MECHANICAL DISORDERS OF SWALLOWING.pdf / KUNNAMPALLIL GEJO

7/27/2019 MECHANICAL DISORDERS OF SWALLOWING.pdf / KUNNAMPALLIL GEJO

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MECHANICAL DISORDERS

OF SWALLOWING

KUNNAMPALLIL GEJOJOHN, MASLP

KUNNAMPALLIL GEJO JOHN


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Patients with mechanical swallowing disordersevidence difficulty secondary to the loss ofsensory guidance of the structures necessary

to complete a normal swallow.. Most patients with mechanical dysphagiahave had oral, pharyngeal, or laryngealstructures removed or reconstructed duringsurgery for cancer. There are, however, othercauses that must be considered in thedifferential diagnosis. The most common of

these are KUNNAMPALLIL GEJO JOHN


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ACUTE INFLAMMATIONS

Acute inflammatory processes that

produce or exacerbate dysphagia are

nonspecific reactions to injury of the

oropharyngeal tissue secondary to fungal,

bacterial, or viral agents, chemical irritants,

or traumatic insults.



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Acute inflammations of the oropharyngeal

tissues alone may not create significant,

extended dysphagia.. Early recognition and treatment of acute

inflammatory reactions can make the

difference between success and failure inattempts at oral feeding.



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They should be ruled out in patients

whose mental state or competenceinterferes with the ability to communicateoral pain and those who evidenceunexplainable dysphagia or suddenrefusal to eat. Early identification isimportant because most inflammationscan be controlled within a short period of

time, and oral nutritional intake canresume.



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Herpes Simplex

Viral in origin, a herpetic infection ischaracterized by round vesicles that breakto form shallow ulcers surrounded by a

narrow zone of inflammation.Typically, they are found on the lips;however, the pharynx and buccal mucosamay be involved. Palatal and pharyngealulcers create significant pain anddiscomfort on swallowing.



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Ludwig's Angina

The most typical type of infection to occur

in the submandibular space that may

compromise swallow is Ludwig's angina.

Odontogenic infections such asabscesses, caries, and postextraction

infection are implicated in 70 to 85 percent

of cases of Ludwig's angina



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Clinical manifestations of Ludwig's angina

include massive swelling and displacement of

the tongue. The floor of the mouth also willappear red, swollen, hard, and tender.

Posterior extension may result in epiglottitis,

with further compromise of the airway.If the patient is able to speak, he or she may

have a muffled, "hot potato" voice. The neck

exhibits a woody, tender swelling, especially inthe suprahyoid region. Patients generally

present with complaints of mouth pain, stiff

neck, drooling, and dysphagia.KUNNAMPALLIL GEJO JOHN


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Lingual Tonsillitis

Patients with lingual tonsillitis havesymptoms similar to those of other throatinfections, except they complain of pain in

the medial pharyngeal region. Often theydescribe a lump in the throat associatedwith complaints of dysphagia.

The mechanism of lingual tonsillitis can beconfirmed by indirect mirror examination ofthe base of the tongue and pharynx.



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Epiglottitis

Epiglottitis is an inflammatory disease that

affects the supraglottic region and often results

in acute respiratory distress due to airway

obstruction. It is most commonly seen in childrenbut has more recently been recognized with

increasing frequency in adults

Patients often complain of sore throat,

dysphagia, respiratory difficulty, muffled voicedrooling, and stridor



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Acute Pharyngitis

Acute pharyngitis may be viral or bacterial

in origin. The reddened inflamnation that it

causes in the oropharyngeal region

frequently precedes the common cold,leading patients to complain of swallowing

difficulty. It often is accompanied by a mild

fever without any other complications. Thepain and dysphagia subside within four to

six days.



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The most common bacterial form of pharyngitis

is streptococcal. The diagnosis is confirmed by

laboratory analysis. The patient has an acutelyinflamed oropharynx with characteristic white

or yellow follicles.

Most complain of headache and muscle joint

pain and have fevers that reach 103 degrees.

