Anatomy, Physiology, abnormalities, signs/symptoms, treatment

1. UNIVERSITY OF KANDAHAR
DEC/23/2013
DES BY: K. ALMAAS DES BY: K.W

2. Presenters:
2
1. Kaleemullah
10mins
2. Nisar Ahmad
10mins
Defenders:

3. SWALLOWING / DEGLUTITION

4. 4
Anatomy

5. • Swallowing is a complicated mechanism, because the
pharynx sub serves respiration as well as swallowing.
• (1) a voluntary stage, which initiates the swallowing process;
• (2) a pharyngeal stage, which is involuntary and constitutes
passage of food through the pharynx into the esophagus;
and
• (3) an esophageal stage, another involuntary phase that
transports food from the pharynx to the stomach.
5
Definition and

6. • When the food is ready for swallowing, it is "voluntarily"
squeezed or rolled posteriorly into the pharynx by pressure
of the tongue upward and backward against the palate.
From here on, swallowing becomes entirely-or almost
entirely-automatic and ordinarily cannot be stopped.
6
Stages of Swallowing

7. • As the bolus of food enters the posterior mouth and
pharynx, it stimulates epithelial swallowing receptor areas
all around the opening of the pharynx, especially on the
tonsillar pillars, and impulses from these pass to the brain
stem to initiate a series of automatic pharyngeal muscle
contractions as follows:
• The soft palate is pulled upward to close the posterior nares,
to prevent reflux of food into the nasal cavities.
• The palatopharyngeal folds are pulled medially, form a
sagittal slit for a selective action, allowing only masticated
food which lasts less than 1 second.
7
Stages of Swallowing

8. • The vocal cords of the larynx are strongly approximated,
and the larynx is pulled upward and anteriorly by the neck
muscles. These actions, combined with the presence of
ligaments that prevent upward movement of the epiglottis,
cause the epiglottis to swing backward over the opening of
the larynx.
• This process pulls up and enlarges the opening to the
esophagus. Causing U.E.S/Pharyngoesophageal S.
relaxation; leading food from the posterior pharynx into the
upper esophagus.
8
Stages of Swallowing

9. • Following U.E.S relaxation, the entire muscular wall of the
pharynx contracts, beginning in the superior part of the
pharynx, then spreading downward over the middle and
inferior pharyngeal areas, which propels the food by
peristalsis into the esophagus.
• The entire process occurring in less than 2 seconds.
9
Stages of Swallowing

10. • The motor impulses from the swallowing center to the
pharynx and upper esophagus that cause swallowing are
transmitted successively by the 5th, 9th, 10th, and 12th
cranial nerves and even a few of the superior cervical nerves.
• In summary, the pharyngeal stage of swallowing is
principally a reflex act. It is almost always initiated by
voluntary movement of food into the back of the mouth,
which in turn excites involuntary pharyngeal sensory
receptors to elicit the swallowing reflex.
10
Stages of Swallowing

11. • The entire pharyngeal stage of swallowing usually occurs in
less than 6 seconds, thereby interrupting respiration for
only a fraction of a usual respiratory cycle. The swallowing
center specifically inhibits the respiratory center of the
medulla during this time, halting respiration at any point in
its cycle to allow swallowing to proceed. Yet, even while a
person is talking, swallowing interrupts respiration for such
a short time that it is hardly noticeable.
11
Stages of Swallowing

12. • With its organized movements, conducts food from pharynx
to stomach.
It exhibits two types of peristaltic movements:
•
• Primary peristalsis is the continuation of pharyngeal
muscles’ contraction which takes 5-8 or 8-10 sec,
depending on the position of the person.
• Secondary peristalsis emerges when the first one is failed to
move all of food to the stomach, originated by esophageal
distention initiated partly by intrinsic neural circuits in the
myenteric nervous system and partly by reflexes that begin
in the pharynx and are then transmitted upward through
vagal afferent fibers to the medulla and back again to the
12
Stages of Swallowing

