7/27/2019 MECHANICAL DISORDERS OF SWALLOWING.pdf / KUNNAMPALLIL GEJO
1/91
MECHANICAL DISORDERS
OF SWALLOWING
KUNNAMPALLIL GEJOJOHN, MASLP
KUNNAMPALLIL GEJO JOHN
7/27/2019 MECHANICAL DISORDERS OF SWALLOWING.pdf / KUNNAMPALLIL GEJO
2/91
Patients with mechanical swallowing disordersevidence difficulty secondary to the loss ofsensory guidance of the structures necessary
to complete a normal swallow.. Most patients with mechanical dysphagiahave had oral, pharyngeal, or laryngealstructures removed or reconstructed duringsurgery for cancer. There are, however, othercauses that must be considered in thedifferential diagnosis. The most common of
these are KUNNAMPALLIL GEJO JOHN
7/27/2019 MECHANICAL DISORDERS OF SWALLOWING.pdf / KUNNAMPALLIL GEJO
3/91
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
7/27/2019 MECHANICAL DISORDERS OF SWALLOWING.pdf / KUNNAMPALLIL GEJO
4/91
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 inattempts at oral feeding.
KUNNAMPALLIL GEJO JOHN
7/27/2019 MECHANICAL DISORDERS OF SWALLOWING.pdf / KUNNAMPALLIL GEJO
5/91
They should be ruled out in patients
whose mental state or competenceinterferes with the ability to communicateoral pain and those who evidenceunexplainable dysphagia or suddenrefusal to eat. Early identification isimportant because most inflammationscan be controlled within a short period of
time, and oral nutritional intake canresume.
KUNNAMPALLIL GEJO JOHN
7/27/2019 MECHANICAL DISORDERS OF SWALLOWING.pdf / KUNNAMPALLIL GEJO
6/91
Herpes Simplex
Viral in origin, a herpetic infection ischaracterized by round vesicles that breakto form shallow ulcers surrounded by a
narrow zone of inflammation.Typically, they are found on the lips;however, the pharynx and buccal mucosamay be involved. Palatal and pharyngealulcers create significant pain anddiscomfort on swallowing.
KUNNAMPALLIL GEJO JOHN
7/27/2019 MECHANICAL DISORDERS OF SWALLOWING.pdf / KUNNAMPALLIL GEJO
7/91
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 asabscesses, caries, and postextraction
infection are implicated in 70 to 85 percent
of cases of Ludwig's angina
KUNNAMPALLIL GEJO JOHN
7/27/2019 MECHANICAL DISORDERS OF SWALLOWING.pdf / KUNNAMPALLIL GEJO
8/91
Clinical manifestations of Ludwig's angina
include massive swelling and displacement of
the tongue. The floor of the mouth also willappear 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 inthe suprahyoid region. Patients generally
present with complaints of mouth pain, stiff
neck, drooling, and dysphagia.KUNNAMPALLIL GEJO JOHN
7/27/2019 MECHANICAL DISORDERS OF SWALLOWING.pdf / KUNNAMPALLIL GEJO
9/91
Lingual Tonsillitis
Patients with lingual tonsillitis havesymptoms similar to those of other throatinfections, except they complain of pain in
the medial pharyngeal region. Often theydescribe a lump in the throat associatedwith complaints of dysphagia.
The mechanism of lingual tonsillitis can beconfirmed by indirect mirror examination ofthe base of the tongue and pharynx.
KUNNAMPALLIL GEJO JOHN
7/27/2019 MECHANICAL DISORDERS OF SWALLOWING.pdf / KUNNAMPALLIL GEJO
10/91
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 childrenbut has more recently been recognized with
increasing frequency in adults
Patients often complain of sore throat,
dysphagia, respiratory difficulty, muffled voicedrooling, and stridor
KUNNAMPALLIL GEJO JOHN
7/27/2019 MECHANICAL DISORDERS OF SWALLOWING.pdf / KUNNAMPALLIL GEJO
11/91
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. Thepain and dysphagia subside within four to
six days.
KUNNAMPALLIL GEJO JOHN
7/27/2019 MECHANICAL DISORDERS OF SWALLOWING.pdf / KUNNAMPALLIL GEJO
12/91
The most common bacterial form of pharyngitis
is streptococcal. The diagnosis is confirmed by
laboratory analysis. The patient has an acutelyinflamed 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
7/27/2019 MECHANICAL DISORDERS OF SWALLOWING.pdf / KUNNAMPALLIL GEJO
13/91
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 spacemay be secondary to primary infection in
the tonsil or pharynx.
KUNNAMPALLIL GEJO JOHN
7/27/2019 MECHANICAL DISORDERS OF SWALLOWING.pdf / KUNNAMPALLIL GEJO
14/91
Clinical presentation of symptoms differs
between anterior and posterior compartments.
