryepiglottic folds together), and draws the epiglottis down to bring its lower half into contact with arytenoids, thus closing the aditus. Retroversion of the epiglottis, while not the primary mechanism of protecting the airway from laryngeal penetration and aspiration, acts to anatomically direct the food bolus laterally towards the piriform fossa. Additionally, the larynx is pulled up with the pharynx under the tongue by stylopharyngeus (IX), salpingopharyngeus (pharyngeal plexus—IX, X), palatopharyngeus (pharyngeal plexus—IX, X) and inferior constrictor (pharyngeal plexus—IX, X).This phase is passively controlled reflexively and involves cranial nerves V, X (vagus), XI (accessory) and XII (hypoglossal). The respiratory center of the medulla is directly inhibited by the swallowing center for the very brief time that it takes to swallow. This means that it is briefly impossible to breathe during this phase of swallowing and the moment where breathing is prevented is known as deglutition apnea. 10) Hyoid elevation The hyoid is elevated by digastric (V & VII) and stylohyoid (VII), lifting the pharynx and larynx up even further. 11) Bolus transits pharynx The bolus moves down towards the esophagus by pharyngeal peristalsis which takes place by sequential contraction of the superior, middle and inferior pharyngeal constrictor muscles (pharyngeal plexus—IX, X). The lower part of the inferior constrictor (cricopharyngeus) is normally closed and only opens for the advancing bolus. Gravity plays only a small part in the upright position—in fact, it is possible to swallow solid food even when standing on one’s head. The velocity through the pharynx depends on a number of factors such as viscosity and volume of the bolus. In one study, bolus velocity in healthy adults was measured to be approximately 30–40 cm/s. 12) Esophageal peristalsis Like the pharyngeal phase of swallowing, the esophageal phase of swallowing is under involuntary neuromuscular control. However, propagation of the food bolus is significantly slower than in the pharynx. The bolus enters the esophagus and is propelled downwards first by striated muscle (recurrent laryngeal, X) then by the smooth muscle (X) at a rate of 3–5 cm/s. The upper esophageal sphincter relaxes to let food pass, after which various striated constrictor muscles of the pharynx as well as peristalsis and relaxation of the lower esophageal sphincter sequentially push the bolus of food through the esophagus into the stomach. 13) Relaxation phase Finally the larynx and pharynx move down with the hyoid mostly by elastic recoil. Then the larynx and pharynx move down from the hyoid to their relaxed positions by elastic recoil. Swallowing therefore depends on coordinated interplay between many various muscles, and although the initial part of swallowing is under voluntary control, once the deglutition process is started, it is quite hard to stop it. Swallowing becomes a great concern for the elderly since strokes and Alzheimer's disease can interfere with the autonomic nervous system. Speech therapy is commonly used to correct this condition since the speech process uses the same neuromuscular structures as swallowing. In terminally ill patients, a failure of the reflex to swallow leads to a build-up of mucus or saliva in the throat and airways, producing a noise known as a death rattle (not to be confused with agonal respiration, which is an abnormal pattern of breathing due to cerebral ischemia or hypoxia). Abnormalities of the pharynx and/or oral cavity may lead to oropharyngeal dysphagia. Abnormalities of the esophagus may lead to esophageal dysphagia. The failure of the lower esophagous sphincter to respond properly to swallowing is called achalasia. In many birds, the esophagus is largely a mere gravity chute, and in such events as a seagull swallowing a fish or a stork swallowing a frog, swallowing consists largely of the bird lifting its head with its beak pointing up and guiding the prey with tongue and jaws so that the prey slides inside and down. In fish, the tongue is largely bony and much less mobile and getting the food to the back of the pharynx is helped by pumping water in its mouth and out of its gills. In snakes, the work of swallowing is done by raking with the lower jaw until the prey is far enough back to be helped down by body undulations. G cells (gastrin)  D cells (somatostatin)  ECL cells (Histamine) enterogastrone: I cells (CCK)  K cells (GIP)  S cells (secretin) M: DIG anat (t, g, p)/phys/devp/enzy noco/cong/tumr, sysi/epon proc, drug (A2A/2B/3/4/5/6/7/14/16), blte

Cleft lip and palate

Cleft lip (cheiloschisis) and cleft palate (palatoschisis), which can also occur together as cleft lip and palate, are variations of a type of clefting congenital deformity caused by abnormal facial development during gestation. A cleft is a fissure or opening—a gap. It is the non-fusion of the body's natural structures that form before birth. Approximately 1 in 700 children born have a cleft lip or a cleft palate or both. In decades past, the condition was sometimes referred to as harelip, based on the similarity to the cleft in the lip of a hare, but that term is now generally considered to be offensive. Clefts can also affect other parts of the face, such as the eyes, ears, nose, cheeks, and forehead. In 1976, Paul Tessier described fifteen lines of cleft. Most of these craniofacial clefts are even rarer and are frequently described as Tessier clefts using the numerical locator devised by Tessier. A cleft lip or palate can be successfully treated with surgery, especially so if conducted soon after birth or in early childhood. If the cleft does not affect the palate structure of the mouth it is referred to as cleft lip. Cleft lip is formed in the top of the lip as either a small gap or an indentation in the lip (partial or incomplete cleft) or it continues into the nose (complete cleft). Lip cleft can occur as a one sided (unilateral) or two sided (bilateral). It is due to the failure of fusion of the maxillary and medial nasal processes (formation of the primary palate). Unilateral incomplete Unilateral complete Bilateral complete A mild form of a cleft lip is a microform cleft. A microform cleft can appear as small as a little dent in the red part of the lip or look like a scar from the lip up to the nostril. In some cases muscle tissue in the lip underneath the scar is affected and might require reconstructive surgery. It is advised to have newborn infants with a microform cleft checked with a craniofacial team as soon as possible to determine the severity of the cleft. 6 month old girl before going into surgery to have her unilateral complete cleft lip repaired The same girl, 1 month after the surgery The same girl, age 8, the scar almost gone Cleft palate is a condition in which the two plates of the skull that form the hard palate (roof of the mouth) are not completely joined. The soft palate is in these cases cleft as well. In most cases, cleft lip is also present. Cleft palate occurs in about one in 700 live births worldwide. Palate cleft can occur as complete (soft and hard palate, possibly including a gap in the jaw) or incomplete (a 'hole' in the roof of the mouth, usually as a cleft soft palate). When cleft palate occurs, the uvula is usually split. It occurs due to the failure of fusion of the lateral palatine processes, the nasal septum, and/or the median palatine processes (formation of the secondary palate). The hole in the roof of the mouth caused by a cleft connects the mouth directly to the nasal cavity. Note: the next images show the roof of the mouth. The top shows the nose, the lips are colored pink. For clarity the images depict a toothless infant. Incomplete cleft palate Unilateral complete lip and palate Bilateral complete lip and palate A result of an open connection between the oral cavity and nasal cavity is called velopharyngeal inadequacy (VPI). Because of the gap, air leaks into the nasal cavity resulting in a hypernasal voice resonance and nasal emissions while talking. Secondary effects of VPI include speech articulation errors (e.g., distortions, substitutions, and omissions) and compensatory misarticulations and mispronunciations (e.g., glottal stops and posterior nasal fricatives). Possible treatment options include speech therapy, prosthetics, augmentation of the posterior pharyngeal wall, lengthening of the palate, and surgical procedures. Submucous cleft palate (SMCP) can also occur, which is a cleft of the soft palate with a classic clinical triad of a bifid, or split, uvula which is found dangling in the back of the throat, a furrow along the midline of the soft palate, and a notch in the back margin of the hard palate. Most children who have their clefts repaired early enough are able to have a happy youth and social life. Having a cleft palate/lip does not inevitably lead to a psychosocial problem. However, adolescents with cleft palate/lip are at an elevated risk for developing psychosocial problems especially those relating to self-concept, peer relationships and appearance. Adolescents may face psychosocial challenges but can find professional help if problems arise. A cleft palate/lip may impact an individual’s self-esteem, social