swallowing
DESCRIPTION
TRANSCRIPT
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Normal Swallowing• Complicated and intricate phenomenon
• Mixture of voluntary and reflex, or automatic, actions
• Total number of swallows per day is about 600:
– 200 while eating and drinking
– 350 while awake without food
– 50 while sleeping
'empty' swallows primarily to the clearance of saliva from
the mouth
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Anatomy of swallowing
• 55 muscles of the oropharyngeal, laryngeal, and
esophageal regions
• Five cranial nerves – V, VII, IX, X, XII
• Two cervical nerve roots
• Centers within the central nervous system
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Anatomy of swallowing
A. Oral cavity
– Separated from the
pharynx by the
faucial pillars
B. Pharynx
C. Esophagus
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Anatomy of swallowing• Laryngeal aditus (upper end of
the larynx) opens into the lower
portion of the pharynx
• Epiglottis
– Originates in the larynx and
is angled upward and
backward
– Attached to the hyoid bone
anteriorly
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Hyoid bone
• Mechanical connections to the
cranial base, mandible,
sternum, and thyroid cartilage
via the suprahyoid and
infrahyoid muscles
• Important role in controlling
the movements of the jaw and
tongue.
Anatomy of swallowing
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Anatomy of swallowingValleculae
• Space between the
pharyngeal surface of the
tongue and the epiglottis
Pyriform recesses
• Two spaces in the pharynx
lateral to the larynx
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Constrictor muscles
• Flattens and contracts the
pharynx in swallowing
Anatomy of swallowing
Cricopharyngeus muscle
•Closes the UES by compressing it against the back of the
cricoid cartilage
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Innervation of major muscles related to swallowingCranial nerves Muscles
Trigeminal Nerve (V)
Masticatory muscles
Mylohyoid
Tensor veli palatini
Anterior belly of digastrics
Facial nerve (VII)
Facial muscle
Stylohyoid
Posterior belly of digastrics
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Cranial nerves MusclesGlossopharyngeal Nerve (IX) Stylopharyngeus
Vagus nerve (X)
Levator veli palatine
Palatopharyngeous
Salpingopharyngeous
Intrinsic laryngeal muscles
Cricopharyngeus
Pharyngeal constrictors
Innervation of major muscles related to swallowing
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Cranial nerves Muscles
Hypoglossal nerve (XII)
Intrinsic tongue muscles
Hyoglossus
Geniohyoid
Genioglossus
Styloglossus
Thyrohyoid
Innervation of major muscles related to swallowing
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Sensory afferents
I. Trigeminal
– Teeth and gums, palate and roof of the pharynx
II. Glossopharyngeal
– Posterior third of the tongue, pharynx, area of the
tonsil
III. Vagus
– Pharynx, larynx
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Brainstem centers
• Central pattern generators – Dorsomedial &
Ventrolateral
• Mainly involves nucleus of the tractus solitarius and
the nucleus ambiguous
• Programs directing the sequential movements of the
various muscles involved
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Brainstem centers
• Activated by
– Descending pathways from the motor cortex
(cortico bulbar tracts)
– Ascending pathways from sensory structures
within the oropharynx and esophagus
Nucleus of the tractus solitarius receives the descending
and peripheral afferent influences
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Dorsomedial pattern generator
• Resides in the medial reticular formation of the
rostral medulla and the reticulum adjacent to the
nucleus tractus solitarius
• Initiation and organization of the swallowing
sequence
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Ventrolateral pattern generator
• Lies near the nucleus ambiguous and its surrounding
reticular formation
• Serves primarily as a connecting pathway to motor
nuclei such as the nucleus ambiguus and the dorsal
motor nucleus of the vagus, which directly control
motor output to the pharyngeal musculature and
proximal esophagus
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Cortical control to brainstem structures
Inferior precentral gyrus
• Cortical representations of tongue and face
• Bilaterally symmetrical activation
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Other cortical areas involved in swallowing
Supplementary motor area
• Preparation for volitional swallowing
Anterior cingulate cortex
• Monitoring autonomic and vegetative functions.