When the patient has an anterior compartmentinfection, the patient may present with
dysphagia, trismus, chills, high fever, hardening
and swelling of the mandibular arch, systemictoxicity, medial buldging of the lateral
pharyngeal will, and pain
KUNNAMPALLIL GEJO JOHN
7/27/2019 MECHANICAL DISORDERS OF SWALLOWING.pdf / KUNNAMPALLIL GEJO
15/91
Treatment of lateral pharyngeal space
infections is similar to that of Ludwigs
angina. Therapeutic management includes
antibiotic therapy, surgical drainage, andairway maintenance.
KUNNAMPALLIL GEJO JOHN
7/27/2019 MECHANICAL DISORDERS OF SWALLOWING.pdf / KUNNAMPALLIL GEJO
16/91
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
7/27/2019 MECHANICAL DISORDERS OF SWALLOWING.pdf / KUNNAMPALLIL GEJO
17/91
They are more common in debilitated and
immunosuppressed patients, in those who
are undergoing extensive antibiotic ther-
apy, and in patients receiving irradiationtreatments.
KUNNAMPALLIL GEJO JOHN
7/27/2019 MECHANICAL DISORDERS OF SWALLOWING.pdf / KUNNAMPALLIL GEJO
18/91
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 thecheek lining, some gargles, and anesthetic
throat lozenges when used excessively
KUNNAMPALLIL GEJO JOHN
7/27/2019 MECHANICAL DISORDERS OF SWALLOWING.pdf / KUNNAMPALLIL GEJO
19/91
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 chemotherapycan 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
7/27/2019 MECHANICAL DISORDERS OF SWALLOWING.pdf / KUNNAMPALLIL GEJO
20/91
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 generallydo not create significant swallowing
complaints except when superimposed on
other mechanisms of dysphagia.
KUNNAMPALLIL GEJO JOHN
7/27/2019 MECHANICAL DISORDERS OF SWALLOWING.pdf / KUNNAMPALLIL GEJO
21/91
Examples include trauma from a toothbrush
and mucosal irritation from ill-fitting dentures.
Patients who complain of a poorly fitted denturecan localize their pain.
Clinical examination usually will reveal a
reddened or whitish change in the mucosa atthe point of contact where the patient has the
sensation of most discomfort. Prolonged irri-
tation can result in gingival hyperplasia that
results in soft, sometimes flexible masses of
tissue that appear markedly inflamed.
KUNNAMPALLIL GEJO JOHN
7/27/2019 MECHANICAL DISORDERS OF SWALLOWING.pdf / KUNNAMPALLIL GEJO
22/91
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 beconsidered in the differential diagnosis.
They include macroglossia secondary to
lymphatic obstruction secondary to surgery orirradiation, hypothyroidism, mongolism, amyloid
deposits, and lymphangiomatous or
hemangiomatous processes.KUNNAMPALLIL GEJO JOHN
7/27/2019 MECHANICAL DISORDERS OF SWALLOWING.pdf / KUNNAMPALLIL GEJO
23/91
PHARYNGOESOPHAGEAL
DIVERTICULUM
A pharyngoesophageal diverticulum,
commonly referred to as Zenker's
deverticuIum'in the cervical esophagus, is
an abnormal muscular outpouchingdiverticulum that forms either above the
cricopharyngeus through Killian's
dehiscence or from below throughLaimers triangle.
KUNNAMPALLIL GEJO JOHN
7/27/2019 MECHANICAL DISORDERS OF SWALLOWING.pdf / KUNNAMPALLIL GEJO
24/91
The exact mechanism of pouch formation
is unknown, although in small percentagesit can be associated with esophageal
disease, including traction diverticula,
varices, achalasia, carcinoma, and hiatal
hernia.
KUNNAMPALLIL GEJO JOHN
7/27/2019 MECHANICAL DISORDERS OF SWALLOWING.pdf / KUNNAMPALLIL GEJO
25/91
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. Patientscomplain of regurgitation of undigested
food, foul breath, and fullness in the neck,
weight loss, and nocturnal cough withaspiration.
KUNNAMPALLIL GEJO JOHN
7/27/2019 MECHANICAL DISORDERS OF SWALLOWING.pdf / KUNNAMPALLIL GEJO
26/91
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 areinvolved.
KUNNAMPALLIL GEJO JOHN
7/27/2019 MECHANICAL DISORDERS OF SWALLOWING.pdf / KUNNAMPALLIL GEJO
27/91
STRUCTURAL DISORDERS
KUNNAMPALLIL GEJO JOHN
7/27/2019 MECHANICAL DISORDERS OF SWALLOWING.pdf / KUNNAMPALLIL GEJO
28/91
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 thesolid material ingested is important for
symptom production. Dysphagia is more
likely to occur when solids are tough orfibrous. Softer, more easily chewed foods
are much less likely to cause difficulty.
KUNNAMPALLIL GEJO JOHN
7/27/2019 MECHANICAL DISORDERS OF SWALLOWING.pdf / KUNNAMPALLIL GEJO
29/91
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
7/27/2019 MECHANICAL DISORDERS OF SWALLOWING.pdf / KUNNAMPALLIL GEJO
30/91
Webs are frequently asymmetric, most
often impinging on the esophageal lumen
from the anterior wall.