skills and behavior. There is research dedicated to the psychosocial development of individuals with cleft palate. Self-concept may be adversely affected by the presence of a cleft lip and or cleft palate, particularly among girls. Research has shown that during the early preschool years (ages 3–5), children with cleft lip and or cleft palate tend to have a self-concept that is similar to their peers without a cleft. However, as they grow older and their social interactions increase, children with clefts tend to report more dissatisfaction with peer relationships and higher levels of social anxiety. Experts conclude that this is probably due to the associated stigma of visible deformities and possible speech impediments. Children who are judged as attractive tend to be perceived as more intelligent, exhibit more positive social behaviors, and are treated more positively than children with cleft lip and or cleft palate. Children with clefts tend to report feelings of anger, sadness, fear, and alienation from their peers, but these children were similar to their peers in regard to "how well they liked themselves." The relationship between parental attitudes and a child’s self-concept is crucial during the preschool years. It has been reported that elevated stress levels in mothers correlated with reduced social skills in their children. Strong parent support networks may help to prevent the development of negative self-concept in children with cleft palate. In the later preschool and early elementary years, the development of social skills is no longer only impacted by parental attitudes but is beginning to be shaped by their peers. A cleft lip and or cleft palate may affect the behavior of preschoolers. Experts suggest that parents discuss with their children ways to handle negative social situations related to their cleft lip and or cleft palate. A child who is entering school should learn the proper (and age-appropriate) terms related to the cleft. The ability to confidently explain the condition to others may limit feelings of awkwardness and embarrassment and reduce negative social experiences. As children reach adolescence, the period of time between age 13 and 19, the dynamics of the parent-child relationship change as peer groups are now the focus of attention. An adolescent with cleft lip and or cleft palate will deal with the typical challenges faced by most of their peers including issues related to self-esteem, dating and social acceptance. Adolescents, however, view appearance as the most important characteristic above intelligence and humor. This being the case, adolescents are susceptible to additional problems because they cannot hide their facial differences from their peers. Adolescent boys typically deal with issues relating to withdrawal, attention, thought, and internalizing problems and may possibly develop anxiousness-depression and aggressive behaviors. Adolescent girls are more likely to develop problems relating to self-concept and appearance. Individuals with cleft lip and or cleft palate often deal with threats to their quality of life for multiple reasons including: unsuccessful social relationships, deviance in social appearance and multiple surgeries. Cleft may cause problems with feeding, ear disease, speech and socialization. Due to lack of suction, an infant with a cleft may have trouble feeding. An infant with a cleft palate will have greater success feeding in a more upright position. Gravity will help prevent milk from coming through the baby's nose if he/she has cleft palate. Gravity feeding can be accomplished by using specialized equipment, such as the Haberman Feeder, or by using a combination of nipples and bottle inserts like the one shown, is commonly used with other infants. A large hole, crosscut, or slit in the nipple, a protruding nipple and rhythmically squeezing the bottle insert can result in controllable flow to the infant without the stigma caused by specialized equipment. Individuals with cleft also face many middle ear infections which may eventually lead to hearing loss. The Eustachian tubes and external ear canals may be angled or tortuous, leading to food or other contamination of a part of the body that is normally self-cleaning. Hearing is related to learning to speak. Babies with palatal clefts may have compromised hearing and therefore, if the baby cannot hear, it cannot try to mimic the sounds of speech. Thus, even before expressive language acquisition, the baby with the cleft palate is at risk for receptive language acquisition. Because the lips and palate are both used in pronunciation, individuals with cleft usually need the aid of a speech therapist. The development of the face is coordinated by complex morphogenetic events and rapid proliferative expansion, and is thus highly susceptible to environmental and genetic factors, rationalising the high incidence of facial malformations. During the first six to eight weeks of pregnancy, the shape of the embryo's head is formed. Five primitive tissue lobes grow: If these tissues fail to meet, a gap appears where the tissues should have joined (fused). This may happen in any single joining site, or simultaneously in several or all of them. The resulting birth defect reflects the locations and severity of individual fusion failures (e.g., from a small lip or palate fissure up to a completely malformed face). The upper lip is formed earlier than the palate, from the first three lobes named a to c above. Formation of the palate is the last step in joining the five embryonic facial lobes, and involves the back portions of the lobes b and c. These back portions are called palatal shelves, which grow towards each other until they fuse in the middle. This process is very vulnerable to multiple toxic substances, environmental pollutants, and nutritional imbalance. The biologic mechanisms of mutual recognition of the two cabinets, and the way they are glued together, are quite complex and obscure despite intensive scientific research. Genetic factors contributing to cleft lip and cleft palate formation have been identified for some syndromic cases, but knowledge about genetic factors that contribute to the more common isolated cases of cleft lip/palate is still patchy. Many clefts run in families, even though in some cases there does not seem to be an identifiable syndrome present, possibly because of the current incomplete genetic understanding of midfacial development. A number of genes are involved including cleft lip and palate transmembrane protein 1 and GAD1, one of the glutamate decarboxylases. Many genes are known to play a role in craniofacial development and are being studied through the FaceBase initiative for their part in clefting. These genes are AXIN2, BMP4, FGFR1, FGFR2, FOXE1, IRF6, MAFB (gene), MMP3, MSX1, MSX2 (Msh homeobox 2), MSX3, PAX7, PDGFC, PTCH1, SATB2, SOX9, SUMO1 (Small ubiquitin-related modifier 1), TBX22, TCOF (Treacle protein), TFAP2A, VAX1, TP63, ARHGAP29, NOG, NTN1, WNT genes, and locus 8q24. In some cases, cleft palate is caused by syndromes which also cause other problems. Many genes associated with syndromic cases of cleft lip/palate (see above) have been identified to contribute to the incidence of isolated cases of cleft lip/palate. This includes in particular sequence variants in the genes IRF6, PVRL1 and MSX1. The understanding of the genetic complexities involved in the morphogenesis of the midface, including molecular and cellular processes, has been greatly aided by research on animal models, including of the genes BMP4, SHH, SHOX2, FGF10 and MSX1. Types include: Environmental influences may also cause, or interact with genetics to produce, orofacial clefting. An example for how environmental factors might be linked to genetics comes from research on mutations in the gene PHF8 that cause cleft lip/palate (see above). It was found that PHF8 encodes for a histone lysine demethylase, and is involved in epigenetic regulation. The catalytic activity of PHF8 depends on molecular oxygen, a fact considered important with respect to reports on increased incidence of cleft lip/palate in mice that have been exposed to hypoxia early during pregnancy. In humans, fetal cleft lip and other congenital abnormalities have also been linked to maternal hypoxia, as caused by e.g. maternal smoking, maternal alcohol abuse or some forms of maternal hypertension treatment. Other environmental factors that have been studied include: seasonal causes (such as pesticide exposure); maternal diet and vitamin intake; retinoids — which are members of the vitamin A family; anticonvulsant drugs; alcohol; cigarette use; nitrate compounds; organic solvents; parental exposure to lead; and illegal drugs (cocaine, crack cocaine, heroin, etc.). Current research continues to investigate the extent to which Folic acid can reduce the incidence of clefting. Traditionally, the diagnosis is made at the time of birth by physical examination. Recent advances in prenatal diagnosis have allowed obstetricians to diagnose facial clefts in utero. Cleft lip and palate is very treatable; however, the kind of treatment depends on the type and severity of the cleft. Most children with a form of clefting are monitored by