MECHANICAL DISORDERS OF SWALLOWING

KUNNAMPALLIL GEJO JOHN, MASLP

KUNNAMPALLIL GEJO JOHN

Patients with mechanical swallowing disorders evidence difficulty secondary to the loss of sensory guidance of the structures necessary to complete a normal swallow. . Most patients with mechanical dysphagia have had oral, pharyngeal, or laryngeal structures removed or reconstructed during surgery for cancer. There are, however, other causes that must be considered in the differential diagnosis. The most common of these are
KUNNAMPALLIL GEJO JOHN

ACUTE INFLAMMATIONS
Acute inflammatory processes that produce or exacerbate dysphagia are nonspecific reactions to injury of the oropharyngeal tissue secondary to fungal, bacterial, or viral agents, chemical irritants, or traumatic insults.

KUNNAMPALLIL GEJO JOHN

Acute inflammations of the oropharyngeal tissues alone may not create significant, extended dysphagia. . Early recognition and treatment of acute inflammatory reactions can make the difference between success and failure in attempts at oral feeding.

KUNNAMPALLIL GEJO JOHN

They should be ruled out in patients whose mental state or competence interferes with the ability to communicate oral pain and those who evidence unexplainable dysphagia or sudden refusal to eat. Early identification is important because most inflammations can be controlled within a short period of time, and oral nutritional intake can resume.

KUNNAMPALLIL GEJO JOHN

Herpes Simplex
Viral in origin, a herpetic infection is characterized by round vesicles that break to form shallow ulcers surrounded by a narrow zone of inflammation. Typically, they are found on the lips; however, the pharynx and buccal mucosa may be involved. Palatal and pharyngeal ulcers create significant pain and discomfort on swallowing.
KUNNAMPALLIL GEJO JOHN

Ludwig's Angina
The most typical type of infection to occur in the submandibular space that may compromise swallow is Ludwig's angina. Odontogenic infections such as abscesses, caries, and postextraction infection are implicated in 70 to 85 percent of cases of Ludwig's angina

KUNNAMPALLIL GEJO JOHN

Clinical manifestations of Ludwig's angina include massive swelling and displacement of the tongue. The floor of the mouth also will appear red, swollen, hard, and tender. Posterior extension may result in epiglottitis, with further compromise of the airway. If the patient is able to speak, he or she may have a muffled, "hot potato" voice. The neck exhibits a woody, tender swelling, especially in the suprahyoid region. Patients generally present with complaints of mouth pain, stiff neck, drooling, and dysphagia.
KUNNAMPALLIL GEJO JOHN

Lingual Tonsillitis
Patients with lingual tonsillitis have symptoms similar to those of other throat infections, except they complain of pain in the medial pharyngeal region. Often they describe a lump in the throat associated with complaints of dysphagia. The mechanism of lingual tonsillitis can be confirmed by indirect mirror examination of the base of the tongue and pharynx.
KUNNAMPALLIL GEJO JOHN

Epiglottitis
Epiglottitis is an inflammatory disease that affects the supraglottic region and often results in acute respiratory distress due to airway obstruction. It is most commonly seen in children but has more recently been recognized with increasing frequency in adults Patients often complain of sore throat, dysphagia, respiratory difficulty, muffled voice drooling, and stridor

KUNNAMPALLIL GEJO JOHN

Acute Pharyngitis
Acute pharyngitis may be viral or bacterial in origin. The reddened inflamnation that it causes in the oropharyngeal region frequently precedes the common cold, leading patients to complain of swallowing difficulty. It often is accompanied by a mild fever without any other complications. The pain and dysphagia subside within four to six days.
KUNNAMPALLIL GEJO JOHN

The most common bacterial form of pharyngitis is streptococcal. The diagnosis is confirmed by laboratory analysis. The patient has an acutely inflamed oropharynx with characteristic white or yellow follicles. Most complain of headache and muscle joint pain and have fevers that reach 103 degrees. Streptococcal infections respond well to a full course of antibiotics

KUNNAMPALLIL GEJO JOHN

Lateral Pharyngeal Space Infections

Infections in the lateral pharyngeal space are classified as anterior or posterior depending on the location of the infection. Infections of the lateral pharyngeal space may be secondary to primary infection in the tonsil or pharynx.