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Other cortical areas involved in swallowing
Anterior insula, particularly on the right
• Activation during volitional swallowing
• Allows gustatory and other intraoral sensations to
modulate swallowing.
• Lesions increase the swallowing threshold and delay
the pharyngeal phase of swallowing
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Other higher centers in swallowing
Cerebellum
• Esp left-sided activation
• Coordination, timing, and sequencing of swallowing
• controls output for the motor nuclei of cranial nerves
V, VII, and XII
Putamen
• Activated during volitional swallowing
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Stages of Swallowing
Initiated reflexly when food or liquid stimulates sensory
nerves in the oropharynx
Three distinct stages or phases:
• Oral
• Pharyngeal
• Esophageal
Horizontal subsystem Volitional in character
Vertical subsystem Primarily under reflex control
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ORAL PHASE
• Oral preparatory and oral propulsive stages
• Food bolus is formed and pushed to pharynx
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Oral preparatory stageChewing
• Cyclic movement of the jaw coordinated with the
movements of the tongue, cheek, soft palate and hyoid bone
• Food particles are reduced in size and softened by salivation
until the food consistency is optimal for swallowing
• Movements of the jaw and tongue pump air into the nasal
cavity through the pharynx, delivering the food's aroma to
chemoreceptors in the nose
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Oral propulsive stage
Overall effect is sweeps or squeezes the bolus towards the fauces to pharynx
Shallow midline gutter in tongue to accommodate bolus
Styloglossi and genioglossi
Emptying of the longitudinal gutter posteriorlyHyoglossus and some intrinsic lingual muscles
Elevation of anterior and mid tongue, hyoid bone and floor of the mouth
Mylohyoid, geniohyoid and stylohyoidRelaxation of the posterior oral seal and a forward movement of the posterior tongue
Palatoglossi.
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ORAL PHASE
• Transported food accumulates on the pharyngeal
surface of the tongue and in the valleculae
• Duration of bolus aggregation in the oropharynx
ranges from a fraction of a second to about ten
seconds in normal individuals eating solid food
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PHARYNGEAL PHASE
• Rapid sequential activity, occurring within a second
• Pharynx changes from being an air channel to food
channel
Two crucial biological features:
1. Food passage
2. Airway protection
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Airway protection
Closing the nasopharynx
• Superior Pharyngeal Constrictor + Palatopharyngeal
forming a variable, ridge-like, structure (Passavant's
Ridge) to which the soft palate is elevated.
• Occurs at same time the bolus head comes into the
pharynx
• Prevents bolus regurgitation into the nasal cavity
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Airway protection
Closure at lower level
a) Vocal folds close to seal the glottis
b) hyoid bone and larynx are pulled upward and forward
– Tucks the larynx under the base of the tongue
Suprahyoid and Thyrohyoid
c) Epiglottis tilts backward to seal the laryngeal
vestibule
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Food passage
• Sequential contraction of three pharyngeal constrictor
muscles
• Driving force which propels the bolus towards the
oesophagus
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OESOPHAGEAL PHASE
Involves
• Relaxation of UES
• Propulsion of food bolus to stomach
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Relaxation of UES
3 factors
1) Relaxation of the cricopharyngeous muscle
– Precedes arrival of the bolus
2) Contraction of the suprahyoid and thyrohyoid muscles
– Pull the hyo-laryngeal complex forward, opening the
sphincter
– Active opening process
3) Pressure of the descending bolus
UES consists of the inferior pharyngeal constrictor,
cricopharyngeous and most proximal part of the esophagus
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OESOPHAGEAL PHASE
Once in the oesophagus, the bolus is propelled by
peristaltic contractions down to the lower
oesophageal sphincter, which opens momentarily to
allow the bolus to enter the stomach
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Synchronization of swallowing with respiration
• Breathing ceases briefly during swallowing
– Physical closure by elevation of the soft palate and
tilting of the epiglottis
– Neural suppression of respiration in the brainstem
• Respiratory pause continues for 0.5 to 1.5 s
• Expiration immediately follows a swallow, thus