Streptococcal infections respond well to a full

course of antibiotics



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Lateral Pharyngeal Space

Infections

Infections in the lateral pharyngeal space

are classified as anterior or posterior

depending on the location of the infection.

Infections of the lateral pharyngeal spacemay be secondary to primary infection in

the tonsil or pharynx.



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Clinical presentation of symptoms differs

between anterior and posterior compartments.

When the patient has an anterior compartmentinfection, the patient may present with

dysphagia, trismus, chills, high fever, hardening

and swelling of the mandibular arch, systemictoxicity, medial buldging of the lateral

pharyngeal will, and pain



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Treatment of lateral pharyngeal space

infections is similar to that of Ludwigs

angina. Therapeutic management includes

antibiotic therapy, surgical drainage, andairway maintenance.



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Fungal Inflammation

One of the common fungal inflammations

is candidiasis (thrush). Most frequently

seen on the tongue, the lesions appear as

soft, white, slightly elevated plaques(Keyes 1980). If left untreated, the lesions

cause associated pain and difficulty

swallowing.



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They are more common in debilitated and

immunosuppressed patients, in those who

are undergoing extensive antibiotic ther-

apy, and in patients receiving irradiationtreatments.



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Chemical Agents

Mucosal inflammation may result from exposure

to chemicals. The subsequent pain interferes

most often with the oropharyngeal stage of

swallowing.Chemical inflammation can result from the

prolonged use of phenol (toothache drops).

Other drugs that precipitate mucosal burns

include aspirin, which causes irritation to thecheek lining, some gargles, and anesthetic

throat lozenges when used excessively



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The most severe form of a chemical burn, lye

ingestion, can cause severe blistering of the

entire digestive tract. The clinician should be

aware that patients who undergo chemotherapycan develop painful oral ulcer- actions that

interfere with swallowing. Drugs used in these

regimens such as doxorubicin (Adriamycin),

methotrexate, and cyclophosphamide (Cytoxan)can cause oral mucositis.



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TRAUMA

Other than major traumatic tissue losses

such as those resulting from t wounds,

more frequently occurring injuries in the

oral cavity are fairly benign and generallydo not create significant swallowing

complaints except when superimposed on

other mechanisms of dysphagia.



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Examples include trauma from a toothbrush

and mucosal irritation from ill-fitting dentures.

Patients who complain of a poorly fitted denturecan localize their pain.

Clinical examination usually will reveal a

reddened or whitish change in the mucosa atthe point of contact where the patient has the

sensation of most discomfort. Prolonged irri-

tation can result in gingival hyperplasia that

results in soft, sometimes flexible masses of

tissue that appear markedly inflamed.



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MACROGLOSSIA

An abnormally large tongue can interfere with

the propulsive action of the bolus. The clinician

should be aware of some of the conditions that

may contribute to macroglossia that may beconsidered in the differential diagnosis.

They include macroglossia secondary to

lymphatic obstruction secondary to surgery orirradiation, hypothyroidism, mongolism, amyloid

deposits, and lymphangiomatous or

hemangiomatous processes.KUNNAMPALLIL GEJO JOHN


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PHARYNGOESOPHAGEAL

DIVERTICULUM

A pharyngoesophageal diverticulum,

commonly referred to as Zenker's

deverticuIum'in the cervical esophagus, is

an abnormal muscular outpouchingdiverticulum that forms either above the

cricopharyngeus through Killian's

dehiscence or from below throughLaimers triangle.



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The exact mechanism of pouch formation

is unknown, although in small percentagesit can be associated with esophageal

disease, including traction diverticula,

varices, achalasia, carcinoma, and hiatal

hernia.



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Zenker's diverticula are more common in

men in the sixth and seventh decades of

life. They must become very large to

produce dysphagic symptoms. Patientscomplain of regurgitation of undigested

food, foul breath, and fullness in the neck,

weight loss, and nocturnal cough withaspiration.



