swallowing

Normal Swallowing• Complicated and intricate phenomenon

• Mixture of voluntary and reflex, or automatic, actions

• Total number of swallows per day is about 600:

– 200 while eating and drinking

– 350 while awake without food

– 50 while sleeping

'empty' swallows primarily to the clearance of saliva from

the mouth

Anatomy of swallowing

• 55 muscles of the oropharyngeal, laryngeal, and

esophageal regions

• Five cranial nerves – V, VII, IX, X, XII

• Two cervical nerve roots

• Centers within the central nervous system

Anatomy of swallowing

A. Oral cavity

– Separated from the

pharynx by the

faucial pillars

B. Pharynx

C. Esophagus

Anatomy of swallowing• Laryngeal aditus (upper end of

the larynx) opens into the lower

portion of the pharynx

• Epiglottis

– Originates in the larynx and

is angled upward and

backward

– Attached to the hyoid bone

anteriorly

Hyoid bone

• Mechanical connections to the

cranial base, mandible,

sternum, and thyroid cartilage

via the suprahyoid and

infrahyoid muscles

• Important role in controlling

the movements of the jaw and

tongue.

Anatomy of swallowing

Anatomy of swallowingValleculae

• Space between the

pharyngeal surface of the

tongue and the epiglottis

Pyriform recesses

• Two spaces in the pharynx

lateral to the larynx

Constrictor muscles

• Flattens and contracts the

pharynx in swallowing

Anatomy of swallowing

Cricopharyngeus muscle

•Closes the UES by compressing it against the back of the

cricoid cartilage

Innervation of major muscles related to swallowingCranial nerves Muscles

Trigeminal Nerve (V)

Masticatory muscles

Mylohyoid

Tensor veli palatini

Anterior belly of digastrics

Facial nerve (VII)

Facial muscle

Stylohyoid

Posterior belly of digastrics

Cranial nerves MusclesGlossopharyngeal Nerve (IX) Stylopharyngeus

Vagus nerve (X)

Levator veli palatine

Palatopharyngeous

Salpingopharyngeous

Intrinsic laryngeal muscles

Cricopharyngeus

Pharyngeal constrictors

Innervation of major muscles related to swallowing

Cranial nerves Muscles

Hypoglossal nerve (XII)

Intrinsic tongue muscles

Hyoglossus

Geniohyoid

Genioglossus

Styloglossus

Thyrohyoid

Innervation of major muscles related to swallowing

Sensory afferents

I. Trigeminal

– Teeth and gums, palate and roof of the pharynx

II. Glossopharyngeal

– Posterior third of the tongue, pharynx, area of the

tonsil

III. Vagus

– Pharynx, larynx

Brainstem centers

• Central pattern generators – Dorsomedial &

Ventrolateral

• Mainly involves nucleus of the tractus solitarius and

the nucleus ambiguous

• Programs directing the sequential movements of the

various muscles involved

Brainstem centers

• Activated by

– Descending pathways from the motor cortex

(cortico bulbar tracts)

– Ascending pathways from sensory structures

within the oropharynx and esophagus

Nucleus of the tractus solitarius receives the descending

and peripheral afferent influences

Dorsomedial pattern generator

• Resides in the medial reticular formation of the

rostral medulla and the reticulum adjacent to the

nucleus tractus solitarius

• Initiation and organization of the swallowing

sequence

Ventrolateral pattern generator

• Lies near the nucleus ambiguous and its surrounding

reticular formation

• Serves primarily as a connecting pathway to motor

nuclei such as the nucleus ambiguus and the dorsal

motor nucleus of the vagus, which directly control

motor output to the pharyngeal musculature and

proximal esophagus

Cortical control to brainstem structures

Inferior precentral gyrus

• Cortical representations of tongue and face

• Bilaterally symmetrical activation

Other cortical areas involved in swallowing

Supplementary motor area

• Preparation for volitional swallowing

Anterior cingulate cortex

• Monitoring autonomic and vegetative functions.

Other cortical areas involved in swallowing

Anterior insula, particularly on the right

• Activation during volitional swallowing

• Allows gustatory and other intraoral sensations to

modulate swallowing.