KUNNAMPALLIL GEJO JOHN
7/27/2019 MECHANICAL DISORDERS OF SWALLOWING.pdf / KUNNAMPALLIL GEJO
31/91
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
7/27/2019 MECHANICAL DISORDERS OF SWALLOWING.pdf / KUNNAMPALLIL GEJO
32/91
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 circularstructure like the esophagus, edema due
to ongoing inflammation and fibrosis part
of the healing process occur at theexpense of luminal diameter
KUNNAMPALLIL GEJO JOHN
7/27/2019 MECHANICAL DISORDERS OF SWALLOWING.pdf / KUNNAMPALLIL GEJO
33/91
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 beadenocarcinomas.
KUNNAMPALLIL GEJO JOHN
7/27/2019 MECHANICAL DISORDERS OF SWALLOWING.pdf / KUNNAMPALLIL GEJO
34/91
Luminal Deformity
KUNNAMPALLIL GEJO JOHN
7/27/2019 MECHANICAL DISORDERS OF SWALLOWING.pdf / KUNNAMPALLIL GEJO
35/91
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 ofthe heart)
KUNNAMPALLIL GEJO JOHN
7/27/2019 MECHANICAL DISORDERS OF SWALLOWING.pdf / KUNNAMPALLIL GEJO
36/91
More pronounced compression can occur
with mediastinal pathology such as aortic
aneurysm, cardiomegaly, congenital
abnormalities of the large mediastinalarteries (e.g. aberrant subclavian artery),
enlarged mediastinal lymph nodes, and
lung cancer.
KUNNAMPALLIL GEJO JOHN
7/27/2019 MECHANICAL DISORDERS OF SWALLOWING.pdf / KUNNAMPALLIL GEJO
37/91
Esophageal Diverticulum
Esophageal diverticula are relatively rare
and most often asymptomatic, even when
they reach relatively large size. When
symptoms do occur, they includedysphagia for liquids and solids and/or
regurgitation of previously swallowed food
back to the mouth
KUNNAMPALLIL GEJO JOHN
7/27/2019 MECHANICAL DISORDERS OF SWALLOWING.pdf / KUNNAMPALLIL GEJO
38/91
Diffuse Esophageal Spasm
Esophageal spasm constitutes the end of
a spectrum of nonspecific esophageal
dysmotility, ranging from the abnormal
contractions seen occasionally in normalindividuals to the repeatedly high-
amplitude, prolonged, symultaneous,
and/or multiphasic contractions in theabsence of any apparent peristaltic activity
KUNNAMPALLIL GEJO JOHN
7/27/2019 MECHANICAL DISORDERS OF SWALLOWING.pdf / KUNNAMPALLIL GEJO
39/91
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 normallyprogressive peristaltic waves (Brand et al.
1977).
KUNNAMPALLIL GEJO JOHN
7/27/2019 MECHANICAL DISORDERS OF SWALLOWING.pdf / KUNNAMPALLIL GEJO
40/91
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 abnormalitiesdetected 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
7/27/2019 MECHANICAL DISORDERS OF SWALLOWING.pdf / KUNNAMPALLIL GEJO
41/91
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 am-plitude and repetitive contractions).
KUNNAMPALLIL GEJO JOHN
ABNORMALITIES OF LOWER
7/27/2019 MECHANICAL DISORDERS OF SWALLOWING.pdf / KUNNAMPALLIL GEJO
42/91
ABNORMALITIES OF LOWERESOPHAGEAL SPHINCTER
FUNCTION
Achalasia- It means failure to relax.
characterized by the degeneration ofneural elements in the wall of the esopha-
gus, particularly at the LES. The distal
segment of the esophagus tapers, givingthe appearance of a "bird's beak
KUNNAMPALLIL GEJO JOHN
7/27/2019 MECHANICAL DISORDERS OF SWALLOWING.pdf / KUNNAMPALLIL GEJO
43/91
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
7/27/2019 MECHANICAL DISORDERS OF SWALLOWING.pdf / KUNNAMPALLIL GEJO
44/91
Although the impairment of LES response
to swallow is key to the functional
obstruction to the flow of food into the
stomach, the motor abnormalitiesachalasia include the complete loss of
progressive peristalsis
KUNNAMPALLIL GEJO JOHN
7/27/2019 MECHANICAL DISORDERS OF SWALLOWING.pdf / KUNNAMPALLIL GEJO
45/91
Curling.
Curlingis an alteration in esophageal
motility frequently seen in elderly
individuals. Curling represents tertiary
contractions, which are nonpropulsive.
KUNNAMPALLIL GEJO JOHN
7/27/2019 MECHANICAL DISORDERS OF SWALLOWING.pdf / KUNNAMPALLIL GEJO
46/91
Diffuse Esophageal Spasm.
