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24
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DYSPHAGIA ASSESSMENT AND TREATMENT PLANNING: A TEAM APPROACH
therefore, receive convergent information from both cortical and peripheral
inputs that trigger swallowing. Finally,
the two hemicentral pattern generators
located in each half of the medulla are
tightly synchronized, and it is thought
that this connection occurs within the
dorsal swallowing group of interneurons (Cunningham & Sawchenko, 2000;
Jean, 2001; Kessler & Jean, 1985).
The interneurons of the ventral
swallowing group are thought to be
“switching” neurons that distribute and
coordinate the swallowing drive to the
various pools of motoneurons involved
in swallowing. The firing behavior of
these neurons also exhibits a sequential pattern, but with more overlap,
longer latency, greater duration variability, and lower frequency than the
interneurons of the dorsal swallowing
group. This type of firing behavior indicates that the connections between the
ventral swallowing group interneurons
and their afferent fibers are likely to be
polysynaptic. The ventral swallowing
group interneurons are probably activated by the interneurons of the dorsal swallowing group. They, in turn,
are connected to all the various groups
of motoneurons involved in swallowing, and within the ventral swallowing
group interneurons, each neuron can
project to more than one motor nucleus.
The trigeminal and hypoglossal motor
nuclei are connected only to the ventral
swallowing group interneurons and
not to the dorsal swallowing group.
Swallowing motoneurons only receive
input from the ipsilateral efferent fibers
of the ventral swallowing interneurons
(Amri et al., 1990; Jean, 2001; Kessler &
Jean, 1985; Larson et al., 1994).
In addition to the interneurons of the
ventral and dorsal swallowing groups,
swallowing interneurons have been
identified within the trigeminal and
hypoglossal motor nuclei, or in close
proximity. They may play the role of
premotor neurons or be involved in the
organization of the swallowing drive
to the various motoneurons involved
in swallowing within a single motor
nucleus. They might also be involved in
the bilateral coordination of the motoneuron pools (Car & Amri, 1987; Jean,
2001; Kessler & Jean, 1985; Ono et al.,
1998).
There is also a population of inter-
neurons, identified more rostrally in the
pons, that fire during the oropharyngeal phase of swallowing. These interneurons have been classified as sensory
relay neurons and are thought to provide information from the oropharyngeal receptors to the higher nervous
centers and may help coordinate swallowing and respiration (Dutschmann &
Dick, 2012; Jean et al., 1994).
In conclusion, the dorsal swallow-
ing group interneurons are involved
in initiating the swallowing sequence.
They stimulate the interneurons of the
ventral swallowing group, which then
modulate and coordinate the stimulation of the various motoneurons
involved in the swallowing sequence
(Bieger, 2001; Roda et al., 2002).
ESOPHAGEAL PHASE
The bolus is transported down the
esophagus into the stomach. The
esophageal phase is quite simple and
consists of a peristaltic wave of contraction that propagates down the esophagus. There is considerable variability in
the speed and strength of the esophageal contractile wave. Once initiated,
1. ANATOMY AND PHYSIOLOGY OF DEGLUTITION
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25
it is not an all-or-none phenomenon
but may dissipate before reaching the
lower esophageal sphincter. Sensory
feedback likely plays a role in regulating the speed and intensity of the
esophageal peristaltic wave, depending on the characteristics of the bolus.
The lower esophageal sphincter is a site
of high pressure, resulting from tonic
contraction of the smooth muscle making up the sphincter. Increased pressure
within the sphincter prevents reflux of
stomach contents into the esophagus.
During swallowing, the lower esophageal sphincter tone is inhibited, relaxing the sphincter for bolus passage into
the stomach (Jean, 2001).
Secondary esophageal peristalsis is
defined as peristalsis without a preceding oropharyngeal phase of swallowing. Secondary peristalsis occurs
in response to stimulation of esophageal sensory receptors by distension
of the esophageal lumen and is otherwise similar in character, with regard
to strength and speed of contraction,
to primary esophageal peristalsis. Tertiary peristalsis of the esophagus refers
to peristalsis of the smooth muscle
portion of the esophagus, unrelated to
extrinsic innervation (Jean, 2001).
The esophageal phase of swallowing
requires both excitatory and inhibitory
input to the muscles of the esophagus.
At rest, the esophagus is electromyographically silent. All of the esophageal motoneurons are strongly inhibited during the oropharyngeal phase
of swallowing, and the contractile wave
of the esophagus during the esophageal
phase is preceded by inhibitory input.
Once the bolus enters the esophagus,
bolus movement involves the coordinated contraction of the smooth and
striated muscles of the esophagus. Con-
traction of esophageal striated muscle
is controlled by the motor nuclei of the
brainstem (nucleus ambiguus) while
smooth muscle contraction is controlled by the autonomic nervous system. Smooth muscle of the esophagus
is innervated by preganglionic fibers
originating in the vagal motor nucleus.
Similar to the muscles of the oropharynx, the muscles of the esophagus are
inhibited and stimulated by motoneurons under the control of interneurons
associated with the swallowing central
pattern generator. They regulate the
esophagus and coordinate the oropharyngeal and esophageal phases of swallowing. It is believed that fewer interneurons are involved in regulating the
esophageal phase of deglutition and
that central control may be more dependent on afferent input than during oropharyngeal swallowing (Jean, 2001).
STUDY QUESTIONS
1. What are the four phases of deglutition? Which are under voluntary
control, and which are primarily involuntary or “reflexive” in
nature?
2. What are the three sphincters in the
upper aerodigestive tract? Which
chambers do they divide? How do
they open and close?
