SWALLOWING DISORDER

Presenter: Laxmi Bhattarai

MPTII
Neurological sciences

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 Content

 Background
 Swallowing
 Anatomical structure
 Neural coordination of swallowing
 Normal physiology of swallowing
 Swallowing disorder
 Pathophysiology of swallowing along with various diseases
 References
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 Objective

At the end of the seminar

 What is swallowing?
 Anatomical structures involve in swallowing
 Normal physiology of swallowing
 Phases of swallowing
 Swallowing disorder
 Pathophysiology of same along with various neurological
condition
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 Background

 Swallowing: The process of swallowing, also known as

deglutition, involves the movement of substances from the mouth
(oral cavity) to the stomach via the pharynx and oesophagus.
 Swallowing is an essential and complex behaviour learned very
early in development. This pathway shares anatomy with the
airway; thus, in addition to directing food into the digestive tract,
the swallowing mechanism serves as a vital protector of the
airway.

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 There is evidence that swallowing begins to develop in utero as
early as 15 weeks gestation to regulate amniotic fluid volume.
 The suck, swallow, and breathing sequence continues to evolve
in the early stages of life as infants are introduced to new foods
and begin to control their swallowing consciously.

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 Multiple organ systems are involved in this process, including the
musculoskeletal, neuromuscular, and respiratory systems.
 Normal swallowing requires a coordinated effort of over thirty
muscles, the central nervous system, and five cranial nerves.
 Additionally, the nose, the nasal cavity, the oral cavity, and the
pharynx are key anatomical structures involved in this process.

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 Anatomical structure

 “ Feeding and breathing share the same anatomy “

1. The nose and nasal cavity: Breathing through the nose occurs
while eating solids since the mouth processes the food, and the
lips are sealed to prevent the food from escaping anteriorly. Nasal
air pressure oscillates with masticatory jaw movement and
becomes positive relative to atmospheric pressure during jaw
closing and negative during jaw opening.
2. The oral cavity: tongue movement corresponds with cyclic jaw
movement when the food is in the mouth. The tongue and the
cheek reposition food laterally (tongue) and medially (cheek).
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 The pharynx: a breathing, mastication and swallowing route.
The pharynx is dilated to maintain the airway for breathing and is
constricted to provide space for bolus aggregation before the
pharyngeal swallow.
 The larynx and the vocal folds: The posterior aspect of the
larynx forms the anterior wall of the upper oesophageal sphincter
(UES).
 The upper oesophageal sphincter (UES): a kidney bean-shaped
space encompassed anteriorly by the larynx, posterolaterally by
the pharyngoesophageal muscles, superiorly by the pharynx and
inferiorly by the oesophagus.
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Neural Coordination of Swallowing

 Swallowing requires a coordinated contraction of muscles in the

mouth, pharynx, upper oesophagal sphincter, and upper
oesophagus via central control. Swallowing centres activate the
voluntary motor centres and inhibit the respiratory centres - this
prevents food from entering the trachea. There is also activation
of the:
• Reflex centres
• Nuclei of the cranial nerves that are involved in the movement
of the tongue, larynx and pharynx
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 Physiology of swallowing

 The act of swallowing occurs in 4 phases :

1. oral phase
2. pharyngeal phase
3. oesophageal phase.

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 Oral Phase

1.) Oral preparatory

In the preparatory phase, the tongue anteriorly and the hard palate
posteriorly seal the bolus for liquids. The bolus is not sealed in the
oral cavity for solids as it undergoes processing via mastication and
manipulation.
2.) Oral Propulsion
The tongue elevates to move the bolus posteriorly into the
oropharynx. This bolus is held in the oropharynx until it aggregates
with repeated cycles or the pharyngeal phase initiates.
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 Pharyngeal Phase
 The pharyngeal phase, the first irreversible step in the swallowing
mechanism, begins when the bolus reaches the palatoglossal arch.
Afferent sensory fibres from CN IX, X, and XI in the oropharynx
transmit the stimulus to the solitary tract nucleus in the
brainstem.
 Efferent muscle fibres then travel to innervate the muscles of the
larynx, pharynx, and oesophagus to coordinate a reflex response.
This stage serves two primary purposes: 1) directs food into the
esophagus and 2) protects the airway from aspiration.
 It is characterised by a wave of coordinated stimuli lasting about
a second, ending as the food bolus reaches the upper oesophagal
sphincter (UES). 14
 Pharyngeal Phase- stages