reducing the risk of aspiration
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Dysphagia
• Impaired swallowing can originate from disturbances
in the mouth, pharynx, or esophagus
• Can involve mechanical, musculoskeletal, or
neurogenic mechanisms
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Consequences of dysphagia
• Inadequate nutrition
• Dehydration
• Recurrent upper respiratory infections
• Frank aspiration with consequent pneumonia and
even asphyxia
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Approach to a case of Dysphagia
Good history will accurately identify the
location and cause of dysphagia in 80%
of cases
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• Dysphagia for solid food but
not liquids
• Equal dysphagia for both
solids and liquids
Approach to a case of Dysphagia
Mechanical obstruction
Esophageal dysmotility
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Mechanical Dysphagia• Structural abnormalities, both within and adjacent to
the mouth, pharynx, and esophagusOralCongenital abnormalities
Intraoral tumors
Burns
Trauma
Temporomandibular joint
dysfunction
PharyngealCervical anterior
osteophytes
Diphtheria
Thyromegaly
Retropharyngeal abscess
Retropharyngeal tumor
Zenker diverticulum
EsophagealEsophageal carcinoma
Esophageal diverticulum
Esophageal infection:
Esophageal stricture
Esophageal webs or rings
GERD
Thoracic aortic aneurysm
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Neurogenic dysphagia
Oropharyngeal
Or
EsophagealPerception of the bolus “sticking” in the neck may
indicate either pharyngeal or esophageal localization
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Oropharyngeal source for the dysphagia
• Difficulty initiating swallowing
• Need for repeated attempts to succeed at swallowing
• Presence of nasal regurgitation during swallowing
• Coughing or choking immediately after attempted
swallowing
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If Oropharyngeal Phase Dysfunction Suspected
Screening tests:
• Clinical examination
• Cervical auscultation
• 3-oz water swallow
Primary test:
• Modified barium swallow
Complementary tests:
•Pharyngeal videoendoscopy
•Pharyngeal manometry
•Electromyography
•Videomanofluorometry
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Oral stage dysfunction
Clinical examination of CN V, VII, XII
Weakness of the buccal or labial muscles
• Food trapped in the buccal or labial sulci (between
the lower teeth and the cheeks or gums, respectively)
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Oral stage dysfunction
Tongue dysfunction
• impaired mastication and bolus formation, and bolus
transport
Sensory impairments
• excessive retention of food in the oral cavity after
eating and swallowing
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Pharyngeal stage dysfunction
• Clinical examination of CN IX and X
• Cervical ausculatation
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Cranial nerve IX
• Examine pain and touch sensation of the pharynx,
tonsilar region and soft palate
• Only muscle with innervation purely from CN IX is
stylopharyngeus
• Only deficit detectable is a slight lowering of the
palatal arch at rest on the involved side.
• Gag reflex
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VAGUS NERVE
• With a contribution from the bulbar portion of CN
XI, supplies all the striated muscles of the soft palate,
pharynx, and larynx except for the stylopharyngeus
(CN IX) and tensor veli palatini (CN V)
• Sensory from the pharynx, larynx
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CN X lesions
• Speech may have a nasal quality
• Dysphagia more marked for liquids than solids with a
tendency to nasal regurgitation
• Droop of the palate and flattening of the palatal arch
– Preserved tensor veli palatini (CN V) may prevent
marked drooping of the palate
• Gag reflex lost on the involved side
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CN X lesions
Vernet's rideau phenomenon
• Due to unilateral weakness of the superior pharyngeal
constrictor
• “curtain movement”, with motion of the pharyngeal
wall toward the nonparalyzed side on testing the gag
reflex or at the beginning of phonation
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Gag reflex
• Elicited by touching the lateral oropharynx in the
region of the anterior faucial pillar (pharyngeal
reflex)
• Or by touching one side of the soft palate or uvula
(palatal reflex)
Pharyngeal reflex is the more active of the two
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Gag reflex
Three motor components
1) Elevation of the soft palate to seal off the
nasopharynx
2) Closure of the glottis to protect the airway
3) Constriction of the pharynx to prevent entry of the
substance.