13. • Both upper third striated muscle portion and the lower two
thirds smooth muscles of esophagus are innervated by
vagus, When the vagus nerves to the esophagus are cut, the
myenteric nerve plexus of the esophagus becomes excitable
enough after several days to cause strong secondary
peristaltic waves even without support from the vagal
reflexes. Therefore, even after paralysis of the brain stem
swallowing reflex, food fed by tube or in some other way
into the esophagus still passes readily into the stomach.
13
Stages of Swallowing

14. • When the esophageal peristaltic wave approaches toward the
stomach, a wave of relaxation, transmitted through
myenteric inhibitory neurons, precedes the peristalsis.
Furthermore, the entire stomach and, to a lesser extent,
even the duodenum become relaxed as this wave reaches
the lower end of the esophagus and thus are prepared
ahead of time to receive the food propelled into the
esophagus during the swallowing act.
14
Stages of Swallowing

15. Position and composition:
• This sphincter normally remains tonically constricted with
an intraluminal pressure at this point in the esophagus of
about 30 mm Hg, in contrast to the midportion of the
esophagus, which normally remains relaxed.
• When a peristaltic swallowing wave passes down the
esophagus, there is "receptive relaxation" of the lower
esophageal sphincter ahead of the peristaltic wave, which
allows easy propulsion of the swallowed food into the
stomach. Rarely, the sphincter does not relax
satisfactorily, resulting in a condition called achalasia.
15
Stages of Swallowing

16. • Lower esophageal Sphincter/Pharyngioesophageal
S./Physiologic S.
• Oblique insertion of esophagus into stomach.
• Right crus of diaphragm grasps the lower portion of
esophagus.
• Gastric sling fibers.
• Mucosal rosette of esophageal epithelium.
• Crico-pharyngeal sphincter is the last resort.
16
Reflux Prevention

17. • Lower one eight portion of the esophagus has a similar
epithelial layer as that of stomach and is quite resistant to
reflux, but the rest of esophagus tends to be susceptible to
gastric juices.
• Otherwise, every time we walked, coughed, or breathed
hard, we might expel stomach acid into the esophagus.
17
Reflux Prevention

18. • General: body habitus, mental status, drooling, wheezing,
dyspnea, voice quality
• Cranial nerves
• Inspection of the tongue and palate for
strength/symmetry
• Laryngeal Examination: pooled secretions, vocal fold
movement, interaretynoid area
18
Evaluation

19. • Plain radiography
• Fiberoptic Endoscopic Evaluation of Swallowing (FEES)
• Modified Barium Swallowing Study (MBSS)
o Video-fluoroscopic Swallowing Examination
• Air Contrast Barium Esophagram
• Manometric Investigations
• Bolus Scintigraphy
19
Reflux Prevention

21. DISORDERS OF SWALLOWING / DYSPHAGIA

22. • Mandibular immobility: Trismus, Ankylosis of
Temporomandibular joint
• Lingual immobility: Cancer; XII/soft palatal Paralysis,
cleft lip/palate
• Hyposalivation: Diabetes, Diuretics
• Tonsillar Hypertrophy
• Lingual Cancer
• Nasopharyngeal Isthmus failure
• XII paralysis
• Pharyngeal muscles’ paralysis or Diverticulae 22
Etiology

23. A. Congenital: Short esophagus, Stricture, T.E fistula,
Thymus hypertrophy
B. Acquired:
1. Inflammatory: Acute/Chronic (Erosive) Esophagitis, Hiatal
hernia…
2. Traumatic: Foreign body, Corrosive stricture/poisoning,
Instrumentation
3. Neoplasms
4. Neurological: Myasthenia gravis, Tetanus, Crico-
pharyngeal spasm
5. Mass lesions: Thyroid tumors, Lymphadenopathy,
Cervical spondylitis, Aortic aneurism, Mediastinal Tumor
6. Miscellaneous: Achalasia, Diverticulum, Hysterical,
23
Etiology
Foreign Body
Tracheostomy; the ITT balloon causes esophageal
obstruction
Cervical Spondylitis