KUNNAMPALLIL GEJO JOHN

Clinical presentation of symptoms differs between anterior and posterior compartments. When the patient has an anterior compartment infection, the patient may present with dysphagia, trismus, chills, high fever, hardening and swelling of the mandibular arch, systemic toxicity, medial buldging of the lateral pharyngeal will, and pain

KUNNAMPALLIL GEJO JOHN

Treatment of lateral pharyngeal space infections is similar to that of Ludwigs angina. Therapeutic management includes antibiotic therapy, surgical drainage, and airway maintenance.

KUNNAMPALLIL GEJO JOHN

Fungal Inflammation
One of the common fungal inflammations is candidiasis (thrush). Most frequently seen on the tongue, the lesions appear as soft, white, slightly elevated plaques (Keyes 1980). If left untreated, the lesions cause associated pain and difficulty swallowing.

KUNNAMPALLIL GEJO JOHN

They are more common in debilitated and immunosuppressed patients, in those who are undergoing extensive antibiotic therapy, and in patients receiving irradiation treatments.

KUNNAMPALLIL GEJO JOHN

Chemical Agents
Mucosal inflammation may result from exposure to chemicals. The subsequent pain interferes most often with the oropharyngeal stage of swallowing. Chemical inflammation can result from the prolonged use of phenol (toothache drops). Other drugs that precipitate mucosal burns include aspirin, which causes irritation to the cheek lining, some gargles, and anesthetic throat lozenges when used excessively
KUNNAMPALLIL GEJO JOHN

The most severe form of a chemical burn, lye ingestion, can cause severe blistering of the entire digestive tract. The clinician should be aware that patients who undergo chemotherapy can develop painful oral ulcer- actions that interfere with swallowing. Drugs used in these regimens such as doxorubicin (Adriamycin), methotrexate, and cyclophosphamide (Cytoxan) can cause oral mucositis.

KUNNAMPALLIL GEJO JOHN

TRAUMA
Other than major traumatic tissue losses such as those resulting from t wounds, more frequently occurring injuries in the oral cavity are fairly benign and generally do not create significant swallowing complaints except when superimposed on other mechanisms of dysphagia.

KUNNAMPALLIL GEJO JOHN

Examples include trauma from a toothbrush and mucosal irritation from ill-fitting dentures. Patients who complain of a poorly fitted denture can localize their pain. Clinical examination usually will reveal a reddened or whitish change in the mucosa at the point of contact where the patient has the sensation of most discomfort. Prolonged irritation can result in gingival hyperplasia that results in soft, sometimes flexible masses of tissue that appear markedly inflamed.
KUNNAMPALLIL GEJO JOHN

MACROGLOSSIA
An abnormally large tongue can interfere with the propulsive action of the bolus. The clinician should be aware of some of the conditions that may contribute to macroglossia that may be considered in the differential diagnosis. They include macroglossia secondary to lymphatic obstruction secondary to surgery or irradiation, hypothyroidism, mongolism, amyloid deposits, and lymphangiomatous or hemangiomatous processes.
KUNNAMPALLIL GEJO JOHN

PHARYNGOESOPHAGEAL DIVERTICULUM
A pharyngoesophageal diverticulum, commonly referred to as Zenker's deverticuIum'in the cervical esophagus, is an abnormal muscular outpouching diverticulum that forms either above the cricopharyngeus through Killian's dehiscence or from below through Laimers triangle.
KUNNAMPALLIL GEJO JOHN

The exact mechanism of pouch formation is unknown, although in small percentages it can be associated with esophageal disease, including traction diverticula, varices, achalasia, carcinoma, and hiatal hernia.

KUNNAMPALLIL GEJO JOHN

Zenker's diverticula are more common in men in the sixth and seventh decades of life. They must become very large to produce dysphagic symptoms. Patients complain of regurgitation of undigested food, foul breath, and fullness in the neck, weight loss, and nocturnal cough with aspiration.
KUNNAMPALLIL GEJO JOHN

MECHANICAL DYSPHAGIA SECONDARY TO CARCINOMA

The largest groups of patients with mechanical swallowing disorders have had oral, pharyngeal, laryngeal, and esophageal structures removed, rearranged, or reconstructed secondary to surgery for carcinoma. Most often, combinations of these structures are involved.
KUNNAMPALLIL GEJO JOHN