• Lesions increase the swallowing threshold and delay

the pharyngeal phase of swallowing

Other higher centers in swallowing

Cerebellum

• Esp left-sided activation

• Coordination, timing, and sequencing of swallowing

• controls output for the motor nuclei of cranial nerves

V, VII, and XII

Putamen

• Activated during volitional swallowing

Stages of Swallowing

Initiated reflexly when food or liquid stimulates sensory

nerves in the oropharynx

Three distinct stages or phases:

• Oral

• Pharyngeal

• Esophageal

Horizontal subsystem Volitional in character

Vertical subsystem Primarily under reflex control

ORAL PHASE

•  Oral preparatory and oral propulsive stages

• Food bolus is formed and pushed to pharynx

Oral preparatory stageChewing

• Cyclic movement of the jaw coordinated with the

movements of the tongue, cheek, soft palate and hyoid bone

• Food particles are reduced in size and softened by salivation

until the food consistency is optimal for swallowing

• Movements of the jaw and tongue pump air into the nasal

cavity through the pharynx, delivering the food's aroma to

chemoreceptors in the nose

Oral propulsive stage

Overall effect is sweeps or squeezes the bolus towards the fauces to pharynx

Shallow midline gutter in tongue to accommodate bolus

Styloglossi and genioglossi

Emptying of the longitudinal gutter posteriorlyHyoglossus and some intrinsic lingual muscles

Elevation of anterior and mid tongue, hyoid bone and floor of the mouth

Mylohyoid, geniohyoid and stylohyoidRelaxation of the posterior oral seal and a forward movement of the posterior tongue

Palatoglossi.

ORAL PHASE

• Transported food accumulates on the pharyngeal

surface of the tongue and in the valleculae

• Duration of bolus aggregation in the oropharynx

ranges from a fraction of a second to about ten

seconds in normal individuals eating solid food

PHARYNGEAL PHASE

•  Rapid sequential activity, occurring within a second

•  Pharynx changes from being an air channel to food

channel

Two crucial biological features:

1. Food passage

2. Airway protection

Airway protection

Closing the nasopharynx

• Superior Pharyngeal Constrictor + Palatopharyngeal

forming a variable, ridge-like, structure (Passavant's

Ridge) to which the soft palate is elevated.