Diffuse esophageal spasmis character-
ized 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, withseverity varying from mild to severe
KUNNAMPALLIL GEJO JOHN
7/27/2019 MECHANICAL DISORDERS OF SWALLOWING.pdf / KUNNAMPALLIL GEJO
47/91
Presbyesophagus.
Presbyesophagus describes esophageal
dismotility associated with normal ageing
process. This may include muscular
weakness muscular atrophy.
KUNNAMPALLIL GEJO JOHN
7/27/2019 MECHANICAL DISORDERS OF SWALLOWING.pdf / KUNNAMPALLIL GEJO
48/91
Diverticula.
Diverticula are out pouchings of one or more
layers of esophageal wall. This diverticula
occurs
(1)above the upper esophagealsphincter(Zenkers diverticulum)
(2)near the midpoint of esophagus(t ract ion
diver t icu lum)
(3)above the lower esophageal sphincter
(epiphern ic diver ticu lum).
KUNNAMPALLIL GEJO JOHN
7/27/2019 MECHANICAL DISORDERS OF SWALLOWING.pdf / KUNNAMPALLIL GEJO
49/91
Schatzki ring
It is a lower esophageal mucosal ring
which is located at the level of
squamocolumnar junction
KUNNAMPALLIL GEJO JOHN
G t h l R fl
7/27/2019 MECHANICAL DISORDERS OF SWALLOWING.pdf / KUNNAMPALLIL GEJO
50/91
Gastroesophageal Reflux
DiseaseGastroesophageal reflux disease (GERD)
is defined as the retrograde movement of
gastric contents from the stomach through
the lower esophageal sphincter and intothe esophagus.
KUNNAMPALLIL GEJO JOHN
Persons with GERD frequently complain of
7/27/2019 MECHANICAL DISORDERS OF SWALLOWING.pdf / KUNNAMPALLIL GEJO
51/91
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 numerousextra-esophageal symptoms including
pharyngitis, laryngitis, hoarseness, chronic
cough, asthma, and pt monary aspiration. Acidreflux induced symptoms referable to the
oropharyngeal, laryngeal, and respiratory tracts
are termed atypical reflux.KUNNAMPALLIL GEJO JOHN
7/27/2019 MECHANICAL DISORDERS OF SWALLOWING.pdf / KUNNAMPALLIL GEJO
52/91
The etiology of oropharyngeal
dysphagia, the difficulty in passing
a food bolus from the oropharynxin to the upper esophagus.
KUNNAMPALLIL GEJO JOHN
7/27/2019 MECHANICAL DISORDERS OF SWALLOWING.pdf / KUNNAMPALLIL GEJO
53/91
KUNNAMPALLIL GEJO JOHN
7/27/2019 MECHANICAL DISORDERS OF SWALLOWING.pdf / KUNNAMPALLIL GEJO
54/91
Gastroesophageal reflux occurs through
one of three mechanisms:(1) inappropriate or transient lower
esophageal sphincter relaxation,
(2) increased abdominal pressure orstress-induced reflux, or
(3) incompetent or reduced lower
esophageal sphincter pressures orspontaneous free reflux.
KUNNAMPALLIL GEJO JOHN
7/27/2019 MECHANICAL DISORDERS OF SWALLOWING.pdf / KUNNAMPALLIL GEJO
55/91
Lower esophageal sphincter competence
is the most important barrier to
esophageal reflux. Transient lower
esophageal sphincter relaxations are themost important cause of gastroesophageal
reflux,
KUNNAMPALLIL GEJO JOHN
7/27/2019 MECHANICAL DISORDERS OF SWALLOWING.pdf / KUNNAMPALLIL GEJO
56/91
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% ofpatients with atypical presentations of
GERD
KUNNAMPALLIL GEJO JOHN
7/27/2019 MECHANICAL DISORDERS OF SWALLOWING.pdf / KUNNAMPALLIL GEJO
57/91
MEDICATIONS
The effects of medication are influenced by sex,
age, body size, meta-bolicstatus, individual
biological response, and concurrent use of other
medications. A variety of medications, includingthose obtained over-the counter and those
medically prescribed, affect swallowing, impair-
consciousness, coordination, motor and
sensitivity functions, and the lubrication of theupper aerodigestive tract.ssss
KUNNAMPALLIL GEJO JOHN
7/27/2019 MECHANICAL DISORDERS OF SWALLOWING.pdf / KUNNAMPALLIL GEJO
58/91
Analgesics
Salcylates (aspirin) and nonsteroidal anti-inflammatoryagents cause gyration of the mouth, throat burning,mucosal hemorrhage, glossing and dry mouth.
AntibioticsSide effects such as glossitis, stomatitis, andesophagitis 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 ofweakness.
KUNNAMPALLIL GEJO JOHN
7/27/2019 MECHANICAL DISORDERS OF SWALLOWING.pdf / KUNNAMPALLIL GEJO
59/91
Antituberculous medications such as isonlazid,rifampin, ethambutol, and cycloserine can causeconfusion, disorientation, and dysarthria.