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Gag reflex
Afferent limb - CN IX
Reflex center - medulla
Efferent limb - CNs IX and X
• Constriction and elevation of the oropharynx
• Midline raphe of the palate and the uvula elevate
• Pharyngeal constrictors contract
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Gag reflex
• Unilateral weakness
– Raphe will deviate away from the weak side and
toward the normal side
• May be bilaterally absent in some normal individuals
• Unilateral absence signifies a lower motor neuron
lesion
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Significance of gag reflex
• Poor gag reflex in an awake patient with an acute
deficit may be a predictor of swallowing difficulties
Useful but limited in assessing airway protection
• Patients with an apparently intact gag reflex may still
aspirate
• Absent in ~ 37% of normals - low predictive value in
the assessment of aspiration risk
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Cervical auscultation
• Assess coordination between respiration and
swallowing
• In the normal situation, swallowing occurs during
exhalation
• Discoordinated swallowing in the midst of inhalation
increases aspiration possibility
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Standardized 3 oz water swallow test
• Simple bedside evaluation for oropharyngeal dysphagia.
• Presence of cough on swallowing
– Positive predictive value of 84% with regard to the
presence of aspiration
– Negative predictive value of 78%.
• After the swallow, observe the patient for 1 minute or
more to see if a delayed cough response is present
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Dysphagia limit
• Normal subjects can swallow a 20-ml bolus of water
in a single attempt
• With dysphagia must divide the bolus into two or
more parts in order to complete the swallow
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Dysphagia limit
• Individuals are administered stepwise increases in
bolus volume, the volume of fluid at which the
division of the bolus first occurs is labeled the
dysphagia limit
Dysphagia limit of less than 20 ml as abnormal and
indicative of dysphagia
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Modified barium swallow test
• Swallowing barium impregnated food of differing
consistencies (thin liquid, pudding, cookie)
• Observed via videofluoroscopy
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Modified barium swallow test
• Oral and pharyngeal function can be characterized
• Presence of aspiration accurately documented
• Response to corrective measures such as positioning
techniques can also be evaluated
• Increasing bolus viscosity typically improves
swallowing function in individuals with neurogenic
dysphagia
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Laryngeal penetration
• passage of the food into the larynx but
above the vocal folds
• sometimes observed in normal
individuals
Aspiration
• passage of material through the vocal
folds
Modified barium swallow test
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Videoendoscopy of the pharynx
• Via the nasal passageway
• Allows direct visualization of the pharyngeal
component of swallowing before and after passage of
the food bolus
• Primary value is to demonstrate the presence of
residual material in the pharynx after a swallow,
indicative of increased risk of aspiration
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Swallowing Electromyography
• Mechanical upward-downward movement of the
larynx is detected by using a piezoelectric sensor
while submental integrated electromyography (EMG)
activity is recorded during dry and wet swallowing
• EMG activity of the cricopharyngeal muscle also can
be recorded.
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Swallowing Electromyography• In muscular disorders, laryngeal elevators are involved,
whereas the cricopharyngeal sphincter is intact
• In pyramidal lesions, discoordination between paretic
laryngeal elevators and the hyperreflexic cricopharyngeal
sphincter is present.