• Occurs at same time the bolus head comes into the

pharynx

• Prevents bolus regurgitation into the nasal cavity

Airway protection

Closure at lower level

a) Vocal folds close to seal the glottis

b) hyoid bone and larynx are pulled upward and forward

– Tucks the larynx under the base of the tongue

Suprahyoid and Thyrohyoid

c) Epiglottis tilts backward to seal the laryngeal

vestibule

Food passage

• Sequential contraction of three pharyngeal constrictor

muscles

• Driving force which propels the bolus towards the

oesophagus

OESOPHAGEAL PHASE

Involves

• Relaxation of UES

• Propulsion of food bolus to stomach

Relaxation of UES

3 factors

1) Relaxation of the cricopharyngeous muscle

– Precedes arrival of the bolus

2) Contraction of the suprahyoid and thyrohyoid muscles

– Pull the hyo-laryngeal complex forward, opening the

sphincter

– Active opening process

3) Pressure of the descending bolus

UES consists of the inferior pharyngeal constrictor,

cricopharyngeous and most proximal part of the esophagus

OESOPHAGEAL PHASE

Once in the oesophagus, the bolus is propelled by

peristaltic contractions down to the lower

oesophageal sphincter, which opens momentarily to

allow the bolus to enter the stomach

Synchronization of swallowing with respiration

• Breathing ceases briefly during swallowing

– Physical closure by elevation of the soft palate and

tilting of the epiglottis

– Neural suppression of respiration in the brainstem

• Respiratory pause continues for 0.5 to 1.5 s

• Expiration immediately follows a swallow, thus

reducing the risk of aspiration

Dysphagia

• Impaired swallowing can originate from disturbances

in the mouth, pharynx, or esophagus

• Can involve mechanical, musculoskeletal, or

neurogenic mechanisms

Consequences of dysphagia

• Inadequate nutrition

• Dehydration

• Recurrent upper respiratory infections

• Frank aspiration with consequent pneumonia and

even asphyxia

Approach to a case of Dysphagia

Good history will accurately identify the

location and cause of dysphagia in 80%

of cases

• Dysphagia for solid food but

not liquids

• Equal dysphagia for both

solids and liquids

Approach to a case of Dysphagia

Mechanical obstruction

Esophageal dysmotility

Mechanical Dysphagia• Structural abnormalities, both within and adjacent to

the mouth, pharynx, and esophagusOralCongenital abnormalities

Intraoral tumors

Burns

Trauma

Temporomandibular joint

dysfunction

PharyngealCervical anterior

osteophytes

Diphtheria

Thyromegaly

Retropharyngeal abscess

Retropharyngeal tumor

Zenker diverticulum

EsophagealEsophageal carcinoma

Esophageal diverticulum

Esophageal infection:

Esophageal stricture

Esophageal webs or rings

GERD

Thoracic aortic aneurysm

Neurogenic dysphagia

Oropharyngeal

Or

EsophagealPerception of the bolus “sticking” in the neck may

indicate either pharyngeal or esophageal localization

Oropharyngeal source for the dysphagia

• Difficulty initiating swallowing

• Need for repeated attempts to succeed at swallowing

• Presence of nasal regurgitation during swallowing

• Coughing or choking immediately after attempted

swallowing

If Oropharyngeal Phase Dysfunction Suspected

Screening tests:

• Clinical examination

• Cervical auscultation

• 3-oz water swallow

Primary test:

• Modified barium swallow

Complementary tests:

•Pharyngeal videoendoscopy

•Pharyngeal manometry

•Electromyography

•Videomanofluorometry

Oral stage dysfunction

Clinical examination of CN V, VII, XII

Weakness of the buccal or labial muscles

• Food trapped in the buccal or labial sulci (between

the lower teeth and the cheeks or gums, respectively)

Oral stage dysfunction

Tongue dysfunction

• impaired mastication and bolus formation, and bolus

transport

Sensory impairments

• excessive retention of food in the oral cavity after

eating and swallowing

Pharyngeal stage dysfunction

• Clinical examination of CN IX and X

• Cervical ausculatation

Cranial nerve IX

• Examine pain and touch sensation of the pharynx,

tonsilar region and soft palate

• Only muscle with innervation purely from CN IX is

stylopharyngeus

• Only deficit detectable is a slight lowering of the

palatal arch at rest on the involved side.

• Gag reflex

VAGUS NERVE

• With a contribution from the bulbar portion of CN

XI, supplies all the striated muscles of the soft palate,

pharynx, and larynx except for the stylopharyngeus

(CN IX) and tensor veli palatini (CN V)

• Sensory from the pharynx, larynx

CN X lesions

• Speech may have a nasal quality

• Dysphagia more marked for liquids than solids with a

tendency to nasal regurgitation

• Droop of the palate and flattening of the palatal arch

– Preserved tensor veli palatini (CN V) may prevent

marked drooping of the palate

• Gag reflex lost on the involved side

CN X lesions

Vernet's rideau phenomenon

• Due to unilateral weakness of the superior pharyngeal

constrictor

• “curtain movement”, with motion of the pharyngeal

wall toward the nonparalyzed side on testing the gag

reflex or at the beginning of phonation

Gag reflex

• Elicited by touching the lateral oropharynx in the

region of the anterior faucial pillar (pharyngeal

reflex)

• Or by touching one side of the soft palate or uvula

(palatal reflex)

Pharyngeal reflex is the more active of the two

Gag reflex

Three motor components

1) Elevation of the soft palate to seal off the

nasopharynx

2) Closure of the glottis to protect the airway

3) Constriction of the pharynx to prevent entry of the

substance.