STRUCTURAL DISORDERS

KUNNAMPALLIL GEJO JOHN

Esophageal stenosis
When the lumen narrows, solid food may be too large to pass. Esophageal stenosis typically causes dysphagia for solid food dysphagia. In addition, the nature of the solid material ingested is important for symptom production. Dysphagia is more likely to occur when solids are tough or fibrous. Softer, more easily chewed foods are much less likely to cause difficulty.
KUNNAMPALLIL GEJO JOHN

Rings and Webs

The esophagus may be narrowed by a band of tissue composed of mucosa and sub bmucosa, This type of lesion is called a ring when located at the esophagogastric junction and a web when located elsewhere in the esophagus or hypopharynx.

KUNNAMPALLIL GEJO JOHN

Webs are frequently asymmetric, most often impinging on the esophageal lumen from the anterior wall.

KUNNAMPALLIL GEJO JOHN

Treatment of webs or rings involves dilatation or ruptures of the ring any one of a variety of esophageal dilator systems. The ring is thin, nonfibrotic and easy to dilate. Complete, or nearly complete, symptomatic relief can anticipated. Dilatation may provide permanent relief, although a large proportion of patients will need periodic redilatation at variable intervals.

KUNNAMPALLIL GEJO JOHN

Benign Stricture
Strictures are rarely seen in children. The vast majority of benign esophageal structures are acquired in adulthood as a consequence of esophagi is. In a circular structure like the esophagus, edema due to ongoing inflammation and fibrosis part of the healing process occur at the expense of luminal diameter
KUNNAMPALLIL GEJO JOHN

Malignant Stricture
Although benign tumors may arise from the esophagus, the vast majority of clinically significant tumors of the esophagus are malignant. Most esophageal malignancies are squamous cell carcinomas, although cancers of the distal esophagus may be adenocarcinomas.
KUNNAMPALLIL GEJO JOHN

Luminal Deformity

KUNNAMPALLIL GEJO JOHN

Extrinsic Compression
Some degree of luminal deformity due to extrinsic compression by normal medinal structures (i.e. the aortic knob, the left mainstem bronchus, and the left atrium of the heart)

KUNNAMPALLIL GEJO JOHN

More pronounced compression can occur with mediastinal pathology such as aortic aneurysm, cardiomegaly, congenital abnormalities of the large mediastinal arteries (e.g. aberrant subclavian artery), enlarged mediastinal lymph nodes, and lung cancer.

KUNNAMPALLIL GEJO JOHN

Esophageal Diverticulum
Esophageal diverticula are relatively rare and most often asymptomatic, even when they reach relatively large size. When symptoms do occur, they include dysphagia for liquids and solids and/or regurgitation of previously swallowed food back to the mouth

KUNNAMPALLIL GEJO JOHN

Diffuse Esophageal Spasm

Esophageal spasm constitutes the end of a spectrum of nonspecific esophageal dysmotility, ranging from the abnormal contractions seen occasionally in normal individuals to the repeatedly highamplitude, prolonged, symultaneous, and/or multiphasic contractions in the absence of any apparent peristaltic activity
KUNNAMPALLIL GEJO JOHN

Nutcracker Esophagus
ln 1977, Brand et al. described a group of patients with chest pain or dysphagia, occurring in association with manometric findings of high amplitude, but normally progressive peristaltic waves (Brand et al. 1977).

KUNNAMPALLIL GEJO JOHN

Nonspecific Esophageal Motility Disorders

A large number of patients referred to the esophageal function laboratory have abnormalities of esophageal motility in which the degree and type of motility abnormalities detected are not sufficient to be labeled esophageal spasm or nutcracker esophagus. Such lesser patterns of dysmotility are referred to as nonspecific esophageal motor disorders (NEMD).

KUNNAMPALLIL GEJO JOHN

Treatment of Disorders of Esophageal Motility

A variety of smooth muscle relaxant drugs (nitrates, hydralazine, calcium channel blockers) have been used in an attempt to decrease esophageal contractile amplitude and repetitive contractions).