EMG can be used for muscle selection and for performing
injections of botulinum toxin in patients with dysphagia
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Esophageal dysfunction
• Sensation of food “hanging up” in a retrosternal
location
• Main concern with esophageal dysphagia is to
exclude malignancy
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Malignancy is likely if there is:
• Short duration (< 4 months)
• Disease progression
• Dysphagia more for solids than for liquids
• Weight loss
Esophageal dysfunction
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If Esophageal Dysfunction Suspected:
Primary tests:
• Videofluoroscopy
• Endoscopy
Complementary test:
• Esophageal manometry
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Oculopharyngeal Muscular Dystrophy
• Rare autosomal dominant disorder
• GCG trinucleotide repeat on chromosome 14
• First appearing between ages 40 and 60
• Slowly progressive ptosis, dysphagia, and proximal
limb weakness
• Evolves slowly over many years
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Oculopharyngeal Muscular Dystrophy
• Dysphagia due to impaired function of the
oropharyngeal musculature
• No specific treatment
• Cricopharyngeal myotomy affords relief in over 80%
• Botulinum toxin injections have been successfully
used
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Myotonic Dystrophy
• autosomal dominant disorder
• cardiac, ophthalmological, and endocrinological
involvement
• Subjective dysphagia in 37% to 56% of patients
• Objective measures demonstrating disturbances in
swallowing in 70% to 80%
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Myotonic Dystrophy• Dysphagia due to
– Abnormal cricopharyngeal muscle activity is present
in 40%
– Impaired esophageal peristalsis
– incomplete relaxation of the UES and esophageal
hypotonia
Both muscle weakness and myotonia play a role in the
development of dysphagia
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Inflammatory Myopathies
• Dysphagia more frequently is present in
dermatomyositis and when present is more severe
• Indicator of poor prognosis
Dysphagia in inclusion body myositis
• May even be the presenting symptom
• In late stages of the disorder, the frequency exceed
that seen in dermatomyositis and polymyositis
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Inflammatory Myopathies
Treatment
• May respond to corticosteroids and other
immunosuppressive drugs
Unresponsive to steroids
• IVIG therapy has produced dramatic improvement
Inclusion-body myositis
• Typically responds poorly
• Myotomy is often necessary
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Mitochondrial Disorders
Dysphagia due to
• Severe abnormalities of pharyngeal and upper-
esophageal peristalsis
• Cricopharyngeal dysfunction
• Impaired deglutitive coordination
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Myasthenia Gravis
• In ~ 6% to 30%, bulbar involvement is evident from
the beginning
• with disease progression, most eventually develop
• major precipitant of myasthenic crisis in 56% of
patients
• Bedside speech pathology assessment is not a reliable
predictor of aspiration
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Myasthenia Gravis
Dysphagia due to
Dysfunction at oral, pharyngeal, or even esophageal levels
• Oral phase involvement due to fatigue and weakness of
the tongue or masticatory muscles
• Decreased amplitude and prolongation of the peristaltic
wave in esophagus
• Cricopharyngeal sphincter pressure reduced
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Stroke• Dysphagia in 45% to 57%
• Aspiration in
– 30% to 55% of stroke patients
– 36% of patients with unilateral cerebral stroke
– 46% with bilateral cerebral stroke
– brainstem strokes - more than 80%
Associated with increased likelihood of severe disability or
death
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Warning signs of post-stroke dysphagia
• Drooling
• Excessive tongue movement
• Spitting food out of the mouth
• Poor tongue control
• Pocketing of food in the mouth
• Facial weakness
• Slurred speech
• Coughing or choking when eating
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Warning signs of post-stroke dysphagia
• Regurgitation of food through the nose
• Wet or “gurgly” voice after eating
• Hoarse or breathy voice
• Complaints of food sticking in the throat
• Absence or delay of laryngeal elevation
• Prolonged chewing
• Prolonged time to eat or reluctance to eat
• Recurrent pneumonia
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Dysphagia and site of stroke
Brainstem infarction
• Pharyngeal phase is primarily impaired
Hemispheric strokes
• Delay in initiation of voluntary swallowing
• Bilateral hemispheric damage is more likely to
produce dysphagia
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Can also occur in the setting of unilateral damage
Right hemisphere
• More impairment of pharyngeal motility
Left hemisphere
• Greater effect on oral stage function
Dysphagia and site of stroke
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Subcortical strokes
• higher incidence of dysphagia and aspiration than
those with cortical damage
• delayed initiation of the pharyngeal stage of
swallowing
Dysphagia and site of stroke
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Foix- Chavany-Marie syndrome (anterior operculum
syndrome)
• Bilateral infarction of the frontoparietal operculum
• inability to perform voluntary movements of the face,
jaw, tongue, and pharynx but fully preserved
involuntary movements of the same muscles
• Impairment of volitional swallowing
Dysphagia and site of stroke
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Tongue deviation & dysphagia
• Classically associated with medullary lesions
damaging the hypoglossal nucleus
• In almost 30% of persons with hemispheric
infarctions
• Dysphagia is present in 43% of affected patients
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Stepwise assessment of swallowing in stroke patients
• Modified swallowing assessment on the day of admission
• Clinical swallowing examination performed within 72 hours
• Performance of flexible transnasal swallowing endoscopy
within 5 days
• Appropriate diet and treatment determined after each step
• Significant reduction in the rate of pneumonia and in
antibiotic consumption (ickenstein et al., 2010)
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Prognosis
• Swallowing often improves spontaneously in the days
and weeks after stroke
• more likely to occur after cortical strokes, compared
with those of brainstem origin
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Dysphagia in other cerebrovascular processes
• Carotid artery aneurysms
• Elongation and dilatation of the basilar artery
• Posterior inferior cerebellar artery aneurysm
• Intracranial vertebral artery dissections
• Giant dissecting vertebrobasilar aneurysms
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Dysphagia in Multiple Sclerosis• Frequent but often overlooked (24% to 34% )
• Prevalence rises with increasing disability
• Individuals with severe brainstem involvement as part of
their MS are especially likely to experience dysphagia.