Gag reflex

Afferent limb - CN IX

Reflex center - medulla

Efferent limb - CNs IX and X

• Constriction and elevation of the oropharynx

• Midline raphe of the palate and the uvula elevate

• Pharyngeal constrictors contract

Gag reflex

• Unilateral weakness

– Raphe will deviate away from the weak side and

toward the normal side

• May be bilaterally absent in some normal individuals

• Unilateral absence signifies a lower motor neuron

lesion

Significance of gag reflex

• Poor gag reflex in an awake patient with an acute

deficit may be a predictor of swallowing difficulties

Useful but limited in assessing airway protection

• Patients with an apparently intact gag reflex may still

aspirate

• Absent in ~ 37% of normals - low predictive value in

the assessment of aspiration risk

Cervical auscultation

• Assess coordination between respiration and

swallowing

• In the normal situation, swallowing occurs during

exhalation

• Discoordinated swallowing in the midst of inhalation

increases aspiration possibility

Standardized 3 oz water swallow test

• Simple bedside evaluation for oropharyngeal dysphagia.

• Presence of cough on swallowing

– Positive predictive value of 84% with regard to the

presence of aspiration

– Negative predictive value of 78%.

• After the swallow, observe the patient for 1 minute or

more to see if a delayed cough response is present

Dysphagia limit

• Normal subjects can swallow a 20-ml bolus of water

in a single attempt

• With dysphagia must divide the bolus into two or

more parts in order to complete the swallow

Dysphagia limit

• Individuals are administered stepwise increases in

bolus volume, the volume of fluid at which the

division of the bolus first occurs is labeled the

dysphagia limit

Dysphagia limit of less than 20 ml as abnormal and

indicative of dysphagia

Modified barium swallow test

• Swallowing barium impregnated food of differing

consistencies (thin liquid, pudding, cookie)

• Observed via videofluoroscopy

Modified barium swallow test

• Oral and pharyngeal function can be characterized

• Presence of aspiration accurately documented

• Response to corrective measures such as positioning

techniques can also be evaluated

• Increasing bolus viscosity typically improves

swallowing function in individuals with neurogenic

dysphagia

Laryngeal penetration

• passage of the food into the larynx but

above the vocal folds

• sometimes observed in normal

individuals

Aspiration

• passage of material through the vocal

folds

Modified barium swallow test

Videoendoscopy of the pharynx

• Via the nasal passageway

• Allows direct visualization of the pharyngeal

component of swallowing before and after passage of

the food bolus

• Primary value is to demonstrate the presence of

residual material in the pharynx after a swallow,

indicative of increased risk of aspiration

Swallowing Electromyography

• Mechanical upward-downward movement of the

larynx is detected by using a piezoelectric sensor

while submental integrated electromyography (EMG)

activity is recorded during dry and wet swallowing

• EMG activity of the cricopharyngeal muscle also can

be recorded.

Swallowing Electromyography• In muscular disorders, laryngeal elevators are involved,

whereas the cricopharyngeal sphincter is intact

• In pyramidal lesions, discoordination between paretic

laryngeal elevators and the hyperreflexic cricopharyngeal

sphincter is present.

EMG can be used for muscle selection and for performing

injections of botulinum toxin in patients with dysphagia

Esophageal dysfunction

• Sensation of food “hanging up” in a retrosternal

location

• Main concern with esophageal dysphagia is to

exclude malignancy

Malignancy is likely if there is:

• Short duration (< 4 months)

• Disease progression

• Dysphagia more for solids than for liquids

• Weight loss

Esophageal dysfunction

If Esophageal Dysfunction Suspected:

Primary tests:

• Videofluoroscopy

• Endoscopy

Complementary test:

• Esophageal manometry

Oculopharyngeal Muscular Dystrophy

• Rare autosomal dominant disorder

• GCG trinucleotide repeat on chromosome 14

• First appearing between ages 40 and 60

• Slowly progressive ptosis, dysphagia, and proximal

limb weakness

• Evolves slowly over many years

Oculopharyngeal Muscular Dystrophy

• Dysphagia due to impaired function of the

oropharyngeal musculature

• No specific treatment

• Cricopharyngeal myotomy affords relief in over 80%

• Botulinum toxin injections have been successfully

used

Myotonic Dystrophy

• autosomal dominant disorder

• cardiac, ophthalmological, and endocrinological

involvement

• Subjective dysphagia in 37% to 56% of patients

• Objective measures demonstrating disturbances in

swallowing in 70% to 80%

Myotonic Dystrophy• Dysphagia due to

– Abnormal cricopharyngeal muscle activity is present

in 40%

– Impaired esophageal peristalsis

– incomplete relaxation of the UES and esophageal

hypotonia

Both muscle weakness and myotonia play a role in the

development of dysphagia

Inflammatory Myopathies

• Dysphagia more frequently is present in

dermatomyositis and when present is more severe

• Indicator of poor prognosis

Dysphagia in inclusion body myositis

• May even be the presenting symptom

• In late stages of the disorder, the frequency exceed

that seen in dermatomyositis and polymyositis

Inflammatory Myopathies

Treatment

• May respond to corticosteroids and other

immunosuppressive drugs

Unresponsive to steroids

• IVIG therapy has produced dramatic improvement

Inclusion-body myositis

• Typically responds poorly

• Myotomy is often necessary

Mitochondrial Disorders

Dysphagia due to

• Severe abnormalities of pharyngeal and upper-

esophageal peristalsis

• Cricopharyngeal dysfunction

• Impaired deglutitive coordination

Myasthenia Gravis

• In ~ 6% to 30%, bulbar involvement is evident from

the beginning

• with disease progression, most eventually develop

• major precipitant of myasthenic crisis in 56% of

patients

• Bedside speech pathology assessment is not a reliable

predictor of aspiration

Myasthenia Gravis

Dysphagia due to

Dysfunction at oral, pharyngeal, or even esophageal levels

• Oral phase involvement due to fatigue and weakness of

the tongue or masticatory muscles

• Decreased amplitude and prolongation of the peristaltic

wave in esophagus

• Cricopharyngeal sphincter pressure reduced

Stroke• Dysphagia in 45% to 57%

• Aspiration in

– 30% to 55% of stroke patients

– 36% of patients with unilateral cerebral stroke

– 46% with bilateral cerebral stroke

– brainstem strokes - more than 80%

Associated with increased likelihood of severe disability or

death

Warning signs of post-stroke dysphagia

• Drooling

• Excessive tongue movement

• Spitting food out of the mouth

• Poor tongue control

• Pocketing of food in the mouth

• Facial weakness

• Slurred speech

• Coughing or choking when eating

Warning signs of post-stroke dysphagia

• Regurgitation of food through the nose

• Wet or “gurgly” voice after eating

• Hoarse or breathy voice

• Complaints of food sticking in the throat

• Absence or delay of laryngeal elevation

• Prolonged chewing

• Prolonged time to eat or reluctance to eat

• Recurrent pneumonia

Dysphagia and site of stroke

Brainstem infarction

• Pharyngeal phase is primarily impaired

Hemispheric strokes

• Delay in initiation of voluntary swallowing

• Bilateral hemispheric damage is more likely to

produce dysphagia

Can also occur in the setting of unilateral damage

Right hemisphere

• More impairment of pharyngeal motility

Left hemisphere

• Greater effect on oral stage function

Dysphagia and site of stroke

Subcortical strokes

• higher incidence of dysphagia and aspiration than

those with cortical damage

• delayed initiation of the pharyngeal stage of

swallowing

Dysphagia and site of stroke

Foix- Chavany-Marie syndrome (anterior operculum

syndrome)

• Bilateral infarction of the frontoparietal operculum

• inability to perform voluntary movements of the face,

jaw, tongue, and pharynx but fully preserved

involuntary movements of the same muscles

• Impairment of volitional swallowing

Dysphagia and site of stroke

Tongue deviation & dysphagia

• Classically associated with medullary lesions

damaging the hypoglossal nucleus

• In almost 30% of persons with hemispheric

infarctions

• Dysphagia is present in 43% of affected patients

Stepwise assessment of swallowing in stroke patients

• Modified swallowing assessment on the day of admission

• Clinical swallowing examination performed within 72 hours

• Performance of flexible transnasal swallowing endoscopy

within 5 days

• Appropriate diet and treatment determined after each step

• Significant reduction in the rate of pneumonia and in

antibiotic consumption (ickenstein et al., 2010)