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MECHANICAL DYSPHAGIA

SECONDARY TO CARCINOMA

The largest groups of patients with

mechanical swallowing disorders have had

oral, pharyngeal, laryngeal, and

esophageal structures removed,rearranged, or reconstructed secondary to

surgery for carcinoma. Most often,

combinations of these structures areinvolved.



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STRUCTURAL DISORDERS



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Esophageal stenosis

When the lumen narrows, solid food may

be too large to pass. Esophageal stenosis

typically causes dysphagia for solid food

dysphagia. In addition, the nature of thesolid material ingested is important for

symptom production. Dysphagia is more

likely to occur when solids are tough orfibrous. Softer, more easily chewed foods

are much less likely to cause difficulty.



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Rings and Webs

The esophagus may be narrowed by a

band of tissue composed of mucosa and

sub bmucosa,

This type of lesion is called a ring when

located at the esophagogastric junction

and a web when located elsewhere in the

esophagus or hypopharynx.



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Webs are frequently asymmetric, most

often impinging on the esophageal lumen

from the anterior wall.



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Treatment of webs or rings involves dilatation

or ruptures of the ring any one of a variety of

esophageal dilator systems. The ring is thin,

nonfibrotic and easy to dilate.

Complete, or nearly complete, symptomatic

relief can anticipated. Dilatation may provide

permanent relief, although a large proportion

of patients will need periodic redilatation at

variable intervals.



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Benign Stricture

Strictures are rarely seen in children. The

vast majority of benign esophageal

structures are acquired in adulthood as a

consequence of esophagi is. In a circularstructure like the esophagus, edema due

to ongoing inflammation and fibrosis part

of the healing process occur at theexpense of luminal diameter



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Malignant Stricture

Although benign tumors may arise from

the esophagus, the vast majority of

clinically significant tumors of the

esophagus are malignant.

Most esophageal malignancies are

squamous cell carcinomas, although

cancers of the distal esophagus may beadenocarcinomas.



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Luminal Deformity



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Extrinsic Compression

Some degree of luminal deformity due to

extrinsic compression by normal medinal

structures (i.e. the aortic knob, the left

mainstem bronchus, and the left atrium ofthe heart)



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More pronounced compression can occur

with mediastinal pathology such as aortic

aneurysm, cardiomegaly, congenital

abnormalities of the large mediastinalarteries (e.g. aberrant subclavian artery),

enlarged mediastinal lymph nodes, and

lung cancer.



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Esophageal Diverticulum

Esophageal diverticula are relatively rare

and most often asymptomatic, even when

they reach relatively large size. When

symptoms do occur, they includedysphagia for liquids and solids and/or

regurgitation of previously swallowed food

back to the mouth



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Diffuse Esophageal Spasm

Esophageal spasm constitutes the end of

a spectrum of nonspecific esophageal

dysmotility, ranging from the abnormal

contractions seen occasionally in normalindividuals to the repeatedly high-

amplitude, prolonged, symultaneous,

and/or multiphasic contractions in theabsence of any apparent peristaltic activity



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Nutcracker Esophagus

ln 1977, Brand et al. described a group of

patients with chest pain or dysphagia,

occurring in association with manometric

findings of high amplitude, but normallyprogressive peristaltic waves (Brand et al.

1977).



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Nonspecific Esophageal Motility

Disorders

A large number of patients referred to the

esophageal function laboratory have

abnormalities of esophageal motility in which the

degree and type of motility abnormalitiesdetected are not sufficient to be labeled

esophageal spasm or nutcracker esophagus.

Such lesser patterns of dysmotility are referred

to as nonspecific esophageal motor disorders(NEMD).



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Treatment of Disorders of

Esophageal Motility

A variety of smooth muscle relaxant drugs

(nitrates, hydralazine, calcium channel

blockers) have been used in an attempt to

decrease esophageal contractile am-plitude and repetitive contractions).