1.) Nasopharynx closure

The pharyngeal phase beings with soft palate elevation via the
tensor palatini and levator palatini to seal the nasopharynx to
prevent pressure escape into the nasal cavity.

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2. Airway Protection
 The pharyngeal phase protects the airway via swallowing apnea,
a well-coordinated physiologic response where respiration ceases
during swallowing. This apneic period tends to interrupt the
expiratory phase of breathing, lasting approximately 0.5 to 1.5
seconds, preventing aspiration during inspiration.
 The primary mechanism of airway protection is the closure of the
vocal folds. The posterior cricoarytenoid, contracted at rest, is
inhibited, and the lateral cricoarytenoids are stimulated to adduct
the cords. The oblique and transverse arytenoid muscles bring the
arytenoid cartilage together, aiding in glottic closure.

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 Concurrently, the arytenoids are tilted forward to contact the
epiglottis and assist in opening the passage towards the
esophagus. While not directly involved in airway protection,
retroversion of the epiglottis by the tongue helps direct the food
bolus towards the piriform fossa and into the esophagus.
3.) Elevation of the hyoid-laryngeal complex
The pharynx becomes elevated and pulled anteriorly by contraction
of the suprahyoid muscles, which helps to open the pharyngeal-
esophageal transition.

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4.) Bolus transport
The bolus is moved inferiorly by a peristaltic-like sequential
contraction of the superior, middle, and inferior pharyngeal
constrictor muscles in a top-to-bottom fashion. A pattern of rapid
stimulation and inhibition in the pharyngeal muscles creates a
cranial-caudal wave of pressure that directs the food bolus towards
the UES. The speed is remarkably fast, occurring at rates of 20 to
40cm/s. Once initiated, the pharyngeal phase behaves in an ‘all or
none’ fashion, much like a reflex, hence why this phase is
considered irreversible.

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5.) Transit through UES
The end of the pharyngeal phase involves the food bolus descending
through a patent UES into the esophagus. The sphincter remains in
tonic contraction at rest to prevent air from entering the esophagus
but is opened by three sequential mechanisms: 1) contraction of the
thyrohyoid to move the larynx and hyoid superiorly and anteriorly,
thereby initiating the opening of the sphincter, 2) manometric
relaxation of the cricopharyngeus, and 3) Pressure-dependent
distension of the UES by the bolus.

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 Esophageal Phase

 A peristalsis wave propagates The bolus inferiorly once it reaches

the esophagus. This is an autonomous process not under
voluntary control, much like the pharyngeal phase.
 It occurs much slower than the pharyngeal phase, at a rate of
about 3 to 4 cm/s. This phase ends once the bolus passes through
the lower esophageal sphincter (LES) and into the stomach.
 At rest, the LES is tonically contracted to prevent reflux from the
stomach, and it undergoes relaxation during the swallowing
phase.

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 Swallowing disorder

 Patients subjectively define dysphagia as difficulty swallowing

and objectively defined by clinicians as an impairment in
swallowing that results in an abnormal delay in the transit of a
liquid or solid bolus from the oral cavity to the stomach.
 Dysphagia may be acute or chronic, intermittent or persistent.