Prognosis

• Swallowing often improves spontaneously in the days

and weeks after stroke

• more likely to occur after cortical strokes, compared

with those of brainstem origin

Dysphagia in other cerebrovascular processes

• Carotid artery aneurysms

• Elongation and dilatation of the basilar artery

• Posterior inferior cerebellar artery aneurysm

• Intracranial vertebral artery dissections

• Giant dissecting vertebrobasilar aneurysms

Dysphagia in Multiple Sclerosis• Frequent but often overlooked (24% to 34% )

• Prevalence rises with increasing disability

• Individuals with severe brainstem involvement as part of

their MS are especially likely to experience dysphagia.

Mild disability

• Abnormalities in the oral phase of swallowing

More severe disability

• Additional pharyngeal phase abnormalities develop

Dysphagia in Parkinson Disease• Frequent phenomenon - 30% to 82%

• More likely to swallow during inspiration and also to

inhale post swallow

• Both increase the risk of aspiration

Oral phase

• Difficulty with bolus formation

• Delayed initiation of swallowing

• Repeated tongue pumping, and other abnormalities

Dysphagia in Parkinson DiseasePharyngeal phase

• Pharyngeal dysmotility and impaired relaxation of the

cricopharyngeal muscle

Esophageal phase

• Slowed esophageal transit

• Both segmental and diffuse esophageal spasm

• Ineffective or tertiary contractions, and even aperistalsis

• Lower-esophageal sphincter dysfunction - reflux as well as

dysphagia.

Dysphagia in Parkinson Disease

Management

• Inconsistent response to levodopa or dopamine agonist

therapy

• Cricopharyngeal muscle dysfunction - cricopharyngeal

myotomy and botulinum toxin injections

• Behavioral swallowing therapy

• PEG tube placement rarely necessary

Other Basal Ganglia Disorders

Parkinsonism-plus syndromes- PSP, MSA, CBD,

DLB

• Dysphagia is a frequent problem

• Develops relatively early in the course of the illness

Appearance of dysphagia within 1 year of symptom

onset virtually eliminates PD as a diagnostic

possibility

Amyotrophic Lateral Sclerosis

• Dysphagia eventually develops in most individuals

• Presenting feature in approximately 25%

• Sensation of solid food sticking in the esophagus may

provide the initial clue to emerging dysphagia

Amyotrophic Lateral Sclerosis• Impaired function of the lips and tongue (particularly the

posterior portion of the tongue) due to evolving muscle

weakness typically appears first

• Next involvement of jaw and suprahyoid musculature

• Finally weakness of pharyngeal and laryngeal muscles

• Delay in, and eventual abolishment of, triggering of the

swallowing reflex for voluntarily initiated swallows, with

relative preservation of spontaneous reflexive swallows until

the terminal stages of the disease

Cranial Neuropathies• Extramedullary, intracranial involvement in processes involving the