KUNNAMPALLIL GEJO JOHN

ABNORMALITIES OF LOWER ESOPHAGEAL SPHINCTER FUNCTION

Achalasia- It means failure to relax. characterized by the degeneration of neural elements in the wall of the esophagus, particularly at the LES. The distal segment of the esophagus tapers, giving the appearance of a "bird's beak
KUNNAMPALLIL GEJO JOHN

Achalasia is a condition in which a nonrelaxing, or incompletely relaxing, ES prevents the passage of swallowed material into the stomach. Patients usually -resent with dysphagia for both liquids and solids. Regurgitation is common,

KUNNAMPALLIL GEJO JOHN

Although the impairment of LES response to swallow is key to the functional obstruction to the flow of food into the stomach, the motor abnormalities achalasia include the complete loss of progressive peristalsis

KUNNAMPALLIL GEJO JOHN

Curling.
Curling is an alteration in esophageal motility frequently seen in elderly individuals. Curling represents tertiary contractions, which are nonpropulsive.

KUNNAMPALLIL GEJO JOHN

Diffuse Esophageal Spasm.

Diffuse esophageal spasm is characterized by intermittent dysphagia, chest pain, and repetitive contractions of the esophagus. Dysphagia is present in 30%, to 60% of patients with diffuse esophageal spasm. Clinically, dysphagia is intermittent, with severity varying from mild to severe
KUNNAMPALLIL GEJO JOHN

Presbyesophagus.
Presbyesophagus describes esophageal dismotility associated with normal ageing process. This may include muscular weakness muscular atrophy.

KUNNAMPALLIL GEJO JOHN

Diverticula.
Diverticula are out pouchings of one or more layers of esophageal wall. This diverticula occurs (1)above the upper esophageal sphincter(Zenkers diverticulum) (2)near the midpoint of esophagus(traction diverticulum) (3)above the lower esophageal sphincter (epiphernic diverticulum).
KUNNAMPALLIL GEJO JOHN

Schatzki ring
It is a lower esophageal mucosal ring which is located at the level of squamocolumnar junction

KUNNAMPALLIL GEJO JOHN

Gastroesophageal Reflux Disease

Gastroesophageal reflux disease (GERD) is defined as the retrograde movement of gastric contents from the stomach through the lower esophageal sphincter and into the esophagus.

KUNNAMPALLIL GEJO JOHN

Persons with GERD frequently complain of noncardiac chest pain, regurgitation of gastric contents, water brash (stimulated salivary secretion esophageal acid). Dysphagia and sometimes odynophagia (pain upon swallowing). Gastroesophageal reflux disease has also bet associated with numerous extra-esophageal symptoms including pharyngitis, laryngitis, hoarseness, chronic cough, asthma, and pt monary aspiration. Acid reflux induced symptoms referable to the oropharyngeal, laryngeal, and respiratory tracts are termed atypical reflux.
KUNNAMPALLIL GEJO JOHN

The etiology of oropharyngeal dysphagia, the difficulty in passing a food bolus from the oropharynx in to the upper esophagus.

KUNNAMPALLIL GEJO JOHN

KUNNAMPALLIL GEJO JOHN

Gastroesophageal reflux occurs through one of three mechanisms: (1) inappropriate or transient lower esophageal sphincter relaxation, (2) increased abdominal pressure or stress-induced reflux, or (3) incompetent or reduced lower esophageal sphincter pressures or spontaneous free reflux.

KUNNAMPALLIL GEJO JOHN

Lower esophageal sphincter competence is the most important barrier to esophageal reflux. Transient lower esophageal sphincter relaxations are the most important cause of gastroesophageal reflux,

KUNNAMPALLIL GEJO JOHN

Barrett's Esophagus
Barrett's esophagus, a compensatory change in the esophageal mucosa from squamous to specialized intestinal epithelium, occurs in up to 10% to 15% of patients with atypical presentations of GERD

KUNNAMPALLIL GEJO JOHN

MEDICATIONS
The effects of medication are influenced by sex, age, body size, meta-bolic status, individual biological response, and concurrent use of other medications. A variety of medications, including those obtained over-the counter and those medically prescribed, affect swallowing, impairconsciousness, coordination, motor and sensitivity functions, and the lubrication of the upper aerodigestive tract.ssss