ABNORMALITIES OF LOWER


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ABNORMALITIES OF LOWERESOPHAGEAL SPHINCTER

FUNCTION

Achalasia- It means failure to relax.

characterized by the degeneration ofneural elements in the wall of the esopha-

gus, particularly at the LES. The distal

segment of the esophagus tapers, givingthe appearance of a "bird's beak



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Achalasia is a condition in which a

nonrelaxing, or incompletely relaxing, ES

prevents the passage of swallowed

material into the stomach. Patients usually-resent with dysphagia for both liquids and

solids. Regurgitation is common,



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Although the impairment of LES response

to swallow is key to the functional

obstruction to the flow of food into the

stomach, the motor abnormalitiesachalasia include the complete loss of

progressive peristalsis



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Curling.

Curlingis an alteration in esophageal

motility frequently seen in elderly

individuals. Curling represents tertiary

contractions, which are nonpropulsive.



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Diffuse Esophageal Spasm.

Diffuse esophageal spasmis character-

ized by intermittent dysphagia, chest pain,

and repetitive contractions of the

esophagus.

Dysphagia is present in 30%, to 60% of

patients with diffuse esophageal spasm.

Clinically, dysphagia is intermittent, withseverity varying from mild to severe



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Presbyesophagus.

Presbyesophagus describes esophageal

dismotility associated with normal ageing

process. This may include muscular

weakness muscular atrophy.



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Diverticula.

Diverticula are out pouchings of one or more

layers of esophageal wall. This diverticula

occurs

(1)above the upper esophagealsphincter(Zenkers diverticulum)

(2)near the midpoint of esophagus(t ract ion

diver t icu lum)

(3)above the lower esophageal sphincter

(epiphern ic diver ticu lum).



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Schatzki ring

It is a lower esophageal mucosal ring

which is located at the level of

squamocolumnar junction


G t h l R fl


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Gastroesophageal Reflux

DiseaseGastroesophageal reflux disease (GERD)

is defined as the retrograde movement of

gastric contents from the stomach through

the lower esophageal sphincter and intothe esophagus.


Persons with GERD frequently complain of


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Persons with GERD frequently complain of

noncardiac chest pain, regurgitation of gastric

contents, water brash (stimulated salivary

secretion esophageal acid).

Dysphagia and sometimes odynophagia (pain

upon swallowing). Gastroesophageal reflux

disease has also bet associated with numerousextra-esophageal symptoms including

pharyngitis, laryngitis, hoarseness, chronic

cough, asthma, and pt monary aspiration. Acidreflux induced symptoms referable to the

oropharyngeal, laryngeal, and respiratory tracts

are termed atypical reflux.KUNNAMPALLIL GEJO JOHN


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The etiology of oropharyngeal

dysphagia, the difficulty in passing

a food bolus from the oropharynxin to the upper esophagus.



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Gastroesophageal reflux occurs through

one of three mechanisms:(1) inappropriate or transient lower

esophageal sphincter relaxation,

(2) increased abdominal pressure orstress-induced reflux, or

(3) incompetent or reduced lower

esophageal sphincter pressures orspontaneous free reflux.



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Lower esophageal sphincter competence

is the most important barrier to

esophageal reflux. Transient lower

esophageal sphincter relaxations are themost important cause of gastroesophageal

reflux,



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Barrett's Esophagus

Barrett's esophagus, a compensatory

change in the esophageal mucosa from

squamous to specialized intestinal

epithelium, occurs in up to 10% to 15% ofpatients with atypical presentations of

GERD



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MEDICATIONS

The effects of medication are influenced by sex,

age, body size, meta-bolicstatus, individual

biological response, and concurrent use of other

medications. A variety of medications, includingthose obtained over-the counter and those

medically prescribed, affect swallowing, impair-

consciousness, coordination, motor and

sensitivity functions, and the lubrication of theupper aerodigestive tract.ssss



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Analgesics

Salcylates (aspirin) and nonsteroidal anti-inflammatoryagents cause gyration of the mouth, throat burning,mucosal hemorrhage, glossing and dry mouth.

AntibioticsSide effects such as glossitis, stomatitis, andesophagitis have been scribed for penicillin,erythromycin, chloramphenicol, and the tetra--lines.Sulfa can cause a Stevens-Johnson type reaction

resulting in ensive mucosal ulceration and glossitis.Aminoglycosides can Tease Parkinsonian symptoms ofweakness.