Mild disability
• Abnormalities in the oral phase of swallowing
More severe disability
• Additional pharyngeal phase abnormalities develop
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Dysphagia in Parkinson Disease• Frequent phenomenon - 30% to 82%
• More likely to swallow during inspiration and also to
inhale post swallow
• Both increase the risk of aspiration
Oral phase
• Difficulty with bolus formation
• Delayed initiation of swallowing
• Repeated tongue pumping, and other abnormalities
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Dysphagia in Parkinson DiseasePharyngeal phase
• Pharyngeal dysmotility and impaired relaxation of the
cricopharyngeal muscle
Esophageal phase
• Slowed esophageal transit
• Both segmental and diffuse esophageal spasm
• Ineffective or tertiary contractions, and even aperistalsis
• Lower-esophageal sphincter dysfunction - reflux as well as
dysphagia.
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Dysphagia in Parkinson Disease
Management
• Inconsistent response to levodopa or dopamine agonist
therapy
• Cricopharyngeal muscle dysfunction - cricopharyngeal
myotomy and botulinum toxin injections
• Behavioral swallowing therapy
• PEG tube placement rarely necessary
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Other Basal Ganglia Disorders
Parkinsonism-plus syndromes- PSP, MSA, CBD,
DLB
• Dysphagia is a frequent problem
• Develops relatively early in the course of the illness
Appearance of dysphagia within 1 year of symptom
onset virtually eliminates PD as a diagnostic
possibility
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Amyotrophic Lateral Sclerosis
• Dysphagia eventually develops in most individuals
• Presenting feature in approximately 25%
• Sensation of solid food sticking in the esophagus may
provide the initial clue to emerging dysphagia
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Amyotrophic Lateral Sclerosis• Impaired function of the lips and tongue (particularly the
posterior portion of the tongue) due to evolving muscle
weakness typically appears first
• Next involvement of jaw and suprahyoid musculature
• Finally weakness of pharyngeal and laryngeal muscles
• Delay in, and eventual abolishment of, triggering of the
swallowing reflex for voluntarily initiated swallows, with
relative preservation of spontaneous reflexive swallows until
the terminal stages of the disease
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Cranial Neuropathies• Extramedullary, intracranial involvement in processes involving the
meninges, extramedullary tumors, aneurysms, and skull fractures
• Lesions at the jugular foramen or in the retroparotid space - some
combination of IX, X, XI, XII, and the cervical sympathetic
• Prominent in the miller fisher variant of AIDP
• Herpes zoster infection - attributed to cranial ganglionic
involvement
• Charcot-marie-tooth disease
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Nuclear lesions
• Brain stem stroke and MS
• Brainstem tumors, both primary and metastatic,
• Central pontine myelinolysis
• Progressive multifocal leukoencephalopathy
• Leukoencephalopathy due to cyclosporin toxicity
• Brainstem encephalitis – Listeria and Epstein-barr
Virus
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Cervical Spinal Cord lesions
• Especially if associated with respiratory insufficiency
• With higher spinal cord injury
• With treatment and time, most patients demonstrate
improvement
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Management of dysphagia
• Dietary modification
• Exercises
• Facilitation techniques
• Compensatory mechanisms
• Enteral feeding
• Surgical methods
• Botulinum toxin therapy
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Dietary Modification• Difficulties with the oral preparatory phase
– Diet of pureed foods
• As patients' swallowing function improves
– Soft and semisolid foods with regular consistencies
• Recommend to patients that they alternate bites with
sips, bite or sip size, and the number of swallows per
size
• Good oral hygiene and dental care
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Viscosity and texture of food
Oropharyngeal neurogenic dysphagia
• Thickened liquids
– Liquids can be thickened with starch-based food
thickeners
Difficulties with mastication
• Chopped or pureed foods
Uniform and viscous bolus of food or beverage - less risk
of aspirating
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Exercises
Indirect
– Strengthen swallowing muscles
Direct
– Performed while swallowing
• Designed to facilitate oral motor strength, range of
motion (ROM), and coordination
• Usually are performed 5-10 times per day
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Lip exercises
• facilitate the patient's ability to prevent food or liquid from
leaking out of the oral cavity
Tongue exercises
• facilitate manipulation of the bolus and its propulsion through
the oral cavity or to facilitate retraction of the tongue base
Jaw exercises
• facilitate the rotatory movements of mastication
Exercises
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Respiratory exercises
• improve respiratory strength
Vocal cord adduction exercises
• promote strengthening of weak vocal cords.