a cleft palate team or craniofacial team through young adulthood. Care can be lifelong. Treatment procedures can vary between craniofacial teams. For example, some teams wait on jaw correction until the child is aged 10 to 12 (argument: growth is less influential as deciduous teeth are replaced by permanent teeth, thus saving the child from repeated corrective surgeries), while other teams correct the jaw earlier (argument: less speech therapy is needed than at a later age when speech therapy becomes harder). Within teams, treatment can differ between individual cases depending on the type and severity of the cleft. Within the first 2–3 months after birth, surgery is performed to close the cleft lip. While surgery to repair a cleft lip can be performed soon after birth, often the preferred age is at approximately 10 weeks of age, following the "rule of 10s" coined by surgeons Wilhelmmesen and Musgrave in 1969 (the child is at least 10 weeks of age; weighs at least 10 pounds, and has at least 10g hemoglobin). If the cleft is bilateral and extensive, two surgeries may be required to close the cleft, one side first, and the second side a few weeks later. The most common procedure to repair a cleft lip is the Millard procedure pioneered by Ralph Millard. Millard performed the first procedure at a Mobile Army Surgical Hospital (MASH) unit in Korea. Often an incomplete cleft lip requires the same surgery as complete cleft. This is done for two reasons. Firstly the group of muscles required to purse the lips run through the upper lip. In order to restore the complete group a full incision must be made. Secondly, to create a less obvious scar the surgeon tries to line up the scar with the natural lines in the upper lip (such as the edges of the philtrum) and tuck away stitches as far up the nose as possible. Incomplete cleft gives the surgeon more tissue to work with, creating a more supple and natural-looking upper lip. The blue lines indicate incisions. Movement of the flaps; flap A is moved between B and C. C is rotated slightly while B is pushed down. Pre-operation Post-operation, the lip is swollen from surgery and will get a more natural look within a couple of weeks. See photos in the section above. In some cases of a severe bi-lateral complete cleft, the premaxillary segment will be protruded far outside the mouth. Nasoalveolar molding prior to surgery can improve long-term nasal symmetry among patients with complete unilateral cleft lip-cleft palate patients compared to correction by surgery alone, according to a retrospective cohort study. In this study, significant improvements in nasal symmetry were observed in multiple areas including measurements of the projected length of the nasal ala (lateral surface of the external nose), position of the superoinferior alar groove, position of the mediolateral nasal dome, and nasal bridge deviation. "The nasal ala projection length demonstrated an average ratio of 93.0 percent in the surgery-alone group and 96.5 percent in the nasoalveolar molding group" this study concluded. Often a cleft palate is temporarily covered by a palatal obturator (a prosthetic device made to fit the roof of the mouth covering the gap). Cleft palate can also be corrected by surgery, usually performed between 6 and 12 months. Approximately 20–25% only require one palatal surgery to achieve a competent velopharyngeal valve capable of producing normal, non-hypernasal speech. However, combinations of surgical methods and repeated surgeries are often necessary as the child grows. One of the new innovations of cleft lip and cleft palate repair is the Latham appliance. The Latham is surgically inserted by use of pins during the child's 4th or 5th month. After it is in place, the doctor, or parents, turn a screw daily to bring the cleft together to assist with future lip and/or palate repair. If the cleft extends into the maxillary alveolar ridge, the gap is usually corrected by filling the gap with bone tissue. The bone tissue can be acquired from the patients own chin, rib or hip. A tympanostomy tube is often inserted into the eardrum to aerate the middle ear. This is often beneficial for the hearing ability of the child. Children with cleft palate typically have a variety of speech problems. Some speech problems result directly from anatomical differences such as velopharyngeal inadequacy. Velopharyngeal inadequacy refers to the inability of the soft palate to close the opening from the throat to the nasal cavity, which is necessary for many speech sounds, such as /p/, /b/, /t/, /d/, /s/, /z/, etc. This type of errors typically resolve after palate repair. However, sometimes children with cleft palate also have speech errors which develop as the result of an attempt to compensate for the inability to produce the target phoneme. These are known as compensatory articulations. Compensatory articulations are usually sounds that are non-existent in normal English phonology, often do not resolve automatically after palatal repair, and make a child’s speech even more difficult to understand. Speech-language pathology can be very beneficial to help resolve speech problems associated with cleft palate. In addition, research has indicated that children who receive early language intervention are less likely to develop compensatory error patterns later. Hearing impairment is particularly prevalent in children with cleft palate. The tensor muscle fibres that open the eustachian tubes lack an anchor to function effectively. In this situation, when the air in the middle ear is absorbed by the mucous membrane, the negative pressure is not compensated, which results in the secretion of fluid into the middle ear space from the mucous membrane. Children with this problem typically have a conductive hearing loss primarily caused by this middle ear effusion. Note that each individual patient's schedule is treated on a case-by-case basis and can vary per hospital. The table below shows a common sample treatment schedule. The colored squares indicate the average timeframe in which the indicated procedure occurs. In some cases this is usually one procedure (for example lip repair) in other cases this is an ongoing therapy (for example speech therapy). age A craniofacial team is routinely used to treat this condition. The majority of hospitals still use craniofacial teams; yet others are making a shift towards dedicated cleft lip and palate programs. While craniofacial teams are widely knowledgeable about all aspects of craniofacial conditions, dedicated cleft lip and palate teams are able to dedicate many of their efforts to being on the cutting edge of new advances in cleft lip and palate care. Many of the top pediatric hospitals are developing their own CLP clinics in order to provide patients with comprehensive multi-disciplinary care from birth through adolescence. Allowing an entire team to care for a child throughout their cleft lip and palate treatment (which is ongoing) allows for the best outcomes in every aspect of a child's care. While the individual approach can yield significant results, current trends indicate that team based care leads to better outcomes for CLP patients. . Prevalence rates reported for live births for cleft lip with or without cleft palate and cleft palate alone varies within different ethnic groups. It caused about 4,000 deaths globally in 2010 down from 8,400 in 1990. The highest prevalence rates for (CL ± P) are reported for Native Americans and Asians. Africans have the lowest prevalence rates. Rate of occurrence of CPO is similar for Caucasians, Africans, North American natives, Japanese and Chinese. The trait is dominant. Prevalence of "cleft uvula" has varied from .02% to 18.8% with the highest numbers found among Chippewa and Navajo and the lowest generally in Africans. In some countries, cleft lip or palate deformities are considered reasons (either generally tolerated or officially sanctioned) to perform abortion beyond the legal fetal age limit, even though the fetus is not in jeopardy of life or limb. Some human rights activists contend this practice of "cosmetic murder" amounts to eugenics. The Japanese anime Ghost Stories caused controversy through an episode featuring a Kuchisake-onna (a ghost with a Glasgow smile) because her scar resembled a cleft lip. The eponymous hero of J.M. Coetzee's 1983 novel, Life & Times of Michael K, has a cleft lip. Cleft lips and palates are occasionally seen in cattle and dogs, and rarely in sheep, cats, horses, pandas and ferrets. Most commonly, the defect involves the lip, rhinarium, and premaxilla. Clefts of the hard and soft palate are sometimes seen with a cleft lip. The cause is usually hereditary. Brachycephalic dogs such as Boxers and Boston Terriers are most commonly affected. An inherited disorder with incomplete penetrance has also been suggested in Shih tzus, Swiss Sheepdogs, Bulldogs, and Pointers. In horses, it is a rare condition usually involving the caudal soft palate. In Charolais cattle, clefts are seen in combination with arthrogryposis, which is inherited as an autosomal recessive trait. It is also inherited as an autosomal recessive trait in Texel sheep. Other contributing factors may include maternal nutritional deficiencies, exposure in utero to viral infections, trauma, drugs, or chemicals, or ingestion of toxins by the mother, such as certain lupines by cattle during the second or third month of gestation. The use of corticosteroids during pregnancy in dogs and the ingestion of Veratrum californicum by pregnant sheep have also been associated with cleft formation. Difficulty with nursing is the most common problem associated with clefts, but aspiration pneumonia, regurgitation, and malnutrition are often seen with cleft palate and is a common cause of death. Providing nutrition through a feeding tube is often necessary, but corrective surgery in dogs can be done by the age of twelve weeks. For cleft palate, there is a high rate of surgical failure resulting in repeated surgeries. Surgical techniques for cleft palate in dogs include prosthesis, mucosal flaps, and microvascular free flaps. Affected animals should not be bred due to the hereditary nature of this condition. Cleft lip in a Boxer Cleft lip in a Boxer with premaxillary involvement Same dog as picture on left, one year later M: MOU anat/devp noco/cofa (c)/cogi/tumr, sysi proc (peri), drug (A1) M: DIG anat (t, g, p)/phys/devp/enzy noco/cong/tumr, sysi/epon proc, drug (A2A/2B/3/4/5/6/7/14/16), blte M: MOU anat/devp noco/cofa (c)/cogi/tumr, sysi proc (peri), drug (A1) 1.2: Feingold syndrome  Saethre–Chotzen syndrome