24. • Damage to the 5th, 9th, or 10th cerebral nerve can cause
paralysis of significant portions of the swallowing
mechanism. poliomyelitis or encephalitis, can damage the
swallowing center in the brain stem. Paralysis of the
swallowing muscles, as occurs in muscle dystrophy or in
failure of neuromuscular transmission in myasthenia gravis
or botulism, can also prevent normal swallowing.
• When the swallowing mechanism is partially or totally
paralyzed, the abnormalities that can occur include
24
Paralysis

25. • One of the most serious instances of paralysis of the
swallowing mechanism occurs when patients are under deep
anesthesia. Often, while on the operating table, they vomit
large quantities of materials from the stomach into the
pharynx; then, instead of swallowing the materials again,
they simply suck them into the trachea because the
anesthetic has blocked the reflex mechanism of swallowing.
As a result, such patients occasionally choke to death on
their own vomitus.
25
Paralysis

26. • Achalasia is a condition in which the lower esophageal
sphincter fails to relax during swallowing. As a result, food
swallowed into the esophagus then fails to pass from the
esophagus into the stomach. Pathological studies have
shown damage in the neural network of the myenteric
plexus in the lower two thirds of the esophagus. As a result,
the musculature of the lower esophagus remains spastically
contracted, and the myenteric plexus has lost its ability to
transmit a signal to cause "receptive relaxation" of the
gastroesophageal sphincter as food approaches this
sphincter during swallowing.
26
Achalasia

27. • When achalasia becomes severe, the esophagus often
cannot empty the swallowed food into the stomach for many
hours, instead of the few seconds that is the normal time.
Over months and years, the esophagus becomes
tremendously enlarged until it often can hold as much as 1
liter of food, which often becomes putridly infected during
the long periods of esophageal stasis. The infection may
also cause ulceration of the esophageal mucosa, sometimes
leading to severe sub-sternal pain or even rupture and
death. Considerable benefit can be achieved by stretching
the lower end of the esophagus by means of a balloon
inflated on the end of a swallowed esophageal tube.
Antispasmodic drugs (drugs that relax smooth muscle) can
also be helpful.
27
Achalasia

28. • For crico-pharyngeal achalasia, crico-pharyngeal myotomy
is the last solution:
28
Achalasia

29. • Numerous nonpropulsive contractions
• “corkscrew/ rosary bead” esophagus
29
Diff. Esophageal Spasm

30. 30
Eso. Webs and rings

31. 1. Pneumonia
• Risk increases as dysphagia worsens
2. Choking
3. Longer Meal Times
4. Malnutrition
5. Dehydration
6. Weight Loss
7. Quality of Life
• Loss of social interaction associated with eating
31
Complications

32. TREATMENT

33. 1. If coughing/choking, never inhibit cough
2. Heimlich Maneuver
3. Stack breathing
4. Portable suction
5. CoughAssist device
33
What to do?
CoughAssist™
Mechanical In-
Exsufflator

34. 1. Don’t talk with mouth full
2. Repeat swallows
3. Alternate solids and liquids
• One sip at a time
4. Sip straws
5. Smaller bites
6. Slowed rate
7. Supervision and cueing
8. Smaller, more frequent meals per day
34
Safe Swallowing

35. 1. Avoid problem textures and consistencies
2. Gel/powder liquid thickener
1. Steak consistency diet
2. Pot roast consistency diet
3. Meat loaf consistency diet
4. Pudding consistency diet
5. Cream consistency diet (tube feedings)
35
Safe Swallowing

36. 1. Chin tuck
1. Reduce distractions
2. Eat more calories early in the day or when there is less
fatigue
1. Take with applesauce, yogurt, pudding, ice cream, or
any other slippery medium
• Long-necked bottles
• Carbonated beverages
2. Crush with pharmacist’s consent
36
Safe Swallowing

37. • Provides nutrition via an alternate route
• Allows one to receive required nutrition and hydration
when no diet texture can be swallowed safely or when
oral feeding is not meeting nutritional / hydration needs
• Allows for the combination of oral eating for pleasure
and tube feeding for fluids and calories
37
Alternative Methods

38. 38
References

39. Arranged and Designed By: Dr. Kaleemullah (Wardak)