Antiviral agents such as acyclovir, amantadine,
gancyclovir, and vidarabine can indirectly causedysphagia with confusion, asthenia, and lingualfacial dyskinesia. Amantadine can cause severexerosnia and xerophonia in some patients-Zidovudine (AZT) causes tongue de 5% to 10%
of patients. Chloroquine (Plaquenil) can causestomatitis
KUNNAMPALLIL GEJO JOHN
7/27/2019 MECHANICAL DISORDERS OF SWALLOWING.pdf / KUNNAMPALLIL GEJO
60/91
Antituberculous medications such as isonlazid,rifampin, ethambutol, and cycloserine can causeconfusion, disorientation, and dysarthria.
Antiviral agents such as acyclovir, amantadine,
gancyclovir, and vidarabine can indirectly causedysphagia with confusion, asthenia, and lingualfacial dyskinesia. Amantadine can cause severexerosnia and xerophonia in some patients-Zidovudine (AZT) causes tongue de 5% to 10%
of patients. Chloroquine (Plaquenil) can causestomatitis
KUNNAMPALLIL GEJO JOHN
7/27/2019 MECHANICAL DISORDERS OF SWALLOWING.pdf / KUNNAMPALLIL GEJO
61/91
Anti muscarinics, Anti cholinergics, andAntispasmodics
Antimuscarinics and antispasmodics are used for avariety of reasons such as bradycardia, excessive oral
secretions, motion sickness, and diarrhea. They diminishthe production of saliva and mucus. Salivary secretion isparticularly sensitive to inhibition by antimuscarinic
Prokinetic agents improve gut motility and speedgastric emptying. The two major drugs in this category
are metoclopramide (Reglan) and cisapride(Propulsid) 'The former is associated with greaterantihistamine-like side
KUNNAMPALLIL GEJO JOHN
7/27/2019 MECHANICAL DISORDERS OF SWALLOWING.pdf / KUNNAMPALLIL GEJO
62/91
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 onadequate water intake.s
KUNNAMPALLIL GEJO JOHN
7/27/2019 MECHANICAL DISORDERS OF SWALLOWING.pdf / KUNNAMPALLIL GEJO
63/91
Anti hypertensivesAlmost all of the antihypertensives have some degreeof parasympathomimetic effect and thus dry the mucousmembranes. Hydration is the first step to improve
swallowing when taking these medications;Antineoplastics
Antineoplastics affect swallowing mainly through themechanism of inflammation, sloughing, and occasionallycausing superinfection of the aerodigestive tract mucosa.
This effect results in mucositis, stomatitis, pharyngitis,esophagitis, and esophageal ulceration's
KUNNAMPALLIL GEJO JOHN
7/27/2019 MECHANICAL DISORDERS OF SWALLOWING.pdf / KUNNAMPALLIL GEJO
64/91
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 similarstomatitis can result with vitamin E over
dosage.
KUNNAMPALLIL GEJO JOHN
7/27/2019 MECHANICAL DISORDERS OF SWALLOWING.pdf / KUNNAMPALLIL GEJO
65/91
Neurologic MedicationsAnt iconvu lsants . Phenobarbital is a sedative andanticonvulsant with side effects similar to the tricyclicantidepressants: dry mouth, sweating, lwpoteiisioti, andtremor. Phenytoin (Dilantin) adverse effects include centralnervous system signs such as ataxia, slurred speech, incoordination, and dystonia.Carbamazepine (Tegretol) is an anticonvulsant usedprimarily for seizures. Digestive symptoms can also beserious such as glossitis, stomatitis, and dryness of themouth.
(Ant ipark insonians. Levodopa may improve all symptomsof Parkinson 's disease including swallowing, but it can causegastrointestinal discomfort, dyskinesia, and oral dryness
KUNNAMPALLIL GEJO JOHN
7/27/2019 MECHANICAL DISORDERS OF SWALLOWING.pdf / KUNNAMPALLIL GEJO
66/91
Ant ipsychot ics .Antipsychotics primarily work by dopamineantagonism. Commonly used drugs in this class includehaloperidol (Haldol) chlorpromazine (Thorazine),thioridazine (Mellaril), and prochlorperazine (Compazine).These medications can have anticholinergic effects such asdry mouth, nasal congestion, and hypotension. Approximately
14% of patients receiving long-term antipsychotic medicationswill develop tardive dyskinesia ranging from tongue rest-lessness and disabling choreiform and/or athetoid movementsthat lead to significant swallowing and feeding problem
Life-threatening dysphagia can occur after prolongedneuroleptic therapy. Neuroleptic drugs can induceextrapyramidal symptoms such as dystonia, akathisia, andtardive dyskinesia. Contrast radiography has revealed poorcontractions in the upper esophagus, a hypertonicesophageal sphincter, and hypokinesia of the pharyngealmuscles.