2.1 (Intracellular receptor): Thyroid hormone resistance  Androgen insensitivity syndrome (PAIS, MAIS, CAIS)  Kennedy's disease  PHA1AD pseudohypoaldosteronism  Estrogen insensitivity syndrome  X-linked adrenal hypoplasia congenita  MODY 1  Familial partial lipodystrophy 3  SF1 XY gonadal dysgenesis 2.2: Barakat syndrome  Tricho–rhino–phalangeal syndrome 2.3: Greig cephalopolysyndactyly syndrome/Pallister–Hall syndrome  Denys–Drash syndrome  Duane-radial ray syndrome  MODY 7  MRX 89  Townes–Brocks syndrome  Acrocallosal syndrome  Myotonic dystrophy 2 3.1: ARX (Ohtahara syndrome, Lissencephaly X2)  HLXB9 (Currarino syndrome)  HOXD13 (SPD1 Synpolydactyly)  IPF1 (MODY 4)  LMX1B (Nail–patella syndrome)  MSX1 (Tooth and nail syndrome, OFC5PITX2 (Axenfeld syndrome 1)  POU4F3 (DFNA15)  POU3F4 (DFNX2)  ZEB1 (Posterior polymorphous corneal dystrophy 3, Fuchs' dystrophy 3)  ZEB2 (Mowat–Wilson syndrome) 3.2: PAX2 (Papillorenal syndrome)  PAX3 (Waardenburg syndrome 1&3)  PAX4 (MODY 9)  PAX6 (Gillespie syndrome, Coloboma of optic nerve)  PAX8 (Congenital hypothyroidism 2)  PAX9 (STHAG3) 3.3: FOXC1 (Axenfeld syndrome 3, Iridogoniodysgenesis, dominant type)  FOXC2 (Lymphedema–distichiasis syndrome)  FOXE1 (Bamforth–Lazarus syndrome)  FOXE3 (Anterior segment mesenchymal dysgenesis)  FOXF1 (ACD/MPV)  FOXI1 (Enlarged vestibular aqueduct)  FOXL2 (Premature ovarian failure 3)  FOXP3 (IPEX) 4.2: Hyperimmunoglobulin E syndrome 4.3: Holt–Oram syndrome  Li–Fraumeni syndrome  Ulnar–mammary syndrome 4.7: Campomelic dysplasia  MODY 3  MODY 5  SF1 (SRY XY gonadal dysgenesis, Premature ovarian failure 7)  SOX10 (Waardenburg syndrome 4c, Yemenite deaf-blind hypopigmentation syndrome) coactivator: CREBBP (Rubinstein–Taybi syndrome) IgSF CAM: OFC7 Cadherin: DSG1 (Striate palmoplantar keratoderma 1)  DSG2 (Arrhythmogenic right ventricular dysplasia 10)  DSG4 (LAH1)  DSC2 (Arrhythmogenic right ventricular dysplasia 11)

The palate is the roof of the mouth in humans and other mammals. It separates the oral cavity from the nasal cavity. A similar structure is found in crocodilians, but, in most other tetrapods, the oral and nasal cavities are not truly separate. The palate is divided into two parts, the anterior bony hard palate, and the posterior fleshy soft palate (or velum). The maxillary nerve branch of the trigeminal nerve supplies sensory innervation to the palate. The hard palate forms before birth. If the fusion is incomplete, it is called a cleft palate. As the roof of the mouth was once considered the seat of the sense of taste, palate can also refer to this sense itself, as in the phrase "a discriminating palate". By further extension, the flavor of a food (particularly beer or wine) may be called its palate, as when a wine is said to have an oaky palate. The English synonyms palate and palatum, and also the related adjective palatine (as in palatine bone), are all from the Latin palatum via Old French palat, words that, like their English derivatives, refer to the "roof of the mouth." The Latin word palatum and its derivatives mentioned above are all unrelated to a similar-sounding Latin word meaning palace, palatium, from which other senses of palatine and the English word palace itself derive. When functioning in conjunction with other parts of the mouth the palate produces certain sounds, particularly velar, palatal, palatalized, postalveolar, alveolo-palatal, and uvular consonants. Lip (Upper, Lower, Vermilion border, Frenulum of lower lip, Labial commissure of mouth, Philtrum)
Interdental papilla  Gingival sulcus  Gingival margin  Free gingival margin  Gingival fibers  Junctional epithelium  Mucogingival junction  Sulcular epithelium  Stippling
Oropharyngeal isthmus/Isthmus of the fauces Soft palate (Uvula, Palatoglossal arch, Palatopharyngeal arch, Plica semilunaris of the fauces) Tonsillar fossa M: MOU anat/devp noco/cofa (c)/cogi/tumr, sysi proc (peri), drug (A1)

Barn Swallow
The Barn Swallow (Hirundo rustica) is the most widespread species of swallow in the world. It is a distinctive passerine bird with blue upperparts, a long, deeply forked tail and curved, pointed wings. It is found in Europe, Asia, Africa and the Americas. In Anglophone Europe it is just called the Swallow; in Northern Europe it is the only common species called a "swallow" rather than a "martin". There are six subspecies of Barn Swallow, which breed across the Northern Hemisphere. Four are strongly migratory, and their wintering grounds cover much of the Southern Hemisphere as far south as central Argentina, the Cape Province of South Africa, and northern Australia. Its huge range means that the Barn Swallow is not endangered, although there may be local population declines due to specific threats. The Barn Swallow is a bird of open country which normally uses man-made structures to breed and consequently has spread with human expansion. It builds a cup nest from mud pellets in barns or similar structures and feeds on insects caught in flight. This species lives in close association with humans, and its insect-eating habits mean that it is tolerated by man; this acceptance was reinforced in the past by superstitions regarding the bird and its nest. There are frequent cultural references to the Barn Swallow in literary and religious works due to both its living in close proximity to humans and its annual migration. The Barn Swallow is the national bird of Austria and Estonia. The adult male Barn Swallow of the nominate subspecies H. r. rustica is 17–19 cm (6.7–7.5 in) long including 2–7 cm (0.79–2.8 in) of elongated outer tail feathers. It has a wingspan of 32–34.5 cm (13–13.6 in) and weighs 16–22 g (0.56–0.78 oz). It has steel blue upperparts and a rufous forehead, chin and throat, which are separated from the off-white underparts by a broad dark blue breast band. The outer tail feathers are elongated, giving the distinctive deeply forked "swallow tail." There is a line of white spots across the outer end of the upper tail. The female is similar in appearance to the male, but the tail streamers are shorter, the blue of the upperparts and breast band is less glossy, and the underparts paler. The juvenile is browner and has a paler rufous face and whiter underparts. It also lacks the long tail streamers of the adult. The song of the Barn Swallow is a cheerful warble, often ending with su-seer with the second note higher than the first but falling in pitch. Calls include witt or witt-witt and a loud splee-plink when excited (or trying to chase intruders away from the nest). The alarm calls include a sharp siflitt for predators like cats and a flitt-flitt for birds of prey like the Hobby. This species is fairly quiet on the wintering grounds. The distinctive combination of a red face and blue breast band render the adult Barn Swallow easy to distinguish from the African Hirundo species and from the Welcome Swallow (Hirundo neoxena) with which its range overlaps in Australasia. In Africa the short tail streamers of the juvenile Barn Swallow invite confusion with juvenile Red-chested Swallow (Hirundo lucida), but the latter has a narrower breast band and more white in the tail. The Barn Swallow was described by Linnaeus in his Systema Naturae in 1758 as Hirundo rustica, characterised as H. rectricibus, exceptis duabus intermediis, macula alba notatîs. Hirundo is the Latin word for "swallow"; rusticus means "of the country." This species is the only one of that genus to have a range extending into the Americas, with the majority of Hirundo species being native to Africa. This genus of blue-backed swallows is sometimes called the "barn swallows." The Oxford English Dictionary dates the English common name "barn swallow" to 1851, though an earlier instance of the collocation in an English-language context is in Gilbert White's popular book The Natural History of Selborne, originally published in 