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Pathophysiology

 Dysphagia can lead to malnutrition, dehydration, inability to

safely protect the airway resulting in respiratory compromise, and
a decrease in quality of life.
 Swallowing disorders are frequently described in terms of stage
affected: oral, pharyngeal, or esophageal.
 Regardless of site, it is useful to consider whether a given
impairment of swallowing affects food transport (preparation and
propulsion of the bolus), airway protection (prevention of
laryngeal aspiration), or both, because these have implications for
treatment.
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 During the oral preparatory and transit stages, the lips, tongue,
cheeks, and jaw are active in completing mastication, bolus
preparation, and transportation from the oral to the pharyngeal
cavity. Weak or uncoordinated oral movements may result in
retention of the bolus in the oral cavity.
 An impaired labial seal can result in spillage anteriorly. Pocketing
in the lateral sulcus can occur as a result of buccal weakness or
lingual incoordination resulting in difficulty with forming a
cohesive bolus. Posterior spillage from the mouth to the throat
can occur secondary to posterior lingual weakness or
incoordination with the bolus falling prematurely into the
pharynx during mastication.
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 Pharyngeal disorders

 Disorders at this stage may include impaired swallow initiation,

ineffective bolus propulsion, retention of a portion of the bolus in
the pharynx after swallowing, and aspiration of the bolus. Nasal
regurgitation may be noted when the soft palate does not elevate
and the pharyngeal wall contraction is incomplete around the soft
palate. When tongue base retraction is weak, pharyngeal
propulsive force can be inadequate, resulting in retention of all or
part of the bolus in the pharyngeal recesses after swallowing.

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 Another cause of food retention in the pharynx after swallowing
is impaired opening of the UES. This can be caused by increased
stiffness of the UES, as in fibrosis or inflammation, or failure to
relax the closing muscle of the sphincter (primarily the
cricopharyngeus muscle). Because UES opening is an active
process, failure of opening can also be caused by weakness of the
muscles of sphincter opening, particularly the anterior suprahyoid
musculature. Dyscoordination of the swallow can also lead to
failure of UES opening. Because the UES is ordinarily closed
between swallows, its opening is obligatory for swallowing to
occur. This means that failure of UES relaxation and opening can
produce obstruction of the food pathway.
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 Airway protection is a critical function of swallowing; however,
airway protection mechanisms are not always effective. Failure of
laryngeal protective mechanisms can reflect reduced laryngeal
elevation, incomplete closure of the laryngeal vestibule, or
inadequate vocal fold closure caused by weakness, paralysis, or
anatomic fixation.

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 Dysphagia can result from a wide variety of disorders. A major
cause of dysphagia is stroke. Dysphagia is found in
approximately half of individuals with a recent stroke. Most
recover within the first 2 weeks, but dysphagia can be severe and
persistent. Brainstem lesions can result in particularly severe
dysphagia, given their proximity to the major swallow centers.
 Reduced laryngeal elevation, insufficient UES opening, vocal
fold weakness, and severe weakness of oropharyngeal muscles
are common in patients with stroke.

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 Cerebral lesions can result in dyscoordination of the swallow,
with impaired oropharyngeal bolus propulsion and airway
protection. Swallow dysfunction is typically more severe in
bilateral cerebral lesions because there is a bilateral cortical
representation for swallow function.
 By contrast, the brainstem motor nuclei innervate only ipsilateral
muscles, so lesions of cranial nerves or their nuclei can result in
unilateral sensory or lower motor neuron dysfunction.

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 In neurodegenerative disorder: Dysphagia can be the first
symptoms.
Oral-stage dysphagia is common in Parkinson disease,
characterized by tremor, dyskinesia, and bradykinesia in lips,
tongue, jaw, and larynx, which hamper oral and pharyngeal food
transport.
In motor neuron disease, progressive degeneration of motor neurons
in the brain and spinal cord results in weakness in the muscles of
mastication, respiration, and swallowing.

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 Inflammatory muscle diseases, including dermatomyositis and
polymyositis, commonly affect striated muscles, resulting in
weakness of the pharynx. By contrast, progressive systemic
sclerosis affects smooth muscle and commonly produces
esophageal dysfunction, including reduced peristalsis, dilatation
of the lower esophagus, and gastroesophageal reflux disease
(GERD).