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Antituberculous medications such as isonlazid,rifampin, ethambutol, and cycloserine can causeconfusion, disorientation, and dysarthria.

Antiviral agents such as acyclovir, amantadine,

gancyclovir, and vidarabine can indirectly causedysphagia with confusion, asthenia, and lingualfacial dyskinesia. Amantadine can cause severexerosnia and xerophonia in some patients-Zidovudine (AZT) causes tongue de 5% to 10%

of patients. Chloroquine (Plaquenil) can causestomatitis



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Antituberculous medications such as isonlazid,rifampin, ethambutol, and cycloserine can causeconfusion, disorientation, and dysarthria.

Antiviral agents such as acyclovir, amantadine,

gancyclovir, and vidarabine can indirectly causedysphagia with confusion, asthenia, and lingualfacial dyskinesia. Amantadine can cause severexerosnia and xerophonia in some patients-Zidovudine (AZT) causes tongue de 5% to 10%

of patients. Chloroquine (Plaquenil) can causestomatitis



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Anti muscarinics, Anti cholinergics, andAntispasmodics

Antimuscarinics and antispasmodics are used for avariety of reasons such as bradycardia, excessive oral

secretions, motion sickness, and diarrhea. They diminishthe production of saliva and mucus. Salivary secretion isparticularly sensitive to inhibition by antimuscarinic

Prokinetic agents improve gut motility and speedgastric emptying. The two major drugs in this category

are metoclopramide (Reglan) and cisapride(Propulsid) 'The former is associated with greaterantihistamine-like side



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Mucolytics

Mucolytics can be used to counter the

effects of drying agents such as

antihistamines. However, no medications,including mucolytic agents, are a

substitute for adequate hydration. Indeed,

these medications are dependent onadequate water intake.s



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Anti hypertensivesAlmost all of the antihypertensives have some degreeof parasympathomimetic effect and thus dry the mucousmembranes. Hydration is the first step to improve

swallowing when taking these medications;Antineoplastics

Antineoplastics affect swallowing mainly through themechanism of inflammation, sloughing, and occasionallycausing superinfection of the aerodigestive tract mucosa.

This effect results in mucositis, stomatitis, pharyngitis,esophagitis, and esophageal ulceration's



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Vitamins

Over dosage of vitamin A causes

hypervitaminosis a syndrome, which

includes dermatologic, gastric, skeletal,and cerebral and optic nerve edema.

Fissures of the lips, dry mouth, and

abdominal discomfort can result. A similarstomatitis can result with vitamin E over

dosage.



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Neurologic MedicationsAnt iconvu lsants . Phenobarbital is a sedative andanticonvulsant with side effects similar to the tricyclicantidepressants: dry mouth, sweating, lwpoteiisioti, andtremor. Phenytoin (Dilantin) adverse effects include centralnervous system signs such as ataxia, slurred speech, incoordination, and dystonia.Carbamazepine (Tegretol) is an anticonvulsant usedprimarily for seizures. Digestive symptoms can also beserious such as glossitis, stomatitis, and dryness of themouth.

(Ant ipark insonians. Levodopa may improve all symptomsof Parkinson 's disease including swallowing, but it can causegastrointestinal discomfort, dyskinesia, and oral dryness



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Ant ipsychot ics .Antipsychotics primarily work by dopamineantagonism. Commonly used drugs in this class includehaloperidol (Haldol) chlorpromazine (Thorazine),thioridazine (Mellaril), and prochlorperazine (Compazine).These medications can have anticholinergic effects such asdry mouth, nasal congestion, and hypotension. Approximately

14% of patients receiving long-term antipsychotic medicationswill develop tardive dyskinesia ranging from tongue rest-lessness and disabling choreiform and/or athetoid movementsthat lead to significant swallowing and feeding problem

Life-threatening dysphagia can occur after prolongedneuroleptic therapy. Neuroleptic drugs can induceextrapyramidal symptoms such as dystonia, akathisia, andtardive dyskinesia. Contrast radiography has revealed poorcontractions in the upper esophagus, a hypertonicesophageal sphincter, and hypokinesia of the pharyngealmuscles.



