By: Abduljabbar Hamid Jabbar

University of Baghdad-College Of Medicine

M. B. Ch. B
By: Abduljabbar Hamid Jabbar
University of Baghdad-College Of Medicine
M. B. Ch. B
Swallowing (deglutition): The voluntary initiation of swallowing takes place in higher brain centers and starts with oral
stage. From here on, the process of swallowing becomes entirely or almost entirely automatic and controlled by swallowing
(or deglutition) center which is located at the medulla and the pons.

• The afferent (sensory) fibers to this center are:

Trigeminal (5th cranial nerves),
Glossopharyngeal (9th cranial nerves),

• The efferent (motor) nerve fibers from the swallowing center are conducted through:
Trigeminal (5th cranial nerves),
Glossopharyngeal (9th cranial nerves),
Vagus (10th cranial nerves),
Hypoglossal (12th cranial nerves),
Few of the superior cervical nerves to the pharynx and upper esophagus

 Swallowing can be divided into the following stages:

Oral stage.
Pharyngeal stage.
Esophageal stage.
Relaxation of lower esophageal sphincter.
[A] Oral (voluntary) stage of swallowing: Food is voluntarily
squeezed posteriorly in the mouth to the oropharynx by
pressure of the tongue upward and backward against the hard
palate.
From here on, the process of swallowing becomes entirely or
almost entirely automatic and cannot be stopped.

[B] Pharyngeal (involuntary) stage: When the bolus of food is

pushed backward in the mouth,
It stimulates swallowing receptor areas around the opening of
the pharynx afferent impulses pass to Swallowing center to
initiate a series of automatic pharyngeal muscular contractions
and to inhibit the respiratory center of the medulla during
swallowing, halting respiration at any point in its cycle to allow
swallowing to proceed.

The sequence of events of the pharyngeal stage of the

swallowing is as follows:
1. The soft palate is pulled upward to close the posterior nares
preventing reflux of food into the nasal cavities.

2. The palatopharyngeal folds on either side of the pharynx are

pulled medial ward to approximate each other. In this way these
folds form sagital slit through which the food must pass into
the posterior pharynx. This slit performs a selective action,
allowing food that has been masticated properly to pass with
ease while impede the passage of large objects.
3. The vocal cords of the larynx are strongly
approximated, and the hyoid bone and larynx are pulled
upward and anteriorly by the neck muscles causing
epiglottis to swing backward over the superior opening of
the larynx. All these effects (especially the approximation
of vocal cords) prevent passage of food into the trachea.

4. The upward movement of the larynx also stretches the

opening of the esophagus. At the same time, the upper 3
to 4 cm of the esophagus, an area called the upper
esophageal sphincter (or pharyngeoesophageal sphincter
or the cricopharyngeal muscle), relaxes, thus allowing
food to move easily and freely from the posterior pharynx
into the upper esophagus.

This sphincter between swallows, remains tonically and

strongly contracted (by the continual firing of the vagal
fibers), thereby prevents air from going into the
esophagus during respiration.

5. At the same time that the larynx is raised and the upper
esophageal sphincter is relaxed, the superior constrictor
muscle of the pharynx contracts, giving rise to a rapid
peristaltic wave passing downward over the pharyngeal
muscles and into the esophagus, which also propels the
food into the esophagus.
Swallowing becomes a great concern for the elderly since strokes and Alzheimer's disease can interfere with the
autonomic nervous system.

there are multiple areas of the central nervous system which, if affected by a stroke, could disrupt the ability to swallow.
This is especially true for strokes of the medulla, as this is a relatively small area that contains multiple structures that are
critical in carrying out the swallowing reflex.

In fact, people with medullary strokes frequently require temporary or permanent feeding tube placement
[C] Esophageal stage of swallowing: The esophagus functions to conduct food from
the pharynx to the stomach. The movement of food down the esophagus is an active
process (primary esophageal peristalsis integrated at swallowing center) that does
not depend on gravity for its normal function. The upper esophageal sphincter and
lower esophageal sphincter are closed in normal resting state.

Closure of the upper esophageal sphincter prevents air from being drawn from the
mouth into the esophagus during inspiration. Closure of the lower esophageal
sphincter prevents gastric contents to move back from the stomach to the
esophagus.

Because most of the esophagus is contained within the thoracic cavity, the pressure
in the lumen of the resting esophagus is approximately equal to intra-thoracic
pressure (atmospheric or slightly below atmospheric) when the upper esophageal
sphincter and lower esophageal sphincter are closed (normal resting state). During
pulmonary inspiration, the intra-esophageal pressure will be sub-atmospheric.