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 Structural abnormalities whether congenital or acquired, can
impair swallow function. Birth defects, such as clefts of the lip
and palate often produce inadequate labial control for sucking
and bolus control, or velopharyngeal insufficiency with nasal
regurgitation. The resulting dysphagia can lead to malnutrition,
requiring surgical repair of the defect during infancy.
 Structural abnormalities can impair pharyngeal transport and
airway protection.

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 GERD can affect swallowing indirectly. In GERD, the LES has
insufficient tone, rendering it ineffective for preventing gastric
contents from passing back through the LES into the esophagus.
Because the esophageal lining is not resistant to acid (as is the
stomach lining), reflux of highly acidic stomach contents can
result in inflammation (esophagitis) or scarring (stricture) of the
esophagus. This can lead to pain or obstructive symptoms.

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 Dysphagia is often iatrogenic. Several drugs can impair
swallowing, including anticholinergic drugs and benzodiazepines.
Neuroleptic agents, also called antipsychotic drugs, can cause
movement disorders affecting the face and mouth, such as tardive
dyskinesia, especially after long-term use. These can impair
eating and swallowing. Any medication that causes sedation can
have an adverse effect on swallowing and potentially impair
airway clearance (e.g., cough) in response to aspiration.

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 Postoperative dysphagia is a common complication of anterior
cervical fusion, occurring in approximately half of patients.139
Individuals with multiple cervical surgical levels demonstrate a
higher risk of having dysphagia when compared with those
undergoing survey at one level.
 The mechanism is unclear, but it might be related to injury of the
pharyngeal constrictor muscles or their innervation. Most patients
recover within the first 2 months.

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 Compromised and altered respiratory function increases the risk
for dysphagia. Chronic obstructive pulmonary disease alters the
coordination of respiration and deglutition. Patients who have
undergone lung transplantation may demonstrate dysphagia, with
a high risk of silent aspiration.

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Evaluation of dysphasia

 Swallowing evaluations can be divided into two main categories

of bedside/clinical assessments and instrumental assessments.
1. Instrumental swallowing assessments include evaluation
procedures, such as the videofluoroscopic swallow study (VFSS),
the fiberoptic endoscopic examination of the swallow (FEES),
high-resolution manometry (HRM), and ultrasonography.

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2. Bedside/Clinical Swallow Assessments
 Swallow Screenings.
 Clinical Swallow Examination.
 Blue Dye Clinical Swallow Examination.
 Cervical Auscultation.

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 References

1. Rommel N, Hamdy S. Oropharyngeal dysphagia: manifestations

and diagnosis. Nature reviews Gastroenterology & hepatology.
2016 Jan;13(1):49-59.
2. Ebot J, Domingo R, Nottmeier E. Post-operative dysphagia in
patients undergoing a four level anterior cervical discectomy and
fusion (ACDF). Journal of Clinical Neuroscience. 2020 Feb
1;72:211-3.
3. Hao N, Sasa A, Kulvanich S, Nakajima Y, Nagoya K, Magara J,
Tsujimura T, Inoue M. Coordination of respiration, swallowing,
and chewing in healthy young adults. Frontiers in Physiology.
2021 Jul 13;12:696071.
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4. Carnaby GD, LaGorio L, Silliman S, Crary M. Exercise ‐based
swallowing intervention (McNeill Dysphagia Therapy) with
adjunctive NMES to treat dysphagia post‐stroke: A double‐blind
placebo‐controlled trial. Journal of Oral rehabilitation. 2020
Apr;47(4):501-10.
5. O'Sullivan SB, Schmitz TJ, Fulk G. Physical rehabilitation. FA
Davis; 2019 Jan 25.
6. Lazaro RT, Reina-Guerra SG, Quiben M, editors. Umphred's
Neurological Rehabilitation: Umphred's Neurological
Rehabilitation-E-Book. Elsevier Health Sciences; 2019 Dec 5.
7. Cifu DX. Braddom's physical medicine and rehabilitation.
Elsevier Health Sciences; 2020 Aug 1.
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THANK YOU

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