Dysphagia

Vorokhta Y., MD, PhD

Phases
 Neuroanatomy
Motor function Sensory function
Zone of innervation Nerves Zone of innervation Nerves
Mimic muscles VII Soft palate, oral mucosa, anterior 2/3 V
of the tongue, nasopharynx

Chewing muscles V3 Anterior 2/3 of the tongue VII

The palate (except the palatal Х Posterior 1/3 of the tongue, ІХ
curtain), pharynx (except the oropharynx
pharyngeal muscle), larynx,
esophagus

Palatal curtain V3 Tongue root, larynx Х

The stylopharyngeal muscle ІХ
Muscles of tongue XII
Cervical Muscles V3, VII,
C1-C2
 Neuroanatomy
Anatomic region
Primary somatosensory, motor
cortex (ВА 1,2,3,4,6)
Cingular gyrus (ВА 24,32)
Orbitofrontal cortex (ВА
10,11,12,44,45,47)
Parieto-occipital cortex (ВА
7,17,18,40)
Cortex of the temporal lobe pole
(ВА 22,38)
Insular cortex
capsula interna
thalamus
Role
Regulation of movements, control and coordination
of the act of swallowing
Planning the act of swallowing, choosing a model of
behavior
?
Swallowing coordination, sensory processing
?
Oral phase modulation, processing of afferent information from
taste buds)
Tr. corticobulbaris
Tr.thalamocorticalis, tr. thalamostriaris
 Neuroanatomy
Anatomic region Role
Basal ganglia (caudate nucleus, Processing of afferent information
putamen)
Middle peduncles of the tractus pontocerebellares,, fibrae corticopontinae
cerebellum
Brainstem Subcortical center of swallowing, nuclei V, VII, IX, X,
XII FMN
Cerebellum Regulation of coordinated movements, learning and
motor memory of muscles involved in the act of
swallowing
Neurophysiology
 Risk factors
• Poor dentition
• Atrophy of the tongue and alveolar ridge
• Diminished taste and smell sensitivity
• Decreased muscle tone
• Increased ligamentous laxity
• Limited laryngeal elevation
Severity
 Manifestations
Signs and symptoms of oral or pharyngeal dysphagia include the following:
• Coughing or choking with swallowing
• Difficulty initiating swallowing
• Food sticking in the throat
• Sialorrhea
• Unexplained weight loss
• Change in dietary habits
• Recurrent pneumonia
• Change in voice or speech (wet voice)
• Nasal regurgitation
Signs and symptoms of esophageal dysphagia include the following:
• Sensation of food sticking in the chest or throat
• Change in dietary habits
• Recurrent pneumonia
• Symptoms of gastroesophageal reflux disease (GERD), including heartburn, belching, sour
regurgitation, and water brash
• Other associated factors/symptoms of dysphagia include the following:
• General weakness
• Mental status changes
?
Rosenbek’s Scale
 Work-up
• Transnasal esophagoscopy
• Cervical auscultation
• Blood tests: Including thyroid-stimulating hormone, vitamin B-
12, and creatine kinase; may be useful, especially in neurogenic
dysphagia
• Imaging studies: May include videofluoroscopy, computed
tomography (CT) scanning, magnetic resonance imaging (MRI),
and chest radiography
• Endoscopic examination
• Esophageal pH monitoring: The criterion standard for diagnosing
reflux disease
• Pulmonary function tests
 Swallowing disorders in Neurological
Diseases
stroke (20-65%)
TBI
tumors
cerebral palsy
iatrogenic dysphagia
Alzheimer's disease, FTD, DTL, vascular dementia
Parkinson's disease
progressive supranuclear palsy
olivopontocerebellar atrophy
Huntington's chorea
Wilson's disease
multiple sclerosis, ALS, Guillain-Barré syndrome
myasthenia
neuroinfections
 Iatrogenic dysphagia
• antipsychotics
• corticosteroids
• colchicine
• aminoglycosides
• cholinolytics
• drugs that damage the mucous membranes of the mouth
and pharynx: potassium chloride, NSAIDs, some antibiotics
(doxycycline, tetracycline, biseptol, clindamycin)
• drugs that cause xerostomia (cholinolytics, alpha-blockers,
ACE inhibitors, antihistamines)
• surgery on the head and neck can also cause dysphagia.
Post-stroke dysphagia (PSD or SRD)
in the acute period of a stroke it is noted in 64-
94% of cases, most often - in the first 3-10 days;
in the recovery period - in 23-50% of patients,
and about 11% of patients in the rehabilitation
phase still need tube feeding.

mortality among stroke patients with dysphagia

is 27-37%.
Recovery
 TREATMENT
Pharmacologic treatment
• Botulinum toxin type A (BoNT-A)
• Diltiazem
• Cystine-depleting therapy with cysteamine
• Nitrates
Dietary treatment
• Dietary modification is the key component in the general treatment program of
dysphagia. Diets for patients with dysphagia include the following:
• Dysphagia diet 1: Thin liquids (eg, fruit juice, coffee, tea)
• Dysphagia diet 2: Nectar-thick liquids (eg, cream soup, tomato juice)
• Dysphagia diet 3: Honey-thick liquids (ie, liquids that are thickened to a honey
consistency)
• Dysphagia diet 4: Pudding-thick liquids/foods (eg, mashed bananas, cooked cereals,
purees)
• Dysphagia diet 5: Mechanical soft foods (eg, meat loaf, baked beans, casseroles)
• Dysphagia diet 6: Chewy foods (eg, pizza, cheese, bagels)
• Dysphagia diet 7: Foods that fall apart (eg, bread, rice, muffins)
• Dysphagia diet 8: Mixed textures
 TREATMENT
Exercise and facilitation techniques
• The following types of exercise can be recommended to patients with dysphagia:
• Indirect (eg, exercises to strengthen swallowing muscles)
• Direct (eg, exercises to be performed while swallowing)
• Facilitation techniques used in the treatment of dysphagia include the following:
• Somatosensory stimulation: In the form of an electrical current applied to the pharynx
• Deep pharyngeal neuromuscular stimulation (DPNS)
• Tactile-thermal stimulation (TTS)
Compensatory techniques
• Maintaining oral feeding often requires compensatory techniques to reduce aspiration
or improve pharyngeal clearance. These include the following:
• Use of the chin-tuck position
• Rotation of the head to the affected side
• Tilting of the head to the strong side
• Lying on one's side or back during swallowing
• Supraglottic swallow
• Bolus-clearing maneuvers
 TREATMENT
Enteral feeding
• Nasogastric tube (NGT) feeing
• Oroesophageal tube feeding
• Percutaneous endoscopic gastrostomy (PEG)
Surgery for chronic aspiration
• Medialization: This helps to restore glottic closure and subglottic pressure
during the swallow
• Laryngeal suspension: The larynx is in a relatively protected position under
the tongue base
• Laryngeal closure: This may be performed to close the glottis off, in this
way protecting the airway at the expense of phonation
• Laryngotracheal separation-diversion: This procedure may be done to
separate the airway from the alimentary tract
Vitastim ™
VitaStim software