3. What muscles are involved in bolus
propulsion through the pharynx?
4. What sensory nerves are important
in triggering the pharyngeal phase
of swallowing and what areas of
the mucosa do they supply?
5. Describe in general terms what is
known about the central control
of pharyngeal swallowing. What
is the central pattern generator?
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DYSPHAGIA ASSESSMENT AND TREATMENT PLANNING: A TEAM APPROACH
What are the inputs to the central
pattern generator? How does the
central pattern generator control
swallowing?
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constrictor
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the salivatory nucleus
2/3 of the tongue and
parasympathetic fibers to
Sensation from the anterior
pharyngeal mucosa
Sensation to posterior
1/3 of the tongue and
phase of swallowing
and stabilization of tongue
base during transition from the
Bolus preparation (mastication)
Temporalis
Lateral Pterygoid
Medial Pterygoid
Muscles of
Divided Cranial Nerve Chart for Chapter 1
Mastication
preparatory phase to the oral
Masseter
Elevation of the hyoid bone
during the pharyngeal phase of
Mylohyoid
pharyngeal chamber
the tongue base, opening the
swallowing. Pull the larynx under
the Digastric
Anterior Belly of
Muscles
Suprahyoid
3
V
Tenses the soft palate during
elevation against the superior
Palatini
Tensor Veli
Palatal Muscle
Orbicularis Oris Anterior oral sphincter
during preparatory phase
Maintain bolus between teeth
Buccinator
Stylopharyngeus Shorten the pharynx
Muscles
Pharyngeal
Plexus
Pharyngeal
Cranial Nerve Branch Muscle Group Muscles Role During Swallowing Other
Nerve
V, Trigeminal
30
VII, Facial Nerve Facial Muscles
IX,
Nerve
Glossopharyngeal
continues
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Depresses the palate and elevates the tongue base
during the preparatory phase of swallowing: posterior oral
Palatoglossus
cavity sphincter
Elevates the palate against the nasopharyngeal walls during
Palatal
Muscles
the pharyngeal phase of swallowing: sphincter between
Levator Veli
oropharynx and nasopharynx
Palatini
of swallowing
Shorten the pharynx during the pharyngeal phase
Palatopharyngeus
Muscles
Pharyngeal
the nasopharynx
Contracts against the soft palate to close off
Superior
Constrictor
Pharyngeal
bolus from the pharynx
phase of swallowing and is required for clearance of the
Contracts against the tongue base during the pharyngeal
Middle
Constrictor
Pharyngeal
Muscles
Constrictor
Pharyngeal
Contracts against the tongue base to clear bolus from
the pharynx during the pharyngeal phase of swallowing.
Inferior
Pharyngeal
pharyngo-esophageal sphincter.
Confluent with the cricopharyngeus muscle that forms the
Constrictor/
Cricopharyngeus
Cranial Nerve Branch Muscle Group Muscles Role During Swallowing
Plexus
Pharyngeal
X, Vagus Nerve
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Sensation from
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the larynx above
the vocal folds
Sensation from
the larynx below
the vocal folds
and the trachea
esophagus
Elevate the hyoid bone
continued
Cricothyroid
Nerve
Superior
Laryngeal
Thyroarytenoid
Cricoarytenoid
Recurrent
muscles adduct the vocal folds
The cricoarytenoid and thyroarytenoid
Posterior
Inner Arytenoid
Muscles
Laryngeal
Nerve
Laryngeal
preparatory phase, move the bolus
Move and position the bolus during
Cricoarytenoid
and contract against the pharyngeal
into the pharynx during the oral phase,
constrictors to propel the bolus into the
Hyoglossus
Styloglossus
Genioglossus
Tongue
Muscles
Thyrohyoid
Geniohyoid
Elevator
Muscles
Laryngeal
Chart for Chapter 1
Cranial Nerve Branch Muscle Group Muscles Role During Swallowing Other
Nerve
X, Vagus Nerve
XII, Hypoglossal
C1
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History and Physical
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Examination in Dysphagia
Katherine A. Kendall
Dysphagia is the sensation that solids
or liquids are not being swallowed
correctly. A comprehensive dysphagia
evaluation includes determining not
only the cause of dysphagia but also
the dysphagia consequences, including the patient’s nutritional status, food
management, oral care, swallowing
issues, weight fluctuations, and airway
protection.
Possible etiologies of dysphagia include neuromuscular disease involving
the oral and pharyngeal musculature
normally active during swallowing,
altered anatomy (such as occurs after
surgical resections), radiation therapy,
trauma, cervical osteophytes, pharyngeal diverticuli, cricopharyngeal spasm,
foreign bodies, tumors, and mucosal
irritation or injury. Patients at risk for
dysphagia may have an underlying
medical condition that predisposes
them to difficulty swallowing, such as
head or chest trauma, neuromuscular
disease, brain tumor, head and neck
cancer, or stroke. It is more difficult to
identify dysphagic patients with conditions that may not clearly signal dysphagia. Patients with dementia or other
mental debilitation, elderly patients,
and malnourished or deconditioned
patients may fall into this category.
All critically ill patients are at risk for
dysphagia due to altered levels of consciousness and general deconditioning.
Deconditioning leads to weakness of
the musculature involved in both bolus
propulsion and preparation and airway
protection during deglutition. Deconditioned patients lack breath support
and have a poor cough in response to
airway penetration by food or liquid,
making them less able to respond effectively to even mild aspiration. Evidence
of repeated fevers, tachycardia, tachypnea, or pneumonia in a patient
should stimulate concern these symptoms could be related to aspiration.
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