Anatomy, physiology and pathophysiology of dysphagia

ArticleinActa oto-rhino-laryngologica Belgica 48(2):97-117 · February 1994with110 Reads
Source: PubMed
Abstract
This is a review paper examining the pathogenesis of oropharyngeal dysphagia. Pharyngeal anatomy and physiology are discussed along with a detailed description of the neuronal architecture and function of the medullary swallowing center. The oropharyngeal swallow is then examined in biomechanical terms emphasizing that the swallow is comprised of several elements (velopharyngeal closure, upper esophageal sphincter opening, closure of the laryngeal vestibule, tongue loading, tongue pulsion and pharyngeal clearance) each of which can be compromised, causing dysphagia. The key modality for evaluating patients with oropharyngeal dysphagia is the videofluoroscopic swallowing study which is analyzed according to the efficacy with which these functional elements of the swallow are accomplished. Specific therapy can then be addressed toward correcting dysfunctional elements.
    • "This fact can justify the absence of severe or profound dysphagia degrees in our sample. Swallowing is described as a function characterized by a dynamic process characterized by a sequence of complex events, interrelated between them [40][41][42]. The swallowing process is divided didactically in stages: anticipatory phase, divided into oral preparatory and oral phase itself, pharyngeal phase and esophageal phase. "
    [Show abstract] [Hide abstract] ABSTRACT: Abstract Introduction: Patients with Acquired Autoimmune Myasthenia Gravis (AAMG) have a frequent complaint of muscle fatigue, resulting in respiratory distress, associated or not to the signs and symptoms of dysphagia. Objective: to characterize the measures of respiratory and appendicular muscle strength, expiratory and cough peak flow and relate to the degree of dysphagia in patients with AAMG. Methods: We assessed 20 patients with a diagnosis of Acquired autoimmune myasthenia gravis, being 14 (70%) female and 6 (30%) male, with an average age of 38.71 and 50.16 years, respectively. The following procedures were performed: speech and swallowing evaluation and respiratory clinical evaluation. It was incorporated measures of maximum inspiratory pressure, maximum expiratory pressure, peak expiratory flow and peak cough flow. Results: there was a statistically significant relationship between alteration of muscles of lips, tongue and buccinator and the severity of dysphagia. 70% of patients referred to dyspnoea, being that the averages of percentage of predicted of MEP and MIP, PFE were below 80% in patients with dysphagia. Significance was found in the correlation between measures of force and of respiratory airflow. Conclusion: the strength of cough expiratory flow is correlated to the inspiratory and expiratory muscle force. The involvement of the orofacial musculature and reduced values of MIP, MEP and PFE were indicators of the deterioration of oropharyngeal dysphagia. Both measures of respiratory muscle strength are lower than predicted. Keywords: Neuromuscular diseases; Myasthenia gravis; Deglutition; Deglutition disorders; Respiration; Muscle strength
    Full-text · Article · Jun 2016 · The Anatomical Record
    Oda AlOda AlBolzan DwBolzan DwCruz CtvCruz Ctv+1more author...[...]