KUNNAMPALLIL GEJO JOHN

Analgesics Salcylates (aspirin) and nonsteroidal anti-inflammatory agents cause gyration of the mouth, throat burning, mucosal hemorrhage, glossing and dry mouth. Antibiotics Side effects such as glossitis, stomatitis, and esophagitis have been scribed for penicillin, erythromycin, chloramphenicol, and the tetra--lines. Sulfa can cause a Stevens-Johnson type reaction resulting in ensive mucosal ulceration and glossitis. Aminoglycosides can Tease Parkinsonian symptoms of weakness.
KUNNAMPALLIL GEJO JOHN

Antituberculous medications such as isonlazid, rifampin, ethambutol, and cycloserine can cause confusion, disorientation, and dysarthria. Antiviral agents such as acyclovir, amantadine, gancyclovir, and vidarabine can indirectly cause dysphagia with confusion, asthenia, and lingual facial dyskinesia. Amantadine can cause severe xerosnia and xerophonia in some patientsZidovudine (AZT) causes tongue de 5% to 10% of patients. Chloroquine (Plaquenil) can cause stomatitis

KUNNAMPALLIL GEJO JOHN

Antituberculous medications such as isonlazid, rifampin, ethambutol, and cycloserine can cause confusion, disorientation, and dysarthria. Antiviral agents such as acyclovir, amantadine, gancyclovir, and vidarabine can indirectly cause dysphagia with confusion, asthenia, and lingual facial dyskinesia. Amantadine can cause severe xerosnia and xerophonia in some patientsZidovudine (AZT) causes tongue de 5% to 10% of patients. Chloroquine (Plaquenil) can cause stomatitis

KUNNAMPALLIL GEJO JOHN

Anti muscarinics, Anti cholinergics, and Antispasmodics Antimuscarinics and antispasmodics are used for a variety of reasons such as bradycardia, excessive oral secretions, motion sickness, and diarrhea. They diminish the production of saliva and mucus. Salivary secretion is particularly sensitive to inhibition by antimuscarinic Prokinetic agents improve gut motility and speed gastric emptying. The two major drugs in this category are metoclopramide (Reglan) and cisapride (Propulsid) 'The former is associated with greater antihistamine-like side

KUNNAMPALLIL GEJO JOHN

Mucolytics Mucolytics can be used to counter the effects of drying agents such as antihistamines. However, no medications, including mucolytic agents, are a substitute for adequate hydration. Indeed, these medications are dependent on adequate water intake.s
KUNNAMPALLIL GEJO JOHN

Anti hypertensives Almost all of the antihypertensives have some degree of parasympathomimetic effect and thus dry the mucous membranes. Hydration is the first step to improve swallowing when taking these medications; Antineoplastics Antineoplastics affect swallowing mainly through the mechanism of inflammation, sloughing, and occasionally causing superinfection of the aerodigestive tract mucosa. This effect results in mucositis, stomatitis, pharyngitis, esophagitis, and esophageal ulceration's

KUNNAMPALLIL GEJO JOHN

Vitamins Over dosage of vitamin A causes hypervitaminosis a syndrome, which includes dermatologic, gastric, skeletal, and cerebral and optic nerve edema. Fissures of the lips, dry mouth, and abdominal discomfort can result. A similar stomatitis can result with vitamin E over dosage.
KUNNAMPALLIL GEJO JOHN

Neurologic Medications Anticonvulsants. Phenobarbital is a sedative and anticonvulsant with side effects similar to the tricyclic antidepressants: dry mouth, sweating, lwpoteiisioti, and tremor. Phenytoin (Dilantin) adverse effects include central nervous system signs such as ataxia, slurred speech, in coordination, and dystonia. Carbamazepine (Tegretol) is an anticonvulsant used primarily for seizures. Digestive symptoms can also be serious such as glossitis, stomatitis, and dryness of the mouth. (Antiparkinsonians. Levodopa may improve all symptoms of Parkinson 's disease including swallowing, but it can cause gastrointestinal discomfort, dyskinesia, and oral dryness