The term secondary esophageal peristalsis describes esophageal peristalsis and

lower esophageal relaxation associated with distension or irritation of the smooth
muscle portion of the esophageal body.

The event is limited to the smooth muscle component of the esophagus and is the
result of activation of enteric nerves. Initiation of secondary peristalsis does not
involve extrinsic neural reflexes and, thus, is not accompanied by the oral-pharyngeal
phase of swallowing.
[D] Relaxation of lower esophageal sphincter: The lower
esophageal sphincter is not anatomically separate identifiable
muscles.

The fundus of the stomach and lower esophageal sphincter

extending about 2-5 cm above its junction with the stomach
both relax during a swallow while the bolus of food is still
higher in the esophagus. This phenomenon is called
receptive relaxation. Receptive relaxation is vagally mediated,
Nitric oxide is the neurotransmitter thought to mediate
receptive relaxation at the smooth muscle cell allowing food
to pass to the stomach.
Reflux of the acidic contents of the stomach up to
the esophagus damages the esophageal mucosa.
This is prevented by:

[1] The muscles of the lower esophageal sphincter

normally remains tonically contracted due to tonic
activity of the vagal fibers innervating the esophagus
(in contrast to the mid- and upper portions of the
esophagus which normally remain completely
relaxed).

Vagal efferent nerve fibers control contraction and

relaxation of the LES. Vagal excitatory fibers
synapse on post-ganglionic, enteric motor neurons
that release acetylcholine within the musculature of
the LES. Vagal inhibitory fibers synapse on enteric
inhibitory motor neurons that release nitric oxide
(NO).

These neurons may also utilize ATP and VIP as

inhibitory transmitters, but NO is the primary
inhibitory neurotransmitter. Sympathetic neurons
also provide excitatory input to the LES via
excitatory motor neurons.
[2] Another factor that prevents reflux is the oblique entrance of the esophagus to the stomach which acts like
a valve-like mechanism of that portion of the esophagus that lies immediately beneath the diaphragm.

Greatly increased intra-abdominal pressure caves the esophagus inward at this point at the same time that the
abdominal pressure also increases the intragastric pressure, preventing the high pressure in the stomach
from forcing stomach contents into the esophagus.
Esophageal reflux: Reflux of stomach acid to the esophagus causes esophageal pain (heartburn) and may
lead to esophagitis. An increase in the intraabdominal pressure (by the ingestion of a very large meal,
production of intestinal gas, pregnancy, an abdominal mass such as a tumor, bending at the waist, straining
against a closed glottis as in defecation) will facilitate gastro-esophageal reflux if the LES is not contracted or
there is distortion of the valve-like mechanism. Esophageal reflux may occur if:

[A] If the intragastric pressure raises high enough to force the lower esophageal sphincter open.
[B] If the lower esophageal sphincter is unable to maintain its normal tone.
[C] If the lower esophageal sphincter is forced through the diaphragm and into the thoracic cavity as in hiatal
hernia, in which the oblique entrance of the esophagus to the stomach is distorted, and consequently the
valve-like mechanism is impaired.
Belching (eructation): Following a heavy meal or the ingestion of large amounts of gas (e.g., from carbonated
beverages), the gas bubble that is usually in the fundus of the stomach is displaced to the cardia.

When lower esophageal sphincter relaxes during the swallowing process, gas enters the esophagus and is
regurgitated.
Dysphagia: Difficulty in swallowing. Persons with dysphagia usually report choking, coughing, or an abnormal sensation of
food sticking in the back of the throat or upper chest when they swallow. If swallowing is painful, it is referred to as
odynophagia. Dysphagia can result from altered nerve function or from disorders such as:

Narrowing of the esophagus.

Lesions of the central nervous system (CNS), such as a stroke, often involve the cranial nerves that control swallowing.

Strictures and cancer of the esophagus and strictures resulting from scarring can reduce the size of the esophageal
lumen and make swallowing difficult.
Achalasia: In which the lower esophageal sphincter fails to relax; food that has been swallowed has difficulty
passing into the stomach, and the esophagus above the lower esophageal sphincter becomes enlarged.

One or several meals may lodge in the esophagus and pass slowly into the stomach. There is danger of
aspiration of esophageal contents into the lungs when the person lies down.
Thank You
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