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Anxiolytics. Significant dysphagia can result

from chronic use ofbenzodiazepines. Reported

effects include hypopharyngeal retention,

cricopharyngeal in coordination, aspiration, anddrooling. Benzodiazepines can inhibit

discharges from interneurons in the nucleus of

the tractus solitaries or ambiguous nucleus, both

of which are critical to the pharyngeal phase ofswallowing-)



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NEOPLASMS

Neoplasia causes distortion, obstruction, reducedmobility, or neuromuscular and sensory dysfunction ofthe upper aerodigestive tract. Exophytic tumorsinterfere with swallowing principally by distorting orobstructing the aerodigestive tract. Tumors with aninfiltrating growth pattern may cause reduced mobility orfixation of the tongue, soft palate, pharynx, or larynx (secTable 3-10). Tumors also affect swallowing by-interferingwith the afferent fibers (sensory input) from the mucosaof the upper aerodigestive tract by invasion and destruc-tion of mucosal nerve endings or sensory nerves such asthe trigeminal (V), glossopharyngeal (IX), and vagus (X)cranial nerves and their branches.



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Neoplasms of the floor of the mouth, tongue, or

buccal mucosa may by mass effect or by

restricting mobility of the tongue and floor of the

mouth impair a patient's ability to interpose foodbetween the teeth. Tumor invasion of the

dorsum of the tongue or involvement of the

lingual nerve (V) may affect sensory input

causing premature spillage of the bolus into thepharynx and, consequently, aspiration


SWALLOWING DISORDERS


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ARISING FROM SURGICAL

TREATMENTANTERIOR CERVICAL SPINAL SURGERY,Anterior cervical spinal surgery is a common

surgical approach.

Surgeons approach the spinal cord anteriorlywith a cervical incision, mobilizing the

laryngotracheal complex away from the great

vessel of the neck and prevertebral space to

visualize and repair the cervical spine.



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Postoperative dysphagia is found in all patientswho undergo anterior cervical spinal surgery.

Although in most patients the dysphagia is of

short duration, in 10% of patients it can persist

longer than 12 months. There are several

possible etiologies for dysphagia following

anterior cervical spinal surgery. Neurologic

damage may result from direct trauma or stretchtrauma to the recurrent laryngeal nerve,



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HEAD AND NECK SURGERY

Head and neck surgery for neoplasms of theupper aerodigestive tract alters the anatomy,causes scarring, and may injure motor andsensory nerves. All these factors contribute tothe presence of dysphagia in the postoperativeperiod. In addition, many of these patientsrequire reconstruction with insensate tissueflaps that can contribute to the discoordinationof the swallowing mechanism or can even cause

mechanical obstruction or diversion of the bolusinto the airway. Head and neck surgery mayresult in disruption of any of the phases ofswallowing



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Skull Base Surgery

Patients undergoing skull base surgery are at risk forinjury to lower cranial nerves, brainstem, brainparenchyma, and soft tissues of the upper aerodigestivetract, depending on tumor location. Injury to these vitalstructures can lead to dysfunction of speech, swallowingand airway protection. In addition to the mentioneddeficits, pal undergoing skull base surgery frequentlyneed reconstruction with insensate soft tissue flaps,which maycompound the deficit due to their bulk. Afterskull base surgery, patients frequently need enteraltubes, prolonged incubation and ventilation, andtracheostonlic, further compound the swallowing deficits.