Exercises
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Head-lift (Shaker) exercise
• to increase anterior movement of the hyolaryngeal
complex and opening of the upper esophageal
sphincter
• lie flat and with shoulders on the floor and raise their
head high enough to see their toes, maintaining this
position for 1 minute
Exercises
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Facilitation techniques
Somatosensory stimulation (electrical
current )applied to the pharynx
• Change the excitability of the corticobulbar projection
• Induce cortical reorganization in patients with
poststroke dysphagia
Repetitive transcranial magnetic stimulation (RTMS)
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Facilitation techniques
Deep pharyngeal neuromuscular stimulation (DPNS)
• To improve pharyngeal swallow
• On stimulating 3 reflex sites
1) Bitter taste buds and tongue base -improve tongue-base
retraction
2) Soft palate - improve palatal elevation
3) Superior and medial pharyngeal constrictor - improve
pharyngeal peristalsis and cricopharyngeal opening
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Compensatory Techniques
Chin-tuck position
• decreases the space between the base of the tongue
and the posterior pharyngeal wall
• creating increased pharyngeal pressure to move the
bolus through the pharyngeal region
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Compensatory Techniques
Rotation of the head to the affected side
• closes the pyriform sinus on the affected side and
directs food down the opposite or stronger side
• also adds external pressure on the damaged vocal
cord and moves it toward the midline, improving
airway closure.
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Compensatory Techniques
Tilting the head to the strong side
• bolus tends to be directed down the stronger side in
the oral cavity and in the pharynx
• effective for patients who have unilateral tongue
dysfunction or a unilateral pharyngeal disorder.
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Compensatory Techniques
Supraglottic swallow
• Close the airway voluntarily before and during the
swallow
• Take a deep breath and hold your breath
• Keep holding your breath while you swallow
• Cough immediately after the swallow
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Compensatory Techniques
Mendelsohn maneuver
• mimics the upward movement of the larynx
voluntarily
• increase the duration of the cricopharyngeal opening
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Enteral Feeding
• Unable to achieve adequate alimentation and
hydration by mouth
• Impaired level of consciousness, massive aspiration,
silent aspiration, esophageal obstruction, or recurrent
respiratory infections
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Enteral Feeding
Nasogastric tube feeding
• In post stroke dysphagia temporarily provide
adequate nutrition and buy time until swallowing
improves
• prolonged use can lead to lesions to the nasal wing,
chronic sinusitis, gastroesophageal reflux, and
aspiration pneumonia
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Enteral Feeding
Percutaneous endoscopic gastrostomy
Oroesophageal tube feeding
• patient is taught to insert the 14F urethral tube into the
mouth and past the side of the tongue, pushing slowly
until the catheter end reaches the lips
• Food supplements and liquid are administered by
means of a 500-mL syringe at a rate of approximately
50 mL/min
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Other methods
Cricopharyngeal Myotomy
• to decrease pressure on the pharyngoesophageal
sphincter
Botulinum toxin injection into the UES
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Thank you