1789: The swallow, though called the chimney-swallow, by no means builds altogether in chimnies [sic], but often within barns and out-houses against the rafters... In Sweden she builds in barns, and is called ladu swala, the barn-swallow. This suggests that the English name may be a calque on the Swedish term. There are few taxonomic problems within the genus, but the Red-chested Swallow—a resident of West Africa, the Congo basin and Ethiopia—was formerly treated as a subspecies of Barn Swallow. The Red-chested Swallow is slightly smaller than its migratory relative, has a narrower blue breast-band, and the adult has shorter tail streamers. In flight, it looks paler underneath than Barn Swallow. Six subspecies of Barn Swallow are generally recognized. In eastern Asia, a number of additional or alternative forms have been proposed, including saturata by Robert Ridgway in 1883, kamtschatica by Benedykt Dybowski in 1883, ambigua by Erwin Stresemann and mandschurica by Wilhelm Meise in 1934. Given the uncertainties over the validity of these forms, this article follows the treatment of Turner and Rose. Unexpectedly, DNA analyses show that Barn Swallows from North America colonised the Baikal region of Siberia, a dispersal direction opposite to that for most changes in distribution between North America and Eurasia. The preferred habitat of the Barn Swallow is open country with low vegetation, such as pasture, meadows and farmland, preferably with nearby water. This swallow avoids heavily wooded or precipitous areas and densely built-up locations. The presence of accessible open structures such as barns, stables, or culverts to provide nesting sites, and exposed locations such as wires, roof ridges or bare branches for perching, are also important in the bird's selection of its breeding range. It breeds in the Northern Hemisphere from sea level to typically 2,700 metres (8,900 feet), but to 3,000 metres (9,800 feet) in the Caucasus and North America, and it is absent only from deserts and the cold northernmost parts of the continents. Over much of its range, it avoids towns, and in Europe is replaced in urban areas by the House Martin. However, in Honshū, the Barn Swallow is a more urban bird, with the Red-rumped Swallow (Cecropis daurica) replacing it as the rural species. In winter, the Barn Swallow is cosmopolitan in its choice of habitat, avoiding only dense forests and deserts. It is most common in open, low vegetation habitats, such as savanna and ranch land, and in Venezuela, South Africa and Trinidad and Tobago it is described as being particularly attracted to burnt or harvested sugarcane fields and the waste from the cane. In the absence of suitable roost sites, they may sometimes roost on wires where they are more exposed to predators. Individual birds tend to return to the same wintering locality each year and congregate from a large area to roost in reed beds. These roosts can be extremely large, one in Nigeria had an estimated 1.5 million birds. These roosts are thought to be a protection from predators, and the arrival of roosting birds is synchronised in order to overwhelm predators like African Hobbies. The Barn Swallow has been recorded as breeding in the more temperate parts of its winter range, such as the mountains of Thailand and in central Argentina. Migration of Barn Swallows between Britain and South Africa was first established on 23 December 1912 when a bird that had been ringed by James Masefield at a nest in Staffordshire, was found in Natal. As would be expected for a long-distance migrant, this bird has occurred as a vagrant to such distant areas as Hawaii, Bermuda, Greenland, Tristan da Cunha and the Falkland Islands. The Barn Swallow is similar in its habits to other aerial insectivores, including other swallow species and the unrelated swifts. It is not a particularly fast flier, with a speed estimated at about 11 m/s, up to 20 m/s and a wing beat rate of approximately 5, up to 7–9 times each second, but it has the manoeuvrability necessary to feed on flying insects while airborne. It is often seen flying relatively low in open or semi-open areas. The Barn Swallow typically feeds 7–8 metres (23–26 ft) above shallow water or the ground, often following animals, humans or farm machinery to catch disturbed insects, but it will occasionally pick prey items from the water surface, walls and plants. In the breeding areas, large flies make up around 70% of the diet, with aphids also a significant component. However, in Europe, the Barn Swallow consumes fewer aphids than the House or Sand Martins. On the wintering grounds, Hymenoptera, especially flying ants, are important food items. When egg-laying, Barn Swallows hunt in pairs, but will form often large flocks otherwise. Isotope studies have shown that wintering populations may utilise different feeding habitats, with British breeders feeding mostly over grassland, whereas Swiss birds utilised woodland more. Another study showed that a single population breeding in Denmark actually wintered in two separate and different areas. The Barn Swallow drinks by skimming low over lakes or rivers and scooping up water with its open mouth. This bird bathes in a similar fashion, dipping into the water for an instant while in flight. Swallows gather in communal roosts after breeding, sometimes thousands strong. Reed beds are regularly favoured, with the birds swirling en masse before swooping low over the reeds. Reed beds are an important source of food prior to and whilst on migration; although the Barn Swallow is a diurnal migrant which can feed on the wing whilst it travels low over ground or water, the reed beds enable fat deposits to be established or replenished. The male Barn Swallow returns to the breeding grounds before the females and selects a nest site, which is then advertised to females with a circling flight and song. The breeding success of the male is related to the length of the tail streamers, with longer streamers being more attractive to the female. Males with longer tail feathers are generally longer-lived and more disease resistant, females thus gaining an indirect fitness benefit from this form of selection, since longer tail feathers indicate a genetically stronger individual which will produce offspring with enhanced vitality. Males in northern Europe have longer tails than those further south; whereas in Spain the male's tail streamers are only 5% longer than the female's, in Finland the difference is 20%. In Denmark, the average male tail length increased by 9% between 1984 and 2004, but it is possible that climatic changes may lead in the future to shorter tails if summers become hot and dry. Males with long streamers also have larger white tail spots, and since feather-eating bird lice prefer white feathers, large white tail spots without parasite damage again demonstrate breeding quality; there is a positive association between spot size and the number of offspring produced each season. Both sexes defend the nest, but the male is particularly aggressive and territorial. Once established, pairs stay together to breed for life, but extra-pair copulation is common, making this species genetically polygamous, despite being socially monogamous. Males guard females actively to avoid being cuckolded. Males may use deceptive alarm calls to disrupt extrapair copulation attempts toward their mates. As its name implies, the Barn Swallow typically nests inside accessible buildings such as barns and stables, or under bridges and wharves. The neat cup-shaped nest is placed on a beam or against a suitable vertical projection. It is constructed by both sexes, although more often by the female, with mud pellets collected in their beaks and lined with grasses, feathers, algae or other soft materials. Barn Swallows may nest colonially where sufficient high-quality nest sites are available, and within a colony, each pair defends a territory around the nest which, for the European subspecies, is four to eight square metres (45 to 90 square feet) in size. Colony size tends to be larger in North America. In North America at least, Barn Swallows frequently engage in a mutualist relationship with Ospreys. Barn Swallows will build their nest below an Osprey nest, receiving protection from other birds of prey which are repelled by the exclusively fish-eating Ospreys. The Ospreys are alerted to the presence of these predators by the alarm calls of the swallows. Before man-made sites became common, the Barn Swallow nested on cliff faces or in caves, but this is now rare. The female lays two to seven, but typically four or five, reddish-spotted white eggs. The eggs are 20 x 14 millimetres (0.6 x 0.8 in) in size, and weigh 1.9 grammes (0.07 oz), of which 5 percent is shell. In Europe, the female does almost all the incubation, but in North America the male may incubate up to 25% of the time. The incubation period is normally 14–19 days, with another 18–23 days before the altricial chicks fledge. The fledged young stay with, and are fed by, the parents for about a week after leaving the nest. Occasionally, first-year birds from the first brood will assist in feeding the second brood. The Barn Swallow will mob intruders such as cats or accipiters that