KUNNAMPALLIL GEJO JOHN

Antipsychotics. Antipsychotics primarily work by dopamine antagonism. Commonly used drugs in this class include haloperidol (Haldol) chlorpromazine (Thorazine), thioridazine (Mellaril), and prochlorperazine (Compazine). These medications can have anticholinergic effects such as dry mouth, nasal congestion, and hypotension. Approximately 14% of patients receiving long-term antipsychotic medications will develop tardive dyskinesia ranging from tongue restlessness and disabling choreiform and/or athetoid movements that lead to significant swallowing and feeding problem Life-threatening dysphagia can occur after prolonged neuroleptic therapy. Neuroleptic drugs can induce extrapyramidal symptoms such as dystonia, akathisia, and tardive dyskinesia. Contrast radiography has revealed poor contractions in the upper esophagus, a hypertonic esophageal sphincter, and hypokinesia of the pharyngeal muscles.
KUNNAMPALLIL GEJO JOHN

Anxiolytics. Significant dysphagia can result from chronic use of benzodiazepines. Reported effects include hypopharyngeal retention, cricopharyngeal in coordination, aspiration, and drooling. Benzodiazepines can inhibit discharges from interneurons in the nucleus of the tractus solitaries or ambiguous nucleus, both of which are critical to the pharyngeal phase of swallowing-)

KUNNAMPALLIL GEJO JOHN

NEOPLASMS
Neoplasia causes distortion, obstruction, reduced mobility, or neuromuscular and sensory dysfunction of the upper aerodigestive tract. Exophytic tumors interfere with swallowing principally by distorting or obstructing the aerodigestive tract. Tumors with an infiltrating growth pattern may cause reduced mobility or fixation of the tongue, soft palate, pharynx, or larynx (sec Table 3-10). Tumors also affect swallowing by-interfering with the afferent fibers (sensory input) from the mucosa of the upper aerodigestive tract by invasion and destruction of mucosal nerve endings or sensory nerves such as the trigeminal (V), glossopharyngeal (IX), and vagus (X) cranial nerves and their branches.
KUNNAMPALLIL GEJO JOHN

Neoplasms of the floor of the mouth, tongue, or buccal mucosa may by mass effect or by restricting mobility of the tongue and floor of the mouth impair a patient's ability to interpose food between the teeth. Tumor invasion of the dorsum of the tongue or involvement of the lingual nerve (V) may affect sensory input causing premature spillage of the bolus into the pharynx and, consequently, aspiration

KUNNAMPALLIL GEJO JOHN

ANTERIOR CERVICAL SPINAL SURGERY ,Anterior cervical spinal surgery is a common surgical approach. Surgeons approach the spinal cord anteriorly with a cervical incision, mobilizing the laryngotracheal complex away from the great vessel of the neck and prevertebral space to visualize and repair the cervical spine.

SWALLOWING DISORDERS ARISING FROM SURGICAL TREATMENT

KUNNAMPALLIL GEJO JOHN

Postoperative dysphagia is found in all patients who undergo anterior cervical spinal surgery. Although in most patients the dysphagia is of short duration, in 10% of patients it can persist longer than 12 months. There are several possible etiologies for dysphagia following anterior cervical spinal surgery. Neurologic damage may result from direct trauma or stretch trauma to the recurrent laryngeal nerve,

KUNNAMPALLIL GEJO JOHN

HEAD AND NECK SURGERY

Head and neck surgery for neoplasms of the upper aerodigestive tract alters the anatomy, causes scarring, and may injure motor and sensory nerves. All these factors contribute to the presence of dysphagia in the postoperative period. In addition, many of these patients require reconstruction with insensate tissue flaps that can contribute to the discoordination of the swallowing mechanism or can even cause mechanical obstruction or diversion of the bolus into the airway. Head and neck surgery may result in disruption of any of the phases of swallowing
KUNNAMPALLIL GEJO JOHN

Skull Base Surgery

Patients undergoing skull base surgery are at risk for injury to lower cranial nerves, brainstem, brain parenchyma, and soft tissues of the upper aerodigestive tract, depending on tumor location. Injury to these vital structures can lead to dysfunction of speech, swallowing and airway protection. In addition to the mentioned deficits, pal undergoing skull base surgery frequently need reconstruction with insensate soft tissue flaps, which may compound the deficit due to their bulk. After skull base surgery, patients frequently need enteral tubes, prolonged incubation and ventilation, and tracheostonlic, further compound the swallowing deficits.