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Floor of the Mouth

The floor of the mouth is considered asulcus for saliva and food particles;however, when obliterated by surgery, the

lack of this sulcus and the loss of mobilityof the anterior tongue become majorimpairments during the preparation of thefood bolus. All efforts should be made to

protect the lingual nerve to preserve thesensation to the tongue



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Partial Glossectomy

Following partial glossectomy, near- normal swallowingand normal speech can be predicted if the patient canprotrude the tongue past the sublabill crease. malldefects of the mobile tongueare repaired primarily. Largedefects often cause the loss of tongue driving force andinability to propel the bolus posteriorly. The bolus is oftenimproperly prepared, and, due to the lack of propercontrol, it may be presented to the oropharynxprematurely. Food and saliva will spill out of the oralcavity because of poor tongue mobility, a problem that isworsened if the oral sphincter has been altered.



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Palate

Tumers of the hard palate that requre partial or totalmaxilactomy affect both speech and swallowing. Recectionresults in loss of oronasal seperation, which causes leakageof food into the nose and hypernasal speech with decreasedTumors of the hard palate that require partial or totalmaxillectomy affect both speech and swallowing. Resection

results in loss of oronasal separation, intelligibility. Unilateralmaxillectomy is usually best reconstructed with a dentalprosthesis. Free microvascular flaps can be used toreconstruct large palatal defects in edentulous patients inwhom a prosthesis would not be retained.

After soft palate resection, patients often have nasalregurgitation. The reconstruction options are limited, anddefects in the soft palate are best managed by dentate'prostheses with extensions to close the nasopharyngealisthmus.



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Lips

The orbicularis oris muscle is crucial to the sphinctericfunction of the lips. This muscle is divided during lip-splitting procedures and must be carefullyreapproximated during closure to restore function. Theloss of lower lip sensation secondary to mental nerve

injury makes sphincteric control difficult if not impossible.

Lip resection may hinder swallowing by creating difficultyin getting food into the mouth (microstomia). Motordenervation of the lower lip secondary to sacrifice of the

marginal mandibular nerve.often manifests itself as lossof sphincteric control, resulting in drooling.



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Oropharynx


O h


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Oropharynx

Resection of the lateral pharyngeal wall leads todecreased pharyngeal wall mobility, which altersoropharyngeal propulsion. The muscles of the base ofthe tongue assist in elevation of the larynx and areessential for the oropharyngeal propulsion pump and for

adequate oral cavity pharyngeal separation. Althoughpartial resection is well tolerated, large defects oftencause dysphagia. Reconstruction of large defects of thebase of the tongue requires a sensate flap. Resection ofeven limited portions of the soft palate producesvelopharyngeal insufficiency, alters the propulsion of thebolus, and can lead to poor oral-pharyngeal separationwith early spillage of the bolus and aspiration before thepharyngeal swallow is initiated.


H h l S


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Hypopharyngeal Surgery

Resection of hypopharyngeal tumors arising on theposterior pharyngeal wall poses several problems for therehabilitation of swallowing. Small defects (less than 2 cm)can be closed primarily, or the edges can be stitched to theprevertebral fascia. Reconstruction with a split thickness skingraft or radial forearm free flap provides a satisfactory closure

of larger defects. However, neither one restores the motility ofthe posterior wall, and impairment of pharyngeal contractionleads to significant postoperative aspiration. Patients lose thenormal gliding action of the hypopharynx on the vertebralfascia because of scarring of the posterior hypopharyngealwall to the prevertebral fascia. Also, the reconstruction of this

area, using grafts and flaps, is almost always devoid ofsensation, which further weakens laryngeal protection.


A i ti


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Aspiration

Aspiration is the entry of material into theairway below ture vocal cords. Aspiration can

occur before, during or after the swallow Pandial

Aspiration pneumonia is a bronchopneumoniaresulting from the entry of foreign materials

usually foods, liquids, or vomitinto the bronchi

of the lungs. There are typically three distinct

pulmonary syndromes caused by types ofaspiration.



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Prolonged mechanical ventilation: Patientsrequiring prolonged mechanical ventilation and

patients with a tracheostomy are especially at

risk for aspiration. Aspiration pneumonia can

occur after only two weeks oil mechanical

ventilation, and nearly 85% of these patients fail

modified barium swallow testing with fluoroscopy

for detection of aspiration.



