Aphagia

Aphagia is the inability or refusal to swallow.[1][2] The word is

Aphagia
derived from the Ancient Greek prefix α, meaning "not" or
"without," and the suffix φαγία, derived from the verb φαγεῖν,
meaning "to eat." It is related to dysphagia which is difficulty
swallowing (Greek prefix δυσ, dys, meaning difficult, or
defective), and odynophagia, painful swallowing (from ὀδύνη,
odyn(o), meaning "pain"). Aphagia may be temporary or long
term, depending on the affected organ. It is an extreme, life-
threatening case of dysphagia. Depending on the cause, untreated
dysphagia may develop into aphagia.

Behavioural classification
The following behavioural classifications result from studies
performed on rats, in which lesions were made on the lateral Arrow pointing to hypothalamus in
hypothalamus region in the brain.
human brain. The hypothalamus is
1. Passive aphagia: An animal with passive aphagia will responsible for controlling food
not respond to food if it is presented. However, if food is intake and swallowing.
inserted into the mouth, the animal will chew. Specialty Gastroenterology
2. Active aphagia: Active aphagia is a complete rejection
Complications Malnutrition,
of food. The animal will physically push food away or
move its head from it. One might first sample the food metabolic disorders
by smelling or tasting, then spit out anything in the
mouth. Afterwards the animal will show a complete repulsion to the food. The animal reacts
to food as if it is bitter or foul.
3. Mixed aphagia: When presented with food, the animal initially does not react positively or
negatively. However, when food is placed in the mouth, the animal demonstrates active
aphagia, spitting out the food and refusing to eat thereafter.[3]

These studies point to the function of the hypothalamus in regulating food intake. Animals in this study also
demonstrated several other types of eating behaviour: "weak eating," in which the animal slowly
approaches, chews, and swallows small observable amounts of food for a brief period; "good eating," in
which the animal reaches normally for the food and eats reliably; and "vigorous eating," in which the
animal gluttonously reaches for and devours the food. In these cases, there was either minor or no damage
to the lateral hypothalamus.[3]

Aphagia not classified under behavioral aphagia typically has a structural cause, see causes.

Causes
Aphagia is usually the result of many different diseases as well as different medical treatments. The most
common causes of aphagia are:
 Aesophageal cancer – there are two types of aesophageal cancer. The squamous cell
cancer from the squamous cells of the tongue or the adenocarcinoma from glandular cells
present at the junction of the esophagus and stomach. This leads to a local tumour growth
with spreading later. This spreading may lead to larger tumors that would result in the
inability to swallow.[4]
Aesophageal webs – thin membranes located in the esophagus. Abnormalities can cause
constrictions within the esophagus.
Globus pharyngis – commonly referred to as lumps in ones throat[5]
Myasthenia gravis – the thymus gland is thought to be necessary for the deletion of auto-
reactive T cells, and seems to have an important role in the pathogenesis of myasthenia
gravis. In patients the thymus is typically enlarged, and contains many germinal centres with
T and B cell areas very similar to those seen in lymph nodes. The tumour in thymoma
associated disease is typically epithelial in nature.[6]
Facioscapulohumeral muscular dystrophy – even though there is not a clear correlation
between the facioscapulohumeral muscular dystrophy and the pharyngeal and upper
aesophageal striated muscle. Minor, and nonspecific, primary aesophageal dysmotility was
present as seen in the 2008 study by Joerg-patrick Stübgen.[7]
Multiple sclerosis – may lead to aesophageal dysmotility [8][9]

Chemotherapy – radiation from cancer therapy may cause a stricture of the throat leading to
the inability to swallow.
Stroke – swallowing problems can cause stroke victims to aspirate food or liquid into the
lungs and cause pneumonia mostly in elderly people.
Parkinson's disease – the mechanism of swallowing disorders in Parkinson's disease may
be related to extrapyramidal and autonomic system disorders. The cardinal symptoms of
Parkinson's disease: tremor, bradykinesia, and rigidity are initially responsible for
swallowing, which is mainly observed in the advanced stages of the disease
Damage to the lateral hypothalamus can also lead to aphagia, as seen in the 1978 study by
Timothy Schallert and Ian Whishaw.[3]
Other causes might be due to depression, cervical spine disease and conversion disorders.

It is important to note that all these causes (except due to the damage of the lateral hypothalamus) are
indirect.

Diagnosis
Modified barium swallow – videofluoroscopic swallow (fluoroscopy). A lateral video X-ray
that provides objective information on bolus transport, safest consistency of bolus, and
possible head positioning and maneuvers that may facilitate swallow function depending on
each individual's anatomy and physiology.
Esophagogastroduodenoscopy – a diagnostic endoscopic procedure that visualizes the
upper part of the gastrointestinal tract.
Esophageal motility study – a test to assess motor function of the upper and lower
esophageal sphincter as well as the esophageal body.

