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Department of Orthodontics and Dentofacial Orthopedics
Department of Orthodontics and Dentofacial Orthopedics
Department of Orthodontics and Dentofacial Orthopedics
3
DEFINITION
Complex series of voluntary and involuntary neuromuscular
contractions proceeding from the mouth to the stomach & is
commonly divided into oropharyngeal & esophageal
stages.
COMPONENTS OF
DEGLUTITION
Deglution has 3 components
Protection of airway
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THEORIES
OF
DEGLUTITI
ON
THEORY OF CONSTANT
PROPORTION
Describes passage of bolus through upper GIT in three phases
PHARYNGEAL
ESOPHAGEAL
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ORAL
PHASE
Tongue plays a vital role
Food is prepared for swallowing
Divided into Oral preparatory phase & Oral phase proper
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MASTICATION OR
CHEWING
CHEWING is a program of mandibular movements patterned in a
sequence of distinctive recurring cycles.
• In cases of acute glossitis tongue fills the oral cavity & protrudes
out of it causing difficulty in mastication
• In unconscious patients tongue may fall back & obstruct the air
passage. This can be prevented by lying the patient in semi
reclined position with head down.
SOFT PALATE
Movable, muscular fold suspended from posterior border of hard palate.
It is composed of :
•Mucous membrane
•Palatine aponeurosis
(forms fibrous basis)
•Muscles
MUSCLES OF THE SOFT PALATE
ORAL PREPARATORY PHASE
Involves breaking down of food in the oral cavity
Food is chewed & mixed with saliva making it into a bolus which
can be swallowed
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Tongue –helps in bolus formation by the action of its intrinsic muscles
which alters its shape. Its extrinsic muscles changes its position within
the oral cavity thereby helping in chewing the food by dental
occlusion
Occlusal action of the lips - seal & prevent the bolus from dribbling
out of the oral cavity
Buccinator muscle – Push the bolus out of the vestibule into the oral
cavity proper
ORAL PREPARATORY PHASE
(CONTD)
SALIVARY GLANDS:
Salivary glands -ducts – saliva- mouth
Saliva contains:
Mucin- holds food together.
Salivary amylase- starts
digesting carbohydrates.
Bicarbonates-maintain PH level of
saliva & protect teeth.
Lysozymes-inhibits bacterial
growth.
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BOLUS FORMATION
Most important function of preparatory
phase
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ORAL PHASE
PROPER
The contraction of soft palate prevents nasal regurgitation
The bolus is moved towards the back of the tongue
The soft palate also prevents premature
movement of bolus into the oropharynx
• Length = 12 cm.
• Width = 3.5 cm & narrows as it goes down.
Divided into
MUSCLES OF PHARYNX
• STYLOPHARYNGEUS
elevates larynx during swallowing
• SALPINGOPHARYNGEUS
elevates larynx
• PALATOPHARYNGEUS
CONSTRICTORS
• SUPERIOR CONSTRICTOR
Aids soft palate in closing the nasopharynx,
propels bolus downwards
• MIDDLE CONSTRICTOR
propels bolus downwards
• INFERIOR CONSTRICTOR
propels bolus downwards & forms sphincter at lower end
(cricopharyngeus)
PHARYNGEAL PHASE
(PUMPINGACTION OF TONGUE & HYPOPHARYNGEAL SUCTION)
Reflexive & involuntary in nature
It just takes a second for the bolus to traverse the pharynx & reach
the cricopharyngeal area
During this stage ,bolus from pharynx can enter into 4 paths:
1. Back to mouth
2. Upwards into nasopharynx
3. forwards into larynx
4. Downwards into esophagus 30
Back into mouth
Position of tongue
High intra oral pressure developed by the movement of tongue
CN
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Stimulation of these trigger points causes dilatation of pharynx due
to
relaxation of the constrictors, &
elevation of pharynx & larynx due to contraction of
longitudinal muscles
When bolus enters this part , the sphincter relaxes , so that the
content enter the stomach.
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APPLIED
PHYSIOLOGY DEGLUTITION
DYSPHAGIA
APNEA
ODYNOPHAGIA
ASPIRATION
GLOBUS HYSTERICUS
CRICOPHARYNGEA
PHAGOPHAGIA L DYSFUNCTION
PRESBYDYSPHAGIA CHOKING
VOMITING ANTIPERISTALSI
S GAG REFLEX
Difficulty in swallowing…….Coexist with heart burn & vomiting
Pathophysiology Of Dysphagia
Lack of coordination or strength of muscles Or Mechanical
obstruction
Management :
Failure of the tonically contracted upper esophageal sphincter to relax
and open when one swallows.