venture too close to their nest, often flying very close to the threat. Adult Barn Swallows have few predators, but some are taken by accipiters, falcons, and owls. Brood parasitism by cowbirds in North America or cuckoos in Eurasia is rare. There are normally two broods, with the original nest being reused for the second brood and being repaired and reused in subsequent years. Hatching success is 90% and the fledging survival rate is 70–90%. Average mortality is 70–80% in the first year and 40–70% for the adult. Although the record age is more than 11 years, most survive less than four years. Barn Swallow nestlings have prominent red gapes, a feature shown to induce feeding by parent birds. An experiment in manipulating brood size and immune system showed the vividness of the gape was positively correlated with T-cell–mediated immunocompetence, and that larger brood size and injection with an antigen led to a less vivid gape. The Barn Swallow has been recorded as hybridising with the Cliff Swallow (Petrochelidon pyrrhonota) and the Cave Swallow (P. fulva) in North America, and the House Martin (Delichon urbicum) in Eurasia, the cross with the latter being one of the most common passerine hybrids. Eggs in the Muséum de Toulouse Chicks and eggs in a nest with horse hair lining Older chicks in nest A juvenile being fed Barn Swallows (and other small passerines) often have characteristic feather holes on their wing and tail feathers. These holes were suggested as being caused by avian lice such as Machaerilaemus malleus and Myrsidea rustica, although other studies suggest that they are mainly caused by species of Brueelia. Several other species of lice have been described from Barn Swallow hosts, including Brueelia domestica and Philopterus microsomaticus. In Texas, the swallow bug (Oeciacus vicarius) which is common on species such as the Cliff Swallow is also known to infest Barn Swallows. Predatory bats such as the Greater False Vampire Bat are known to prey on Barn Swallows. Swallows at their communal roosts attract predators and several falcon species make use of these opportunities. Falcon species confirmed as predators include the Peregrine Falcon and the African Hobby. The Barn Swallow has an enormous range, with an estimated global extent of 51.7 million square kilometres (19.96 million square miles) and a population of 190 million individuals. Although global population trends have not been quantified, the species is not believed to approach the thresholds for the population decline criterion of the IUCN Red List (that is, declining more than 30 percent in ten years or three generations). For these reasons, the species is evaluated as "least concern" on the 2007 IUCN Red List, and has no special status under the Convention on International Trade in Endangered Species of Wild Fauna and Flora (CITES), which regulates international trade in specimens of wild animals and plants. This is a species which has greatly benefited historically from forest clearance, which has created the open habitats it prefers, and from human habitation, which have given it an abundance of safe man-made nest sites. There have been local declines due to the use of DDT in Israel in the 1950s, competition for nest sites with House Sparrows in the US in the 19th century, and an ongoing gradual decline in numbers in parts of Europe and Asia due to agricultural intensification, reducing the availability of insect food. However, there has been an increase in the population in North America during the 20th century with the greater availability of nesting sites and subsequent range expansion, including the colonisation of northern Alberta. A specific threat to wintering birds from the European populations is the transformation by the South African government of a light aircraft runway near Durban into an international airport for the 2010 FIFA World Cup. The roughly 250 metres (270 yards) square Mount Moreland reed bed is a night roost for more than three million Barn Swallows, which represent one percent of the global population and eight percent of the European breeding population. The reed bed lies on the flight path of aircraft using the proposed La Mercy airport, and there were fears that it would be cleared because the birds could threaten aircraft safety. However, following detailed evaluation, advanced radar technology will be installed to enable planes using the airport to be warned of bird movements and, if necessary, take appropriate measures to avoid the flocks. Climate change may affect the Barn Swallow; drought causes weight loss and slow feather regrowth, and the expansion of the Sahara will make it a more formidable obstacle for migrating European birds. Hot dry summers will reduce the availability of insect food for chicks. Conversely, warmer springs may lengthen the breeding season and result in more chicks, and the opportunity to use nest sites outside buildings in the north of the range might also lead to more offspring. The Barn Swallow is an attractive bird which feeds on flying insects and has therefore been tolerated by humans when it shares their buildings for nesting. As one of the earlier migrants, this conspicuous species is also seen as an early sign of summer's approach. In the Old World, the Barn Swallow appears to have used man-made structures and bridges since time immemorial. An early reference is in Virgil's Georgics (29 BC) ...garrula quam tignis nidum suspendat hirundo (...the twittering swallow hangs its nest from the rafters). It is believed that the Barn Swallow began attaching its nest to Native American habitations in the early 19th century, and the subsequent spread of settlement across North America is thought to have resulted in a dramatic population expansion of the species across the continent. Many cattle farmers believed that swallows spread Salmonella infections, however a study in Sweden showed no evidence of the birds being reservoirs of the bacteria. Many literary references are based on the Barn Swallow's northward migration as a symbol of spring or summer. The proverb about the necessity for more than one piece of evidence goes back at least to Aristotle's Nicomachean Ethics: "For as one swallow or one day does not make a spring, so one day or a short time does not make a fortunate or happy man." The Barn Swallow symbolizes the coming of spring and thus love in the Pervigilium Veneris, a late Latin poem. In "The Waste Land", T. S. Eliot quoted the line "Quando fiam uti chelidon [ut tacere desinam]?" ("When will I be like the swallow, so that I can stop being silent?") This refers to a version of the myth of Philomela in which she turns into a Nightingale and her sister Procne into a Swallow; in less familiar versions, the two species are reversed. On the other hand, an image of the assembly of Swallows for their southward migration concludes John Keats's ode "To Autumn". There are mentions of the Barn Swallow in the Bible, although it seems likely that it is confused with the swifts in many translations, or possibly other hirundine species which breed in Israel. However, "Yea, the sparrow hath found her a house, And the swallow a nest for herself, where she may lay her young" from Psalms 84:3 likely applies to the Barn Swallow. The swallow is also notably cited in several of William Shakespeare's plays for the swiftness of its flight; for example: "True hope is swift, and flies with swallow's wings ..." from Act 5 of Richard III, and "I have horse will follow where the game Makes way, and run like swallows o'er the plain." from the second act of Titus Andronicus. Shakespeare also references the annual migration of the species poetically in The Winter's Tale, Act 4: "Daffodils, That come before the swallow dares, and take The winds of March with beauty; violets dim, ...". Gilbert White studied the Barn Swallow in detail in his pioneering work The Natural History of Selborne, but even this careful observer was uncertain whether it migrated or hibernated in winter. Elsewhere, its long journeys have been well observed, and a swallow tattoo is popular amongst nautical men as a symbol of a safe return; the tradition was that a mariner had a tattoo of this fellow wanderer after sailing 5,000 nautical miles (9,260 km, 5,755 statute miles). A second swallow would be added after 10,000 nautical miles (18,520 km, 11,510 statute miles) at sea. In the past, the tolerance for this beneficial insectivore was reinforced by superstitions regarding damage to the Barn Swallow's nest. Such an act might lead to cows giving bloody milk, or no milk at all, or to hens ceasing to lay. This may be a factor in the longevity of swallows' nests. Survival, with suitable annual refurbishment, for 10–15 years is regular, and one nest was reported to have been occupied for 48 years. It is depicted as the Martlet, Merlette or Merlot in heraldry, where it represents younger sons who have no lands. It is also represented as lacking feet as this was a common belief at the time. As a result of a campaign by ornithologists, the Barn Swallow has been the national bird of Estonia since 23 June 1960. Smiddy, P. 2010. Post-fledging roosting at the nest in juvenile barn swallows (Hirundo rustica). Ir Nat. J. : 31: 44 – 46.