Treatment and compensatory techniques

During the treatment of aphagia (or dysphagia), it is important to provide adequate nutrition and hydration.
If a person is not able to tolerate a regular diet, diet modifications and alternative means of nutrition may be
considered. These include thickening liquids (typical thickening hierarchy is nectar/syrup thick, honey
thick, and pudding thick) or by changing the texture of the solid foods to reduce the required amount of
mastication (chewing) needed or to reduce other symptoms of oral dysphagia (such as buccal pocketing or
anterior loss). Alternative means of nutrition may also be needed in more severe cases (such as when a
person is deemed NPO and is not safe to eat anything orally). In these cases, nasogastric (NG) or
percutaneous endoscopic gastronomy (PEG) tubes may be placed. Other compensatory measures may
include reducing the bolus size (small bites/sips) or postural strategies (such as tucking the chin, turning the
head to one side or the other). A speech-language pathologist is one professional who evaluates and treats
aphagia and dysphagia and can recommend these strategies depending on the etiology of the deficit and the
location of the breakdown within the swallowing mechanism. True treatment of aphagia/dysphagia comes
from neuromuscular re-education and strengthening/coordination in most cases. This can be achieved by
use of pharyngeal strengthening exercises, thermal stimulation of the swallowing trigger and oral motor
exercises. In some cases, it is also appropriate to complete therapeutic exercises in conjunction with
neuromuscular electrical stimulation (NMES) which utilizes low-level electrical currents to target muscle
fibers from an external source (electrodes placed on the surface of the skin in strategic places to target
muscles and nerves needed during the swallowing process).

References
1. "Aphagia". Dorland's Illustrated Medical Dictionary for Health Consumers. Saunders. 2007.
2. Borror, Donald J. (1988). Dictionary of Word Roots and Combining Forms. Mountain View,
CA: Mayfield.
3. Schallert, T; Whishaw, I (1978). "Two types of aphagia and two types of sensorimotor
impairment after lateral hypothalamic lesions: Observations in normal weight, dieted, and
fattened rats". Journal of Comparative and Physiological Psychology. 92 (4): 720–741.
doi:10.1037/h0077504 (https://doi.org/10.1037%2Fh0077504). PMID 690292 (https://pubme
d.ncbi.nlm.nih.gov/690292).
4. Kademani, D (2007). "Oral cancer". Mayo Clinic Proceedings. 82 (7): 878–887.
doi:10.4065/82.7.878 (https://doi.org/10.4065%2F82.7.878). PMID 17605971 (https://pubme
d.ncbi.nlm.nih.gov/17605971).
5. I.J. Deary, J.A. Wilson, M.B. Harris, G. Macdougall, Globus pharyngis: Development of a
symptom assessment scale, Journal of Psychosomatic Research, Volume 39, Issue 2,
February 1995, pages 203v213, ISSN 0022-3999,
6. Vincent, A.; Palace, J.; Hilton-Jones, D. (2001). "Myasthenia gravis". The Lancet. 357
(9274): 2122–8. doi:10.1016/s0140-6736(00)05186-2 (https://doi.org/10.1016%2Fs0140-673
6%2800%2905186-2). PMID 11445126 (https://pubmed.ncbi.nlm.nih.gov/11445126).
S2CID 7218479 (https://api.semanticscholar.org/CorpusID:7218479).
7. Stübgen, J (2008). "Facioscapulohumeral Muscular Dystrophy: A Radiologic and
Manometric Study of the Pharynx and Esophagus" (https://repository.up.ac.za/bitstream/226
3/9142/1/Stubgen_Faciocapulohumeral%282008%29.pdf) (PDF). Dysphagia. 23 (4): 341–7.
doi:10.1007/s00455-007-9141-0 (https://doi.org/10.1007%2Fs00455-007-9141-0).
hdl:2263/9143 (https://hdl.handle.net/2263%2F9143). PMID 18259705 (https://pubmed.ncbi.
nlm.nih.gov/18259705). S2CID 14549148 (https://api.semanticscholar.org/CorpusID:145491
48).
8. Pauw, A De; Dejaeger, E; D'hooghe, B; Carton, H (2002). "Dysphagia in multiple sclerosis".
Clinical Neurology and Neurosurgery. 104 (4): 345–351. doi:10.1016/S0303-
8467(02)00053-7 (https://doi.org/10.1016%2FS0303-8467%2802%2900053-7).
PMID 12140103 (https://pubmed.ncbi.nlm.nih.gov/12140103). S2CID 24969601 (https://api.s
emanticscholar.org/CorpusID:24969601).
9. Takubo K. "Pathology of the aesophagus : an atlas and textbook. 2nd ed..: Springer Verlag;
2007.
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