KUNNAMPALLIL GEJO JOHN

Floor of the Mouth

The floor of the mouth is considered a sulcus for saliva and food particles; however, when obliterated by surgery, the lack of this sulcus and the loss of mobility of the anterior tongue become major impairments during the preparation of the food bolus. All efforts should be made to protect the lingual nerve to preserve the sensation to the tongue
KUNNAMPALLIL GEJO JOHN

Partial Glossectomy
Following partial glossectomy, near- normal swallowing and normal speech can be predicted if the patient can protrude the tongue past the sublabill crease. mall defects of the mobile tongueare repaired primarily. Large defects often cause the loss of tongue driving force and inability to propel the bolus posteriorly. The bolus is often improperly prepared, and, due to the lack of proper control, it may be presented to the oropharynx prematurely. Food and saliva will spill out of the oral cavity because of poor tongue mobility, a problem that is worsened if the oral sphincter has been altered.

KUNNAMPALLIL GEJO JOHN

Palate
Tumers of the hard palate that requre partial or total maxilactomy affect both speech and swallowing. Recection results in loss of oronasal seperation, which causes leakage of food into the nose and hypernasal speech with decreased Tumors of the hard palate that require partial or total maxillectomy affect both speech and swallowing. Resection results in loss of oronasal separation, intelligibility. Unilateral maxillectomy is usually best reconstructed with a dental prosthesis. Free microvascular flaps can be used to reconstruct large palatal defects in edentulous patients in whom a prosthesis would not be retained. After soft palate resection, patients often have nasal regurgitation. The reconstruction options are limited, and defects in the soft palate are best managed by dentate' prostheses with extensions to close the nasopharyngeal isthmus.
KUNNAMPALLIL GEJO JOHN

Lips
The orbicularis oris muscle is crucial to the sphincteric function of the lips. This muscle is divided during lipsplitting procedures and must be carefully reapproximated during closure to restore function. The loss of lower lip sensation secondary to mental nerve injury makes sphincteric control difficult if not impossible. Lip resection may hinder swallowing by creating difficulty in getting food into the mouth (microstomia). Motor denervation of the lower lip secondary to sacrifice of the marginal mandibular nerve.often manifests itself as loss of sphincteric control, resulting in drooling.

KUNNAMPALLIL GEJO JOHN

Oropharynx

KUNNAMPALLIL GEJO JOHN

Oropharynx
Resection of the lateral pharyngeal wall leads to decreased pharyngeal wall mobility, which alters oropharyngeal propulsion. The muscles of the base of the tongue assist in elevation of the larynx and are essential for the oropharyngeal propulsion pump and for adequate oral cavity pharyngeal separation. Although partial resection is well tolerated, large defects often cause dysphagia. Reconstruction of large defects of the base of the tongue requires a sensate flap. Resection of even limited portions of the soft palate produces velopharyngeal insufficiency, alters the propulsion of the bolus, and can lead to poor oral-pharyngeal separation with early spillage of the bolus and aspiration before the pharyngeal swallow is initiated.
KUNNAMPALLIL GEJO JOHN

Hypopharyngeal Surgery
Resection of hypopharyngeal tumors arising on the posterior pharyngeal wall poses several problems for the rehabilitation of swallowing. Small defects (less than 2 cm) can be closed primarily, or the edges can be stitched to the prevertebral fascia. Reconstruction with a split thickness skin graft or radial forearm free flap provides a satisfactory closure of larger defects. However, neither one restores the motility of the posterior wall, and impairment of pharyngeal contraction leads to significant postoperative aspiration. Patients lose the normal gliding action of the hypopharynx on the vertebral fascia because of scarring of the posterior hypopharyngeal wall to the prevertebral fascia. Also, the reconstruction of this area, using grafts and flaps, is almost always devoid of sensation, which further weakens laryngeal protection.

KUNNAMPALLIL GEJO JOHN

Aspiration
Aspiration is the entry of material into the airway below ture vocal cords. Aspiration can occur before, during or after the swallow Pandial Aspiration pneumonia is a bronchopneumonia resulting from the entry of foreign materials usually foods, liquids, or vomitinto the bronchi of the lungs. There are typically three distinct pulmonary syndromes caused by types of aspiration.

KUNNAMPALLIL GEJO JOHN

Prolonged mechanical ventilation: Patients requiring prolonged mechanical ventilation and patients with a tracheostomy are especially at risk for aspiration. Aspiration pneumonia can occur after only two weeks oil mechanical ventilation, and nearly 85% of these patients fail modified barium swallow testing with fluoroscopy for detection of aspiration.