KUNNAMPALLIL GEJO JOHN
7/27/2019 MECHANICAL DISORDERS OF SWALLOWING.pdf / KUNNAMPALLIL GEJO
67/91
Anxiolytics. Significant dysphagia can result
from chronic use ofbenzodiazepines. Reported
effects include hypopharyngeal retention,
cricopharyngeal in coordination, aspiration, anddrooling. 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 ofswallowing-)
KUNNAMPALLIL GEJO JOHN
7/27/2019 MECHANICAL DISORDERS OF SWALLOWING.pdf / KUNNAMPALLIL GEJO
68/91
NEOPLASMS
Neoplasia causes distortion, obstruction, reducedmobility, or neuromuscular and sensory dysfunction ofthe upper aerodigestive tract. Exophytic tumorsinterfere with swallowing principally by distorting orobstructing the aerodigestive tract. Tumors with aninfiltrating growth pattern may cause reduced mobility orfixation of the tongue, soft palate, pharynx, or larynx (secTable 3-10). Tumors also affect swallowing by-interferingwith the afferent fibers (sensory input) from the mucosaof the upper aerodigestive tract by invasion and destruc-tion of mucosal nerve endings or sensory nerves such asthe trigeminal (V), glossopharyngeal (IX), and vagus (X)cranial nerves and their branches.
KUNNAMPALLIL GEJO JOHN
7/27/2019 MECHANICAL DISORDERS OF SWALLOWING.pdf / KUNNAMPALLIL GEJO
69/91
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 foodbetween 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 thepharynx and, consequently, aspiration
KUNNAMPALLIL GEJO JOHN
SWALLOWING DISORDERS
7/27/2019 MECHANICAL DISORDERS OF SWALLOWING.pdf / KUNNAMPALLIL GEJO
70/91
ARISING FROM SURGICAL
TREATMENTANTERIOR CERVICAL SPINAL SURGERY,Anterior cervical spinal surgery is a common
surgical approach.
Surgeons approach the spinal cord anteriorlywith 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.
KUNNAMPALLIL GEJO JOHN
7/27/2019 MECHANICAL DISORDERS OF SWALLOWING.pdf / KUNNAMPALLIL GEJO
71/91
Postoperative dysphagia is found in all patientswho 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 stretchtrauma to the recurrent laryngeal nerve,
KUNNAMPALLIL GEJO JOHN
7/27/2019 MECHANICAL DISORDERS OF SWALLOWING.pdf / KUNNAMPALLIL GEJO
72/91
HEAD AND NECK SURGERY
Head and neck surgery for neoplasms of theupper aerodigestive tract alters the anatomy,causes scarring, and may injure motor andsensory nerves. All these factors contribute tothe presence of dysphagia in the postoperativeperiod. In addition, many of these patientsrequire reconstruction with insensate tissueflaps that can contribute to the discoordinationof the swallowing mechanism or can even cause
mechanical obstruction or diversion of the bolusinto the airway. Head and neck surgery mayresult in disruption of any of the phases ofswallowing
KUNNAMPALLIL GEJO JOHN
7/27/2019 MECHANICAL DISORDERS OF SWALLOWING.pdf / KUNNAMPALLIL GEJO
73/91
Skull Base Surgery
Patients undergoing skull base surgery are at risk forinjury to lower cranial nerves, brainstem, brainparenchyma, and soft tissues of the upper aerodigestivetract, depending on tumor location. Injury to these vitalstructures can lead to dysfunction of speech, swallowingand airway protection. In addition to the mentioneddeficits, pal undergoing skull base surgery frequentlyneed reconstruction with insensate soft tissue flaps,which maycompound the deficit due to their bulk. Afterskull base surgery, patients frequently need enteraltubes, prolonged incubation and ventilation, andtracheostonlic, further compound the swallowing deficits.
KUNNAMPALLIL GEJO JOHN
7/27/2019 MECHANICAL DISORDERS OF SWALLOWING.pdf / KUNNAMPALLIL GEJO
74/91
Floor of the Mouth
The floor of the mouth is considered asulcus for saliva and food particles;however, when obliterated by surgery, the
lack of this sulcus and the loss of mobilityof the anterior tongue become majorimpairments during the preparation of thefood bolus. All efforts should be made to
protect the lingual nerve to preserve thesensation to the tongue
KUNNAMPALLIL GEJO JOHN
7/27/2019 MECHANICAL DISORDERS OF SWALLOWING.pdf / KUNNAMPALLIL GEJO
75/91
Partial Glossectomy
Following partial glossectomy, near- normal swallowingand normal speech can be predicted if the patient canprotrude the tongue past the sublabill crease. malldefects of the mobile tongueare repaired primarily. Largedefects often cause the loss of tongue driving force andinability to propel the bolus posteriorly. The bolus is oftenimproperly prepared, and, due to the lack of propercontrol, it may be presented to the oropharynxprematurely. Food and saliva will spill out of the oralcavity because of poor tongue mobility, a problem that isworsened if the oral sphincter has been altered.