The tongue is a muscular hydrostat on the floors of the mouths of most vertebrates which manipulates food for mastication. It is the primary organ of taste (gustation), as much of the upper surface of the tongue is covered in papillae and taste buds. It is sensitive and kept moist by saliva, and is richly supplied with nerves and blood vessels. In humans a secondary function of the tongue is phonetic articulation. The tongue also serves as a natural means of cleaning one's teeth. The ability to perceive different tastes is not localised in different parts of the tongue, as is widely believed. This error arose because of misinterpretation of some 19th-century research (see tongue map). The word tongue derives from the Old English tunge, which comes from Proto-Germanic *tungōn. It has cognates in other Germanic languages — for example tonge in West Frisian, tong in Dutch/Afrikaans, Zunge in German, tunge in Danish/Norwegian and tunga in Icelandic/Faroese/Swedish. The ue ending of the word seems to be a fourteenth-century attempt to show "proper pronunciation", but it is "neither etymological nor phonetic". Some used the spelling tunge and tonge as late as the sixteenth century. It can be used as a metonym for language, as in the phrase mother tongue. Many languages have the same word for "tongue" and "language". A common temporary failure in word retrieval from memory is referred to as the tip-of-the-tongue phenomenon. The expression tongue in cheek refers to a statement that is not to be taken entirely seriously – something said or done with subtle ironic or sarcastic humour. A tongue twister is a phrase made specifically to be very difficult to pronounce. Aside from being a medical condition, "tongue-tied" means being unable to say what you want to due to confusion or restriction. The phrase "cat got your tongue" refers to when a person is speechless. To "bite one's tongue" is a phrase which describes holding back an opinion to avoid causing offence. A "slip of the tongue" refers to an unintentional utterance, such as a Freudian slip. Speaking in tongues is a common phrase used to describe glossolalia, which is to make smooth, language-resembling sounds that is no true spoken language itself. A deceptive person is said to have a forked tongue, and a smooth-talking person said to have a silver tongue. The eight muscles of the human tongue are classified as either intrinsic or extrinsic. The four intrinsic muscles act to change the shape of the tongue, and are not attached to any bone. The four extrinsic muscles act to change the position of the tongue, and are anchored to bone. The extrinsic muscles originate from bone and extend to the tongue. Their main functions are altering the tongue's position allowing for protrusion, retraction, and side-to-side movement. The main function of the intrinsic muscles is to provide shape. They are not involved with changing the position of the tongue and are not attached to bone. The tongue receives its blood supply primarily from the lingual artery, a branch of the external carotid artery and lingual veins which drain into internal jugular vein. The floor of the mouth also receives its blood supply from the lingual artery. The triangle formed by the intermediate tendon of the digastric muscle, the posterior border of the mylohyoid muscle, and the hypoglossal nerve is sometimes called Pirogov's, Pirogoff's, or Pirogov-Belclard's triangle. The lingual artery is a good place to stop severe hemorrage from the tongue. There is also secondary blood supply to the tongue from the tonsillar branch of the facial artery and the ascending pharyngeal artery. Anterior 2/3rds of tongue Posterior 1/3rd of tongue Motor The average length of the human tongue from the oropharynx to the tip is 10 cm (4 in). Chemicals that stimulate taste receptor cells are known as tastants. Once a tastant is dissolved in saliva, it can make contact with the plasma membrane of the gustatory hairs, which are the sites of taste transduction. The tongue is equipped with many taste buds on its dorsal surface, and each taste bud is equipped with taste receptor cells that can sense particular classes of tastes. There are taste cells for: sweet, bitter, salty or sour, and umami. Umami receptor cells are the least understood but research into the key features is making progress. After the gums, the tongue is the second most common soft tissue site for various pathologies in the oral cavity.][ Examples of pathological conditions of the tongue include glossitis (e.g. geographic tongue, median rhomboid glossitis), burning mouth syndrome, oral hairy leukoplakia, oral candidiasis and squamous cell carcinoma. The sublingual region underneath the front of the tongue is a location where the oral mucosa is very thin, and underlain by a plexus of veins. This is an ideal location for introducing certain medications to the body. The sublingual route takes advantage of the highly vascular quality of the oral cavity, and allows for the speedy application of medication into the cardiovascular system, bypassing the gastrointestinal tract. This is the only convenient and efficacious route of administration (apart from I.V. administration) of nitroglycerin to a patient suffering chest pain from angina pectoris. Most vertebrate animals have tongues. In mammals such as dogs and cats, the tongue is often used to clean the fur and body. The tongues of these species have a very rough texture which allows them to remove oils and parasites. A dog's tongue also acts as a heat regulator. As a dog increases its exercise the tongue will increase in size due to greater blood flow. The tongue hangs out of the dog's mouth and the moisture on the tongue will work to cool the bloodflow. Some animals have tongues that are specially adapted for catching prey. For example, chameleons, frogs, and anteaters have prehensile tongues. Many species of fish have small folds at the base of their mouths that might informally be called tongues, but they lack a muscular structure like the true tongues found in most tetrapods. Other animals may have organs that are analogous to tongues, such as a butterfly's proboscis or a radula on a mollusc, but these are not homologous with the tongues found in vertebrates, and often have little resemblance in function, for example, butterflies do not lick with their proboscides; they suck thorough them, and the proboscis is not a single organ, but two jaws held together to form a tube. The tongues of some animals are consumed and sometimes considered delicacies. Hot tongue sandwiches are frequently found on menus in Kosher delicatessens in America. Taco de lengua (lengua being Spanish for tongue) is a taco filled with beef tongue, and is especially popular in Mexican cuisine. As part of Colombian gastronomy, Tongue in Sauce (Lengua en Salsa), is a dish prepared by frying the tongue, adding tomato sauce, onions and salt. Tongue can also be prepared as birria. Pig and beef tongue are consumed in Chinese cuisine. Duck tongues are sometimes employed in Szechuan dishes, while lamb's tongue is occasionally employed in Continental and contemporary American cooking. Fried cod "tongue" is a relatively common part of fish meals in Norway and Newfoundland. In Argentina and Uruguay cow tongue is cooked and served in vinegar (lengua a la vinagreta). In the Czech Republic and Poland, a pork tongue is considered a delicacy,and there are many ways of preparing it. In Eastern Slavic countries, pork and beef tongues are commonly consumed, boiled and garnished with horseradish or jelled; beef tongues fetch a significantly higher price and are considered more of a delicacy. In Alaska, cow tongues are among the more common. Tongues of seals and whales have been eaten, sometimes in large quantities, by sealers and whalers, and in various times and places have been sold for food on shore. Sticking one's tongue out at someone is considered a childish gesture of rudeness and/or defiance in many countries; the act may also have sexual connotations, depending on the way in which it is done. However, in Tibet it is considered a greeting. In 2009, a farmer from Fabriano, Italy was convicted and fined by the country's highest court for sticking his tongue out at a neighbor with whom he had been arguing. Proof of the affront had been captured with a cell phone camera. Blowing a raspberry can also be meant as a gesture of derision. Being a cultural custom for long time, tongue piercing and splitting has become quite common in western countries in recent decades, with up to one-fifth of young adults having at least one piece of body art in the tongue. Human pharynx. Posterior view. Deep dissection of larynx, pharynx and tongue seen from behind Notes
Lip (Upper, Lower, Vermilion border, Frenulum of lower lip, Labial commissure of mouth, Philtrum)
Interdental papilla  Gingival sulcus  Gingival margin  Free gingival margin  Gingival fibers  Junctional epithelium  Mucogingival junction  Sulcular epithelium  Stippling
Oropharyngeal isthmus/Isthmus of the fauces Soft palate (Uvula, Palatoglossal arch, Palatopharyngeal arch, Plica semilunaris of the fauces) Tonsillar fossa M: MOU anat/devp noco/cofa (c)/cogi/tumr, sysi proc (peri), drug (A1) medulla: Solitary tract (VII, IX, X)   Solitary nucleus (Gustatory nucleus) pons: Central tegmental tract  Medial parabrachial nucleus (Hypothalamus, Amygdala) thalamus: Ventral posteromedial nucleus M: TST anat, phys sysi – M: TST anat, phys sysi –

Soft palate