meninges, extramedullary tumors, aneurysms, and skull fractures

• Lesions at the jugular foramen or in the retroparotid space - some

combination of IX, X, XI, XII, and the cervical sympathetic

• Prominent in the miller fisher variant of AIDP

• Herpes zoster infection - attributed to cranial ganglionic

involvement

• Charcot-marie-tooth disease

Nuclear lesions

• Brain stem stroke and MS

• Brainstem tumors, both primary and metastatic,

• Central pontine myelinolysis

• Progressive multifocal leukoencephalopathy

• Leukoencephalopathy due to cyclosporin toxicity

• Brainstem encephalitis – Listeria and Epstein-barr

Virus

Cervical Spinal Cord lesions

• Especially if associated with respiratory insufficiency

• With higher spinal cord injury

• With treatment and time, most patients demonstrate

improvement

Management of dysphagia

• Dietary modification

• Exercises

• Facilitation techniques

• Compensatory mechanisms

• Enteral feeding

• Surgical methods

• Botulinum toxin therapy

Dietary Modification• Difficulties with the oral preparatory phase

– Diet of pureed foods

• As patients' swallowing function improves

– Soft and semisolid foods with regular consistencies

• Recommend to patients that they alternate bites with

sips, bite or sip size, and the number of swallows per

size

• Good oral hygiene and dental care

Viscosity and texture of food

Oropharyngeal neurogenic dysphagia

• Thickened liquids

– Liquids can be thickened with starch-based food

thickeners

Difficulties with mastication

• Chopped or pureed foods

Uniform and viscous bolus of food or beverage - less risk

of aspirating

Exercises

Indirect

– Strengthen swallowing muscles

Direct

– Performed while swallowing

• Designed to facilitate oral motor strength, range of

motion (ROM), and coordination

• Usually are performed 5-10 times per day

Lip exercises

• facilitate the patient's ability to prevent food or liquid from

leaking out of the oral cavity

Tongue exercises

• facilitate manipulation of the bolus and its propulsion through

the oral cavity or to facilitate retraction of the tongue base

Jaw exercises

• facilitate the rotatory movements of mastication

Exercises

Respiratory exercises

• improve respiratory strength

Vocal cord adduction exercises

• promote strengthening of weak vocal cords.

Exercises

Head-lift (Shaker) exercise

• to increase anterior movement of the hyolaryngeal

complex and opening of the upper esophageal

sphincter

• lie flat and with shoulders on the floor and raise their

head high enough to see their toes, maintaining this

position for 1 minute

Exercises

Facilitation techniques

Somatosensory stimulation (electrical

current )applied to the pharynx

• Change the excitability of the corticobulbar projection

• Induce cortical reorganization in patients with

poststroke dysphagia

Repetitive transcranial magnetic stimulation (RTMS)

Facilitation techniques

Deep pharyngeal neuromuscular stimulation (DPNS)

• To improve pharyngeal swallow

• On stimulating 3 reflex sites

1) Bitter taste buds and tongue base -improve tongue-base

retraction

2) Soft palate - improve palatal elevation

3) Superior and medial pharyngeal constrictor - improve

pharyngeal peristalsis and cricopharyngeal opening

Compensatory Techniques

Chin-tuck position

• decreases the space between the base of the tongue

and the posterior pharyngeal wall

• creating increased pharyngeal pressure to move the

bolus through the pharyngeal region

Compensatory Techniques

Rotation of the head to the affected side

• closes the pyriform sinus on the affected side and

directs food down the opposite or stronger side

• also adds external pressure on the damaged vocal

cord and moves it toward the midline, improving

airway closure.

Compensatory Techniques

Tilting the head to the strong side

• bolus tends to be directed down the stronger side in

the oral cavity and in the pharynx

• effective for patients who have unilateral tongue

dysfunction or a unilateral pharyngeal disorder.

Compensatory Techniques

Supraglottic swallow

• Close the airway voluntarily before and during the

swallow

• Take a deep breath and hold your breath

• Keep holding your breath while you swallow

• Cough immediately after the swallow

Compensatory Techniques

Mendelsohn maneuver

• mimics the upward movement of the larynx

voluntarily

• increase the duration of the cricopharyngeal opening

Enteral Feeding

• Unable to achieve adequate alimentation and

hydration by mouth

• Impaired level of consciousness, massive aspiration,

silent aspiration, esophageal obstruction, or recurrent

respiratory infections

Enteral Feeding

Nasogastric tube feeding

• In post stroke dysphagia temporarily provide

adequate nutrition and buy time until swallowing

improves

• prolonged use can lead to lesions to the nasal wing,

chronic sinusitis, gastroesophageal reflux, and

aspiration pneumonia

Enteral Feeding

Percutaneous endoscopic gastrostomy

Oroesophageal tube feeding

• patient is taught to insert the 14F urethral tube into the

mouth and past the side of the tongue, pushing slowly

until the catheter end reaches the lips

• Food supplements and liquid are administered by

means of a 500-mL syringe at a rate of approximately

50 mL/min

Other methods

Cricopharyngeal Myotomy

• to decrease pressure on the pharyngoesophageal

sphincter

Botulinum toxin injection into the UES

Thank you