KUNNAMPALLIL GEJO JOHN
7/27/2019 MECHANICAL DISORDERS OF SWALLOWING.pdf / KUNNAMPALLIL GEJO
76/91
Palate
Tumers of the hard palate that requre partial or totalmaxilactomy affect both speech and swallowing. Recectionresults in loss of oronasal seperation, which causes leakageof food into the nose and hypernasal speech with decreasedTumors of the hard palate that require partial or totalmaxillectomy affect both speech and swallowing. Resection
results in loss of oronasal separation, intelligibility. Unilateralmaxillectomy is usually best reconstructed with a dentalprosthesis. Free microvascular flaps can be used toreconstruct large palatal defects in edentulous patients inwhom a prosthesis would not be retained.
After soft palate resection, patients often have nasalregurgitation. The reconstruction options are limited, anddefects in the soft palate are best managed by dentate'prostheses with extensions to close the nasopharyngealisthmus.
KUNNAMPALLIL GEJO JOHN
7/27/2019 MECHANICAL DISORDERS OF SWALLOWING.pdf / KUNNAMPALLIL GEJO
77/91
Lips
The orbicularis oris muscle is crucial to the sphinctericfunction of the lips. This muscle is divided during lip-splitting procedures and must be carefullyreapproximated during closure to restore function. Theloss of lower lip sensation secondary to mental nerve
injury makes sphincteric control difficult if not impossible.
Lip resection may hinder swallowing by creating difficultyin getting food into the mouth (microstomia). Motordenervation of the lower lip secondary to sacrifice of the
marginal mandibular nerve.often manifests itself as lossof sphincteric control, resulting in drooling.
KUNNAMPALLIL GEJO JOHN
7/27/2019 MECHANICAL DISORDERS OF SWALLOWING.pdf / KUNNAMPALLIL GEJO
78/91
Oropharynx
KUNNAMPALLIL GEJO JOHN
O h
7/27/2019 MECHANICAL DISORDERS OF SWALLOWING.pdf / KUNNAMPALLIL GEJO
79/91
Oropharynx
Resection of the lateral pharyngeal wall leads todecreased pharyngeal wall mobility, which altersoropharyngeal propulsion. The muscles of the base ofthe tongue assist in elevation of the larynx and areessential for the oropharyngeal propulsion pump and for
adequate oral cavity pharyngeal separation. Althoughpartial resection is well tolerated, large defects oftencause dysphagia. Reconstruction of large defects of thebase of the tongue requires a sensate flap. Resection ofeven limited portions of the soft palate producesvelopharyngeal insufficiency, alters the propulsion of thebolus, and can lead to poor oral-pharyngeal separationwith early spillage of the bolus and aspiration before thepharyngeal swallow is initiated.
KUNNAMPALLIL GEJO JOHN
H h l S
7/27/2019 MECHANICAL DISORDERS OF SWALLOWING.pdf / KUNNAMPALLIL GEJO
80/91
Hypopharyngeal Surgery
Resection of hypopharyngeal tumors arising on theposterior pharyngeal wall poses several problems for therehabilitation of swallowing. Small defects (less than 2 cm)can be closed primarily, or the edges can be stitched to theprevertebral fascia. Reconstruction with a split thickness skingraft or radial forearm free flap provides a satisfactory closure
of larger defects. However, neither one restores the motility ofthe posterior wall, and impairment of pharyngeal contractionleads to significant postoperative aspiration. Patients lose thenormal gliding action of the hypopharynx on the vertebralfascia because of scarring of the posterior hypopharyngealwall to the prevertebral fascia. Also, the reconstruction of this
area, using grafts and flaps, is almost always devoid ofsensation, which further weakens laryngeal protection.
KUNNAMPALLIL GEJO JOHN
A i ti
7/27/2019 MECHANICAL DISORDERS OF SWALLOWING.pdf / KUNNAMPALLIL GEJO
81/91
Aspiration
Aspiration is the entry of material into theairway below ture vocal cords. Aspiration can
occur before, during or after the swallow Pandial
Aspiration pneumonia is a bronchopneumoniaresulting 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 ofaspiration.
KUNNAMPALLIL GEJO JOHN
7/27/2019 MECHANICAL DISORDERS OF SWALLOWING.pdf / KUNNAMPALLIL GEJO
82/91
Prolonged mechanical ventilation: Patientsrequiring 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
7/27/2019 MECHANICAL DISORDERS OF SWALLOWING.pdf / KUNNAMPALLIL GEJO
83/91
Upper-aerod igestive- tract tumors:Most of these patients ex . peri- encesome swallowing difficulty, either from the
mechanical effects of the tumor,itsinterference with the sphinctericmechanism of the larynx, or due to theanatomic and functional changes
produced by surgery, radiation therapy,and chemotherapy
KUNNAMPALLIL GEJO JOHN
A t i Di
7/27/2019 MECHANICAL DISORDERS OF SWALLOWING.pdf / KUNNAMPALLIL GEJO
84/91
Autoimmune Diseases
Auto immune diseases are characterizedby the production of antibodies that react
with host tissue or immune effector T cells
that react to self-peptides. Autoirnmunediseases may affect swallowing by
causing intrinsic obstruction, external
compression, abnormal motility, or inad-equate lubrication.