The soft palate (also known as velum or muscular palate) is, in mammals, the soft tissue constituting the back of the roof of the mouth. The soft palate is distinguished from the hard palate at the front of the mouth in that it does not contain bone. The soft palate is movable, consisting of muscle fibers sheathed in mucous membrane. It is responsible for closing off the nasal passages during the act of swallowing, and also for closing off the airway. During sneezing, it protects the nasal passage by diverting a portion of the excreted substance to the mouth. In humans, the uvula hangs from the end of the soft palate. Research shows that the uvula is not actually involved in snoring processes. This has been shown through inconsistent results from uvula removal surgery. Snoring is more closely associated with fat deposition in the pharynx, enlarged tonsils of Waldeyer's ring, or deviated septum problems. Touching the uvula or the end of the soft palate evokes a strong gag reflex in most people. A speech sound made with the middle part of the tongue (dorsum) touching the soft palate is known as a velar consonant. It is possible for the soft palate to retract and elevate during speech to separate the oral cavity (mouth) from the nasal cavity in order to produce the oral speech sounds. If this separation is incomplete, air escapes through the nose, causing speech to be perceived as nasal. The muscle of the soft palate play important roles in swallowing and breathing. Levator veli palatani and tensor veli palatani are the two muscles involved in elevating the soft palate during swallowing. Pathology of the soft palate includes mucosal lesions such as pemphigus vulgaris, herpangina and migratory stomatitis, and muscular conditions such as the congenital cleft palate and cleft uvula. Petechiae on the soft palate are mainly associated with streptococcal pharyngitis, and as such it is an uncommon but highly specific finding. 10 to 30 percent of palatal petechiae cases are estimated to be caused by suction, which can be habitual or secondary to fellatio. Within the microstructure of the soft palate, lie a variety of of complexly oriented fibers that create a nonuniform surface with a nonuniform density distribution. The tissue has been characterized as viscoelastic, nonlinear, and anisotropic in the direction of the fibers. Young modulus values range from 585Pa at the posterior free edge of the soft palate to 1409Pa where the soft palate attaches to the maxilla. These properties are useful when quantifying the effects of corrective orthopedic devices such as the Hotz Plate on cleft lip. Quantitative analyses have been done on bilateral and unilateral cleft palate to better understand geometric differences in cleft palate throughout the course of its development and correction. Despite the difficulty in finding common, comparable landmarks between normal soft palates and cleft palates, analytical methods have been done to assess differences in degree of curvature of the alveolar crest, 2-dimmensional and 3-dimmensional surface area, and slope of the alveolar crest. Finite element analysis has demonstrated effective modeling of soft-palate extension and movement. It has also been an effective tool for evaluating the craniofacial effects of corrective orthopedic devices and cleft lip. Soft palate without tonsils (after tonsillectomy) Mouth (oral cavity) Mouth Sagittal section of nose mouth, pharynx, and larynx. The mouth cavity. The cheeks have been slit transversely and the tongue pulled forward. Human pharynx.Posterior view. Lip (Upper, Lower, Vermilion border, Frenulum of lower lip, Labial commissure of mouth, Philtrum)
Interdental papilla  Gingival sulcus  Gingival margin  Free gingival margin  Gingival fibers  Junctional epithelium  Mucogingival junction  Sulcular epithelium  Stippling
Oropharyngeal isthmus/Isthmus of the fauces Soft palate (Uvula, Palatoglossal arch, Palatopharyngeal arch, Plica semilunaris of the fauces) Tonsillar fossa M: MOU anat/devp noco/cofa (c)/cogi/tumr, sysi proc (peri), drug (A1)

Orofacial myological disorders
Orofacial myofunctional disorders (OMD) (sometimes called “oral myofunctional disorder", and “tongue thrust”) are disorders of the muscles involving the face, mouth, lips, or jaw. Recent studies on incidence and prevalence of tongue thrust behaviors are not available. However, according to the previous research, 38% of various populations have OMD. The incidence is as high as 81% in children exhibiting speech/articulation problems (Kellum, 1992). OMD refers to abnormal resting posture of the orofacial musculature, atypical chewing and swallowing patterns, dental malocclusions, blocked nasal airways, and speech problems (Hanson,1988). OMD are patterns involving oral and/orofacial musculature that interferes with normal growth, development, or function of structures, or calls attention to itself (ASHA, 1993). OMD are found in both children and adults. OMD that are commonly seen in children include tongue thrust that is also known as swallowing with an anterior tongue posture. OMD also refers to factors such as nonnutritive sucking behaviors, such as thumb sucking, clenching, bruxing, etc. that lead to abnormal development of dentition and oral cavity. OMD in adult and geriatric population are due to various neurological impairments, oral hygiene, altered functioning of muscles due to aging, systemic diseases, etc. Tongue thrusting is a type of orofacial myofunctional disorder, which is defined as habitual resting or thrusting the tongue forward and/or sideways against or between the teeth while swallowing, chewing, resting, or speaking. Abnormal swallowing patterns push the upper teeth forward and away from the upper alveolar processes and cause open bites. In children, tongue thrusting is common due to immature oral behavior, narrow dental arch, prolonged upper respiratory tract infections, spaces between the teeth (diastema), muscle weakness, malocclusion, abnormal sucking habits, and open mouth posture due to structural abnormalities of genetic origin. Large tonsils and adenoids also contribute to tongue thrust swallowing. From the dental perspective, teeth move in relation to the balance of the soft tissue; the normal relationship of teeth lies in occlusion; and any deviation from the normal occlusion can lead to dental distress (Garliner, 1974). Tongue posture plays an important role in swallowing and dentofacial growth. In case of tongue thrust swallowing, the tip of the tongue can come against or between the dentition; the midpoint may be collapsed or extended unilaterally or bilaterally; or the posterior part of the hard palate. In these conditions, there are chances of abnormal dentofacial growth and other concerns regarding development of the craniofacial complex. There are pertinent symptomatic questions that can be considered for the diagnosis of tongue thrust swallow. Some of these questions are geared toward tongue protrusion and an opening of lips when the client is in repose; habitual mouth breathing; digit sucking; existence of high and narrow palatal arch; ankyloglossia (tongue-tie); malocclusions, (Class II, III); weak chewing muscles (master); weak lip muscles (orbicularis oris); overdeveloped chin muscles (mentalis); muscular imbalance; abnormal dentition. Tongue thrusting and speech problems may co-occur. Due to unconventional postures of the tongue and other articulators, interdental and frontal lisping are very common. The alveolar sounds /s/ and /z/ are produced more anteriorly thus leading to interdental fricative like sounds, /th/ (Biegenzahn, Fischman, & Mayrhofer-Krammel, 1992). While identifying the causes of tongue thrust, it is important to remember that the resting posture of the tongue, jaw, and lips are crucial to normal development of mouth and its structures. If tongue rests against the upper front teeth, the teeth may protrude forward, and adverse tongue pressure can restrict the development of the oral cavity. The tongue lies low in the mouth or oral cavity and is typically forwarded between upper and lower teeth. If tongue thrust behavior is not corrected, it may affect the normal dental development. The teeth may be pushed around in different directions during the growth of permanent teeth. The adaptation from nasal to mouth breathing takes pace when changes such as chronic middle ear infections, sinusitis, allergic rhinitis, upper airway infections, and sleep disturbances (e.g., snoring) take place. In addition, mouth breathing is often associated with a decrease in oxygen intake into the lungs. Mouth breathing can particularly affect the growing face, as the abnormal pull of these muscle groups on facial bones slowly deforms these bones, causing misalignment. The earlier in life these changes take place, the greater the alterations in facial growth, and ultimately an open mouth posture is created where the upper lip is raised and the lower jaw is maintained in an open posture. The tongue, which is normally tucked under the roof of the mouth, drops to the floor of the mouth and protrudes to allow a greater volume of air intake. Consequently, an open mouth posture can leads to malocclusions and problems in swallowing. Other causes of open-mouth posture are weakness of lip muscles, overall lack of tone in the body or hypotonia, and prolonged/chronic allergies of the respiratory tract. Also called myofunctional therapy, the basic treatment aims of orofacial myofunctional therapist is to reeducate the movement of muscles, restore correct swallowing patterns, and establish adequate labial-lingual postures (ASHA, 1991; Benkert, 1997; Garliner, 1974; Hemmings, Griffiths, Hobkirk, & Scully, 2000). An interdisciplinary nature of treatment is always desirable to reach functional goals in terms of swallowing, speech, and other esthetic factors. A team approach has been shown to be effective in correcting orofacial myofunctional disorders. The teams include an orthodontist, dental hygienist, certified orofacial myologist, general dentist, otorhinolaryngologist, and a speech-language pathologist.
Orofacial Myofunctional Therapist Human

Speech-language pathology professionals (speech-language pathologists (SLPs); informally, speech therapists) specialize in communication disorders as well as swallowing disorders.

The components of speech production include: phonation, producing sound; resonance; intonation, variance of pitch; and voice, including aeromechanical components of respiration. The components of language include: phonology, manipulating sound according to the rules of a language; morphology, understanding and using minimal units of meaning; syntax, constructing sentences by using languages' grammar rules; semantics, interpreting signs or symbols of communication to construct meaning; and pragmatics, social aspects of communication.

Orofacial myofunctional disorders (OMD) (sometimes called “oral myofunctional disorder", and “tongue thrust”) are muscle disorders of the face, mouth, lips, or jaw.

Recent studies on incidence and prevalence of tongue thrust behaviors are not available. However, according to the previous research, 38% of various populations have OMD. The incidence is as high as 81% in children exhibiting speech/articulation problems (Kellum, 1992).

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