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Upper-aerod igestive- tract tumors:Most of these patients ex . peri- encesome swallowing difficulty, either from the

mechanical effects of the tumor,itsinterference with the sphinctericmechanism of the larynx, or due to theanatomic and functional changes

produced by surgery, radiation therapy,and chemotherapy


A t i Di


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Autoimmune Diseases

Auto immune diseases are characterizedby the production of antibodies that react

with host tissue or immune effector T cells

that react to self-peptides. Autoirnmunediseases may affect swallowing by

causing intrinsic obstruction, external

compression, abnormal motility, or inad-equate lubrication.


Gi t C ll A t iti


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Giant Cell Arteritis

Giant cell arteritis, also known as temporalarteritis, is all inflammatory disorder affectinglarge and medium size vessels. These arteriesthat originate from the arch of the aorta are the

most affected. Pharyngeal, tongue, or jawclaudication Illay occur when the ascendingpharyngeal, lingual, deep temporal, ormasseteric arteries are affected. Systemic cor-

ticosteroids often resolve all symptoms withinone to two weeks.


Mixed Connective Tissue


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Mixed Connective Tissue

DiseaseMixed connective tissue disease is characterized byclinical findings that may be found in a variety ofautoimmune disorders, including progressive systemicsclerosis, systemic lupus erythematosus, andpolymyositis/dermatomyositis. Similarly, the swallowing

disorders described under each of these disorders canbe a part of mixed connective tissue disease.

Esophageal motility is severely affected, and the majorityof the patients have no peristalsis or low-amplitudeperistalsis contributory to gastroesophageal refluxdisease (GERD). I leartburn all dysphagia are present inup to 501/2 of the patients with mixed connective tissuedisease. The treatment of the GERD may reduce thedysphagia ss


M iti


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Myositis

Polymyositis and dermatomyositis arecharacterized by inflammation of the skeletalmuscle. Thus, muscles of the pharynx are oftenaffected while esophageal smooth muscle isspared. A modified barium swallow frequentlyshows prominence of the cricopharyngeusmuscle, decreased epiglottis tilt, and moderateto severe pharyngeal residue. Two thirds ofpatients with myosins have demonstrable

delayed esophageal transit. Polymyositis andderniatomyositis are treated with corticosteroids.


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Rheumatoid Arthritis

Rheumatoid arthritis (RA) is a chronicrelapsing inflammatory arthritis, usually

affecting multiple diarthrodial joints and

present with a variable degree of systemicinvolvement. Women are more commonly

affected than men, with a ratio of 3:1.



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Rheumatoid arthritis is associated withxerostomia, temporomandibular joint (TMJ)syndrome, a decrease in the amplitude of theperistaltic pressure complex in the striated partof the esophagus proximal, and cervical spinearthritic disease, all of which cause or contributeto swallowing problems. Rheumatic laryngealinvolvement can result in cricoarytenoid jointfiitioii. 0111cctivc functional testing is necessary

to determine the contributions of the oral phaseand the pha-LI dysphagia vilgeal phase to thesvl,all()iVing disorder


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Sarcoidosis

Sarcoidosis is a chronic systemic disorderpresumed to have autoimmunepathogenesis. Sarcoidosis may cause

laryngeal lesion extrinsic compression ofthe esophagus by mediastinal aderiopatl,and esophageal' dysmotility due tomyopathy, infiltration of ALI( bach's plexus,

or granulomatous infiltration of theesophageal wa which may produce longsegments of esophageal stenosi-SD


Scleroderma


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Scleroderma

Scleroderma, or progressive systemic sclerosis,is a disorder char terized by progressive fibrosisand vascular changes. The most coi mon andthe earliest symptom in people with progressivesysten sclerosis is Raynaud's phenomenon,characterized by pallor a sweating of the fingersor hands that progress to cyanosis and paDysphagia, which is the second most commonsymptom of this dis, der, usually first noticed

while swallowing solid4sphagia is most often due to poor motilitythrough the infer two thirds of the esophagus.

Documents

MECHANICAL DISORDERS OF SWALLOWING.pdf / KUNNAMPALLIL GEJO