KUNNAMPALLIL GEJO JOHN
Gi t C ll A t iti
7/27/2019 MECHANICAL DISORDERS OF SWALLOWING.pdf / KUNNAMPALLIL GEJO
85/91
Giant Cell Arteritis
Giant cell arteritis, also known as temporalarteritis, is all inflammatory disorder affectinglarge and medium size vessels. These arteriesthat originate from the arch of the aorta are the
most affected. Pharyngeal, tongue, or jawclaudication Illay occur when the ascendingpharyngeal, lingual, deep temporal, ormasseteric arteries are affected. Systemic cor-
ticosteroids often resolve all symptoms withinone to two weeks.
KUNNAMPALLIL GEJO JOHN
Mixed Connective Tissue
7/27/2019 MECHANICAL DISORDERS OF SWALLOWING.pdf / KUNNAMPALLIL GEJO
86/91
Mixed Connective Tissue
DiseaseMixed connective tissue disease is characterized byclinical findings that may be found in a variety ofautoimmune disorders, including progressive systemicsclerosis, systemic lupus erythematosus, andpolymyositis/dermatomyositis. Similarly, the swallowing
disorders described under each of these disorders canbe a part of mixed connective tissue disease.
Esophageal motility is severely affected, and the majorityof the patients have no peristalsis or low-amplitudeperistalsis contributory to gastroesophageal refluxdisease (GERD). I leartburn all dysphagia are present inup to 501/2 of the patients with mixed connective tissuedisease. The treatment of the GERD may reduce thedysphagia ss
KUNNAMPALLIL GEJO JOHN
M iti
7/27/2019 MECHANICAL DISORDERS OF SWALLOWING.pdf / KUNNAMPALLIL GEJO
87/91
Myositis
Polymyositis and dermatomyositis arecharacterized by inflammation of the skeletalmuscle. Thus, muscles of the pharynx are oftenaffected while esophageal smooth muscle isspared. A modified barium swallow frequentlyshows prominence of the cricopharyngeusmuscle, decreased epiglottis tilt, and moderateto severe pharyngeal residue. Two thirds ofpatients with myosins have demonstrable
delayed esophageal transit. Polymyositis andderniatomyositis are treated with corticosteroids.
KUNNAMPALLIL GEJO JOHN
Rh t id A th iti
7/27/2019 MECHANICAL DISORDERS OF SWALLOWING.pdf / KUNNAMPALLIL GEJO
88/91
Rheumatoid Arthritis
Rheumatoid arthritis (RA) is a chronicrelapsing inflammatory arthritis, usually
affecting multiple diarthrodial joints and
present with a variable degree of systemicinvolvement. Women are more commonly
affected than men, with a ratio of 3:1.
KUNNAMPALLIL GEJO JOHN
7/27/2019 MECHANICAL DISORDERS OF SWALLOWING.pdf / KUNNAMPALLIL GEJO
89/91
Rheumatoid arthritis is associated withxerostomia, temporomandibular joint (TMJ)syndrome, a decrease in the amplitude of theperistaltic pressure complex in the striated partof the esophagus proximal, and cervical spinearthritic disease, all of which cause or contributeto swallowing problems. Rheumatic laryngealinvolvement can result in cricoarytenoid jointfiitioii. 0111cctivc functional testing is necessary
to determine the contributions of the oral phaseand the pha-LI dysphagia vilgeal phase to thesvl,all()iVing disorder
KUNNAMPALLIL GEJO JOHN
S id i
7/27/2019 MECHANICAL DISORDERS OF SWALLOWING.pdf / KUNNAMPALLIL GEJO
90/91
Sarcoidosis
Sarcoidosis is a chronic systemic disorderpresumed to have autoimmunepathogenesis. Sarcoidosis may cause
laryngeal lesion extrinsic compression ofthe esophagus by mediastinal aderiopatl,and esophageal' dysmotility due tomyopathy, infiltration of ALI( bach's plexus,
or granulomatous infiltration of theesophageal wa which may produce longsegments of esophageal stenosi-SD
KUNNAMPALLIL GEJO JOHN
Scleroderma
7/27/2019 MECHANICAL DISORDERS OF SWALLOWING.pdf / KUNNAMPALLIL GEJO
91/91
Scleroderma
Scleroderma, or progressive systemic sclerosis,is a disorder char terized by progressive fibrosisand vascular changes. The most coi mon andthe earliest symptom in people with progressivesysten sclerosis is Raynaud's phenomenon,characterized by pallor a sweating of the fingersor hands that progress to cyanosis and paDysphagia, which is the second most commonsymptom of this dis, der, usually first noticed
while swallowing solid4sphagia is most often due to poor motilitythrough the infer two thirds of the esophagus.
Top Related