    • "In the human, the anterior and posterior tonsillar pillars and the posterior pharyngeal wall (Pommerenk, 1928; Doty, 1968; Goyal and Cobb, 1981) are the most sensitive areas for initiation of the pharyngeal phase of swallowing. Several investigators believed that the swallowing reflex is mainly triggered from the IX nerve (Levine, 1988; Kahrilas, 1994). "
    [Show abstract] [Hide abstract] ABSTRACT: To date, the details of human sensory innervation to the pharynx and upper airway have not been demonstrated. In this study, a single human oro- and laryngopharynx obtained from autopsy was processed with a whole-mount nerve staining technique, Sihler's stain, to determine its entire sensory nerve supply. The Sihler's stain rendered all mucosa and soft tissue translucent while counterstaining nerves. The stained specimen was then dissected and the nerves were traced from their origins to the terminal branches. It was found that the sensory innervation of the human pharynx is organized into discrete primary branches that innervate specific areas, although these areas are often connected by small neural anastomoses. The density of innervation varied, with some areas receiving almost no identifiable nerve supply (e.g., posterior wall of the hypopharynx) and certain areas contained much higher density of sensory nerves: the posterior tonsillar pillars; the laryngeal surface of the epiglottis; and the postcricoid and arytenoid regions. The posterior tonsillar pillar was innervated by a dense plexus formed by the pharyngeal branches of the IX and X nerves. The epiglottis was densely innervated by the internal superior laryngeal nerve (ISLN) and IX nerve. Finally, the arytenoid and postcricoid regions were innervated by the ISLN. The postcricoid region had higher density of innervation than the arytenoid area. The use of the Sihler's stain allowed the entire sensory nerve supply of the pharyngeal areas in a human to be demonstrated for the first time. The areas of dense sensory innervation are the same areas that are known to be the most sensitive for triggering reflex swallowing or glottic protection. The data would be useful for further understanding swallowing reflex and guiding sensory reinnervation of the pharynx to treat neurogenic dysphagia and aspiration disorders. Anat Rec 258:406–420, 2000. © 2000 Wiley-Liss, Inc.
    Full-text · Article · Apr 2000
  • [Show abstract] [Hide abstract] ABSTRACT: Das Wallenberg-Syndrom besteht aus einer Vielfalt neurologischer Symptome, die Adolf Wallenberg bereits 1895 sehr detailliert beschrieben und auf eine vergleichsweise winzige Läsion in der dorsolateralen Medulla oblongata zurückgeführt hat. Ein in der neueren Literatur wenig beachtetes, klinisch jedoch sehr relevantes Symptom ist die Dysphagie. Hierzu liegen sowohl hinsichtlich der Art der Störung wie auch bezüglich der Interventionsmöglichkeiten kaum systematische Untersuchungen vor. Ziel der vorliegenden prospektiven Studie war es, einerseits herauszufinden, welche Phase und Funktionen des Schluckablaufs beim Wallenberg-Syndrom beeinträchtigt sind bzw. ob es ein typisches Störungsmuster gibt und andererseits die Wirksamkeit spezifischer Schlucktherapie zu evaluieren. Es wurden 28 Patienten untersucht, die unter einer neurogenen Dysphagie litten, klinisch ein Wallenberg-Syndrom aufwiesen und bei denen kernspintomographisch eine einseitige Läsion der dorsolateralen Medulla oblongata vorlag. Hierbei zeigte sich, dass vor allem eine Störung der pharyngealen Schluckphase vorlag, was sich insbesondere in einer gestörten Schluckreflextriggerung und in einer Öffnungsstörung des oberen Ösophagussphinkters äußerte. Bezüglich der Frage nach der Effektivität einer spezifischen Schlucktherapie konnte gezeigt werden, dass die Aspirationsgefahr unter gezielter, individuell angepasster stationärer Schlucktherapie deutlich abnahm. So konnte eine signifikante Verbesserung der Hauptzielvariablen "Ernährungsweise", definiert durch eine ordinale Skala mit 7 Ausprägungsgraden von 0 (voll-oral ernährt) bis 6 (vollständige Ernährung über PEG oder nasogastrale Sonde) erreicht werden. Klinisch bedeutet dies, dass nach Schlucktherapie 21 Patienten (75,0%) voll-oral ernährt werden konnten, im Vergleich zu einem Patienten (3,6%) vor Therapie. Zusammenfassend weisen die Ergebnisse darauf hin, dass beim Wallenberg-Syndrom insbesondere die Schluckreflextriggerung und die Öffnung des oberen Ösophagussphinkters gestört ist. Unter gezielter und qualifizierter Schlucktherapie kann die Prognose der Dysphagie bei Patienten mit Wallenberg-Syndrom jedoch auch bei initial schwerer bzw. bereits längere Zeit bestehender Störung als gut bezeichnet werden.
    Article · · The Anatomical Record
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