Symptoms
pills or solid food begin to lodge at the level of the lower part of
the larynx.
Treatment
Resolved through surgical procedure Cricopharyngeal Myotomy
Mechanical obstruction of the flow of air from the environment into
the lungs that prevents breathing
Prolonged choking-asphyxa-anoxia-fatal
Causes:
Foreign body,respiratory disease,compression of laryngopharynx
Treatment
BLS & ALS
Heimlich maneuver
Wave of contraction in digestive tract that moves toward the oral
end of tract -regurgitation
Characteristic changes in the swallowing mechanism of
otherwise healthy older adults.
Gagging
Causes
chemical irritants, toxic materials, specific drugs, severe pain,
mild stimulation of pharynx etc.
Treatment
• Removal of factors
• Local anesthetic may be used while working
• Drugs like atropine along with a sedative may be prescribed
• Acupressure
STUDY OF
SWALLOWING
Plain X-Ray
Barium swallow
CT & MRI
Videofluroscop
y
PLAIN X-
RAY
X-RAY SOFT TISSUE NECK
Lateral view &AP view
LATERAL VIEW(taken in full inspiration with neck extention)
Examine patency of airway
Examine soft tissues of neck
Examine the cervical
vertebra Foreign body
AP VIEW
For glottic & subglottic areas
CHEST X-RAY
PA View
Lateral View
Prevertebral
abscess
BARIUM SWALLOW
PROCEDURE
Patient is given liquid barium(Barium suphate)to swallow while bolus
is followed fluroscopically.
ADVANTAGES:
Inert,Suspendable in water
Very minimal absorption in GIT
DISADVANTAGES:
Outside the lumen of GIT acts as foreign body
Contrast leak in mediastinum leads to inflammatory reaction
Diffuse Esophageal Esophagea
AchalasiaCardia Spasm l
Carcinoma
AIR CONTRAST
OESOPHAGRAM
Performed like barium swallow but with addition of effervescent
granules to barium
Advantages:
Better anatomical details especially edge contra st
Disadvantages:
Irradiation
Documented on plain film
Normal
Fungal
Plagues
VIDEOFLUOROSCOPY
Definition
Dynamic fluoroscopic imaging procedure that enables visualization
of rapid & integrated movements involved in all phases of
deglutition
Equipment
X-Ray screening facility
Digital/video recorder with microphone & timer
CT &
MRI
CT used to stage the disease in malignant
DISADVANTAGES
Expensive
Patient has to be in supine which does not reflect stages of
swallowing
SPECIAL
TECHNIQUES
Manometry
Manofluroscopy
Direct pharyngoscopy
Endoscopy
Bolus scintigraphy
24 hr oesophageal ph
monitoring
MANOMETR
Y
Definition
Technique used to measure intraluminal pressure & coordination of
pressures in 3 regions
Lower esophageal sphinchter(LES)
Oesophageal body
Upper esophageal sphinchter(UES)
Advantages
Combines pressure & bolus information simultaneously
Disadvantages
Not widely used
Costly
DIRECT
PHARYNGOSCOPY
Done under general anaesthesia
Procedure
Patient sits upright,nose examined for any septal deviation
Decongestants & lubrication of nasal passages along with
topical anaesthesia
Scope passed between inferior turbinate & floor of nose
Examine nasopharynx for nasal reflux, oropharynx and
BOLUS
SCINTIGRAPHY
Short lived isoptope mixed with single swallow bolus
Gamma camera registers the radiation
Bolus transit & aspiration assessed
Advantages
Aspiration assessed
Disadvantages
Oropharyngeal anatomy not assessed
Cannot perform multiple swallows
Technical expertise needed
ULTRASOUN
D Submental transducers used to image
Structures
Mobility of bolus transit
Vallecular status
Advantages
Avoids irradiation
Normal food used(no barium)
Disadvantages
Cannot be used to visualize larynx & pharynx due to
skeletal interference
Not effective for esophageal phase
OESOPHAGEAL PH
MONITORING
24hrs ambulatory Ph monitoring –reliable for GERD
Procedure
Proximal probe placed below UES
Distal probe placed 5cm above LES(position detected
by manometry)
Reflux measured along entire length of esophagus
Disadvantage
Invasive
Provokes relux