KUNNAMPALLIL GEJO JOHN

Upper-aerod igestive- tract tumors: Most of these patients ex . peri- ence some swallowing difficulty, either from the mechanical effects of the tumor,its interference with the sphincteric mechanism of the larynx, or due to the anatomic and functional changes produced by surgery, radiation therapy, and chemotherapy
KUNNAMPALLIL GEJO JOHN

Autoimmune Diseases
Auto immune diseases are characterized by the production of antibodies that react with host tissue or immune effector T cells that react to self-peptides. Autoirnmune diseases may affect swallowing by causing intrinsic obstruction, external compression, abnormal motility, or inadequate lubrication.
KUNNAMPALLIL GEJO JOHN

Giant Cell Arteritis

Giant cell arteritis, also known as temporal arteritis, is all inflammatory disorder affecting large and medium size vessels. These arteries that originate from the arch of the aorta are the most affected. Pharyngeal, tongue, or jaw claudication Illay occur when the ascending pharyngeal, lingual, deep temporal, or masseteric arteries are affected. Systemic corticosteroids often resolve all symptoms within one to two weeks.

KUNNAMPALLIL GEJO JOHN

Mixed Connective Tissue Disease

Mixed connective tissue disease is characterized by clinical findings that may be found in a variety of autoimmune disorders, including progressive systemic sclerosis, systemic lupus erythematosus, and polymyositis/dermatomyositis. Similarly, the swallowing disorders described under each of these disorders can be a part of mixed connective tissue disease. Esophageal motility is severely affected, and the majority of the patients have no peristalsis or low-amplitude peristalsis contributory to gastroesophageal reflux disease (GERD). I leartburn all dysphagia are present in up to 501/2 of the patients with mixed connective tissue disease. The treatment of the GERD may reduce the dysphagia ss
KUNNAMPALLIL GEJO JOHN

Myositis
Polymyositis and dermatomyositis are characterized by inflammation of the skeletal muscle. Thus, muscles of the pharynx are often affected while esophageal smooth muscle is spared. A modified barium swallow frequently shows prominence of the cricopharyngeus muscle, decreased epiglottis tilt, and moderate to severe pharyngeal residue. Two thirds of patients with myosins have demonstrable delayed esophageal transit. Polymyositis and derniatomyositis are treated with corticosteroids.

KUNNAMPALLIL GEJO JOHN

Rheumatoid Arthritis
Rheumatoid arthritis (RA) is a chronic relapsing inflammatory arthritis, usually affecting multiple diarthrodial joints and present with a variable degree of systemic involvement. Women are more commonly affected than men, with a ratio of 3:1.

KUNNAMPALLIL GEJO JOHN

Rheumatoid arthritis is associated with xerostomia, temporomandibular joint (TMJ) syndrome, a decrease in the amplitude of the peristaltic pressure complex in the striated part of the esophagus proximal, and cervical spine arthritic disease, all of which cause or contribute to swallowing problems. Rheumatic laryngeal involvement can result in cricoarytenoid joint fiitioii. 0111cctivc functional testing is necessary to determine the contributions of the oral phase and the pha-LI dysphagia vilgeal phase to the svl,all()iVing disorder
KUNNAMPALLIL GEJO JOHN

Sarcoidosis
Sarcoidosis is a chronic systemic disorder presumed to have autoimmune pathogenesis. Sarcoidosis may cause laryngeal lesion extrinsic compression of the esophagus by mediastinal aderiopatl, and esophageal' dysmotility due to myopathy, infiltration of ALI( bach's plexus, or granulomatous infiltration of the esophageal wa which may produce long segments of esophageal stenosi-SD
KUNNAMPALLIL GEJO JOHN

Scleroderma
Scleroderma, or progressive systemic sclerosis, is a disorder char terized by progressive fibrosis and vascular changes. The most coi mon and the earliest symptom in people with progressive systen sclerosis is Raynaud's phenomenon, characterized by pallor a sweating of the fingers or hands that progress to cyanosis and pa Dysphagia, which is the second most common symptom of this dis, der, usually first noticed while swallowing solid 4sphagia is most often due to poor motility through the infer two thirds of the esophagus.
KUNNAMPALLIL GEJO JOHN