Pharyngeal stage
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Transcript Pharyngeal stage
Dysphagia
นพ.โกสิ นทร์ ชัยชำนำญ
Ent
Objectives
Normal physiology
Dysphagia
Definition
Cause and classification
History taking,physical examination
and investigation
Disease
Normal physiology
4 stage
Oral preparatory stage
Oral stage
Pharyngeal stage
Esophageal stage
Normal physiology
Oral preparatory stage
Prepare food for swallow
Mechanism of action
1.lip closure to hold food in mouth anteriorly
2.tension in labial&buccal musculature to close
Ant&Lat sulci
3.rotatory motion of jaw for chewing
4.lateral rolling motion of tongue position food on
teeth during mastication – most important
5.bulging forward of soft palate to seal oral cavity
posterior and widen nasal airway
Oral preparatory stage
1.Muscle of facial expression (VII) –oral sphincter
Orbicularis
oris
– sphincter of lip
– compress
lip@flatten cheek
Buccinator
Oral preparatory stage
2.Muscle of mastication (V) – jaw movement
pterygoid –
open@grinding
Lateral
Masseter
jaw
– close
–
open@A/P move
Temporalis
pterygoid –
close@grinding
Medial
Oral
preparatory
stage
y
3.Tongue muscle
– down
soft palate@up BOT
Palatoglossus(X)
Genioglossus(XII)
elevate BOT
–
Hyoglossus(XII)
depress
--
Oral
preparatory
stage
er
Time : depend on type of food
Normal physiology
Oral stage
Move food from front oral cavity
to pharynx
Mechanism of action
○ 1.Upward&backward by midline& Lat
margin of tongue – most important
○ 2.Backward by tension in
buccal musculature
○ 3.trigger swallowing reflex
(locate at anterior pillar)
Oral stage
swallow
buccal musculature
tongue
Styloglossus
Hyoglossus
muscle
muscle
Oral stage
swallow
trigger zone at
anterior pillar
Oral
stage
ri
swallow
trigger swallowing reflex
sensory impulse at CN IX
Oral stage
swallow
Tractus solitarius nucleus/
Solitary tract nucleus
trigger swalling reflex
sensory impulse at CN IX
(& Sup. Laryngeal nerve)
Oral stage
swallow
nucleus ambiguus
nucleus ambiguus to
motor neuron of CN X at
pharynx
Oral stage
swallow
nucleus ambiguus
nucleus ambiguus to
motor neuron of CN X at
pharynx
Oral
stage
er
Time : take 1 second
Pharyngeal stage
Move food from pharynx to esophagus
Mechanism of action
1.velopharyngeal closure
(prevent backflow of material up nose)
2.tongue base retraction
(propel bolus through pharynx)
3.pharynx contraction
(clear redisue through pharynx)
4.larynx elevate and closure
(airway protection)
5.cricopharyngeal opening
(allow bolus to pass into esophagus)
t
Pharyngeal stage
swallow
1.tongue
Styloglossus
Hyoglossus
muscle
muscle
Pharyngeal stage
swallow
2.Levator @ Tensor palatini
Tensor
palatini
Levator
palatini
Pharyngeal stage
swallow
3.pharyngeal constrictor muscle
Superior
Middle
Inferior
Pharyngeal stage
swallow
4.aryepiglottic fold/true vocal fold
/false vocal fold
AEF
FVF/TVF
Pharyngeal
stage
er
Time : take less than 1 second
(not vary with age and gender)
Esophageal stage
Close UES
Body of esophagus
Outer -> longitudinal ,Inner -> circular
Peristalsis
primary peristalsis :
○ upper 1/3 striated & transitional zone
○ mix voluntary & involuntary
secondary peristalsis :
○ lower 2/3 smooth
○ Involuntary
Open LES
Esophageal
stage
er
Time : take 8 to 20 seconds
(depend on food influence by
peristalsis&gravity)
Dysphagia
History
Onset & Site
Cough or choke or food coming back
through your nose
Liquid or solid or both
Liquid and solid motility disorder
Solid progress to liquid benign or
malignant stricture
Progression
Dysphagia
History
Other symptoms
Loss of appetite,weight loss ,N/V
regurgitation,heart burn,weakness,
hematemesis,pain
Medical problems
DM, HT, cancer
Hx. Of surgery
Dysphagia
History
Hx. Of radiation
Medications
In children
Feeding
Growth
Development
Dysphagia
Physical examination
Complete examination
Head and neck
Mass
Thyroid
Lymph node
Salivary gland
Oral mucosa
Gag
reflex, Cough reflex
Dysphagia
Investigation
Procedure to evaluate -- major
1.Fluoroscopy
2.Endoscopy
3.Manometry
4.Ultrasonography
Dysphagia
Fluoroscopy
Barium swallow
conventional barium swallow
modified barium swallow
Dysphagia
Fluoroscopy
Modified barium swallow
Gold standard
Examine oral cavity & pharyngeal
swallowing
Ba(1/3 teaspoon per swallow) & vary
food consistency
Seated upright in normal eating position
Dysphagia
Fluoroscopy
Modified barium swallow
View in lat. plane with
fluoroscope tube
Focus on lips & C7th
Dysphagia
Fluoroscopy
Modified barium swallow
Purpose restore oral intake as quickly
○ 1.define oral&pharyngeal disorder during
swallow
○ 2.identify aspiration of any food consistency
○ 3.assess speed of swallow to determine
adequate nutrition
○ 4.assess effect of Tx eg.postural change
,heightened sensory input ,Tx procedure
(swallowing maneuvers)
Dysphagia
Fluoroscopy
convention barium swallow
Examine anatomy & motility esophagus
Ba(a cup of barium)(250 cc)swallow repeatedly
Lies in supine position
View in anteroposterior plane
Dysphagia
Fluoroscopy
Dysphagia
Achalasia(failure to relax) (bird's beak
appearance)
A:Contrast
penetrate laryngeal vestibule
within boundary of vocal cord
B:aspirate tracheobronchial tree
Dysphagia
Endoscope
Via transnasal placement of flexible fiberoptic
scope
Can not examine oral stage & during swallow
May be identified residual
food in pharynx after
swallow
Dysphagia
Manometry
Used examine esophageal peristalsis & function
of UES & LES
Swallow soft tube contain 3 pressure sensor
First register --- UES
Second register – body of esophagus
Third register – pressure in LES
No information on aspirate or function in oral
cavity or larynx
Dysphagia
Ultrasonography
Used assess anatomy & physiology of tongue
during swallowing (oral stage )
Can not examine pharynx or larynx because of
skeletal interference
Dysphagia
Other investigate
Plain film : film lateral neck(soft tissue
technique) -- FB,Infection
CT/MRI
24 hrs.pH monitoring วัดภาวะกรดด่ างในหลอดอาหาร คน
ปกติจะมี pH<4 ที่เหนือกล้ามเนื้อหูรดู ล่าง 5 cm ไม่เกิน 1 hr./วัน
Dysphagia
Other investigate
Scintigraphy
Nuclear medicine test
Swallow several selected bolus of radioactive
material
Gamma camera detect amount radiation
passing
Oropharyngeal anatomy not visible
Aspiration – two trial material swallows
○ One to esophagus
○ Another to airway
The end…