III. Abnormal Swallowing

1
III. Abnormal Swallowing

• Etiology and Conditions Adults

2
Neurological Disorders

• Neurologic disorders affecting swallowing can be
  categorized in many different ways
• by the anatomic site of the lesion, such as the
  central or peripheral nervous system
• by the pathologic process, such as ischemia and
  degeneration
• by the underlying etiology or
• by the clinical presentation such as dementia and
  movement disorders.

3
Disorders of the Central Nervous System (CNS)

• Disorders of the CNS can be nondegenerative or
  degenerative.
• Nondegeneratative disorders of the CNS are
  outlined in Table 1 and include vascular,
  traumatic, neoplastic, congenital, and iatrogenic
  etiologies.

4
Table 1 Nondegenerative Disorders Affecting
Swallow
5
Disorders of the Central Nervous System (CNS)

• Based on clinical progression, degenerative
  disorders may be subclassified into progressive
  and relapsing disorders.
• Progressive degenerative disorders may be further
  subclassified based on their salient clinical
  characteristic into dementias and movement
  disorders (see Table 2).
• In contrast to the CNS, most of the peripheral
  nervous system disorders that impact swallowing
  are degenerative in nature.

6
Table 2 Degenerative Disorders Affecting Swallow
7
Epidemiology of Dysphagia in CNS Disorders

• It is estimated that 400,000 to 800,000
  individuals worldwide develop neurogenic
  dysphagia per year.
• The reported incidence of dysphagia in specific
  neurologic diseases is variable, owing in part to
  patient selection methods (e.g., consecutive
  patients, case series) and evaluation methods
  (e.g., questionnaire, clinical evaluation,
  diagnostic evaluation).

8
Epidemiology of Dysphagia in CNS Disorders

• Determination of dysphagia based on patient
  complaint or clinical swallowing evaluation
  generally underestimates the incidence.
• It is generally agreed that stroke is the most
  common cause of neurogenic dysphagia.
• Dysphagia, as identified by VFSS, occurs in
  approximately 65 of acute stroke patients, with
  the incidence of aspiration ranging from 43 to
  58

9
Table 3. Prevalence of dysphagia for specific
neurologic diseases
10
Stroke

• Stroke affects 2000 people per million worldwide
  each year and approximately 700,000 individuals
  in the United States annually.
• 80 of strokes are secondary to ischemia, whereas
  hemorrhage accounts for 20.
• Neurologic symptoms of stroke vary depending on
  the specific location of stroke.

11
Stroke

• With a supratentorial infarct, symptoms may
  include ipsilesional hemiparesis, dysarthria,
  aphasia, and hemispatial neglect.
• With a lateral medullary infarct, neurologic
  presentation may include ataxia, reduced
  ipsilesional limb pain and temperature sensation,
  reduced contralesional pain and sensation of the
  trunk and limbs, and ipsilesional velar,
  pharyngeal, and laryngeal paralysis.

12
Stroke

• Prevalence reports of dysphagia following stroke
  depend on when in the course of recovery the
  detection of a swallowing impairment was made.
• In patients with acute stroke (less than 5 days
  after onset), the prevalence of dysphagia is as
  high as 50.
• Two weeks after stroke the prevalence may be only
  10 - 28

13
Stroke

• Swallowing abnormalities in stroke are variable
  and may include
• oral lateral sulci retention
• delayed oral transfer
• delayed elicitation of a pharyngeal swallow
• decreased hyolaryngeal elevation, and
• aspiration.

14
Traumatic Brain Injury (TBI)

• Dysphagia following TBI is common.
• Dysphagia from TBI dependd on the brain region
  involved.
• Brain injury resulting from trauma is generally
  more diffuse than that following stroke, and
  cognitive impairments are often prominent
  depending on the site and severity of injury.

15
Traumatic Brain Injury (TBI)

• The secondary effects of head injury on cortical
  and respiratory function may necessitate
  tracheostomy with or without ventilation, which
  interfere with swallow ability.
• Patients who are semicomatose cannot concentrate
  or cooperate during attempts at feeding.

16
Traumatic Brain Injury (TBI)

• Prevalence data for patients who survive head
  injury and enter a rehabilitation setting vary.
• Lazarus and Logemann (1987) found that
  approximately 45 of patients admitted to rehab
  during a nine-month period had signs of
  dysphagia.
• Winstein (1983) found that 33 were dysphagic
  upon admission and that only 6 were dysphagic
  after five months of rehab.

17
Brain Tumor

• As with stroke and TBI, brain tumors may result
  in dysphagia depending on which brain region is
  involved.
• Pathologically, brain tumors may be benign or
  malignant.
• However, their space-occupying nature can result
  in significant neurologic dysfunction.
• Swallowing may be affected by infiltration of the
  tumor into brain regions important in
  deglutition.

18
Brain Tumor

• In addition, the treatment modalities for the
  tumor including surgery and radiation therapy may
  affect swallowing.
• Unlike the dysphagia resulting from stroke or
  TBI, swallowing disorders secondary to a brain
  tumor may be progressive as the tumor invasion
  increases.

19
IatrogenicMedication Induced

• Any drug capable of causing extrapyramidal side
  effects (EPS) and tardive dyskinesia (TD) is by
  definition a neuroleptic (Latin for seize the
  neuron).
• EPS, especially TD, can occur in up to 20 of
  patients receiving neuroleptics.
• Neurologic symptoms include repetitive movement
  of the lower face, lips, and tongue
  (orobuccolingual dyskinesia), and movement of the
  trunk and pelvis.

20
IatrogenicMedication Induced

• Neuroleptics are a class of drugs which includes
  anti-psychotics used for schizophrenia
• phenothaizines
• prochlorperazine
• perphenazine,
• chlorpromazine
• anti-emetics
• domperidone
• thiethylperazine maleate
• trimethobenzamide

21
IatrogenicMedication Induced

• anti-spasmodics
• hycosamine sulfate
• baclofen
• and the prokinetic medications commonly used in
  gastroenterology
• metaclopramide (Reglan)
• cisapride (Propulsid)
• ranitidine (Zantac)
• rabeprazole (AcipHex)

22
IatrogenicMedication Induced

• Symptoms suggestive of EPS or isolated reports of
  movement disorders are associated with
  medications used to treat irritable bowel
  syndrome (scopolamine), ulcerative colitus
  (olsalazine, mesalamine, and cimetidine),
  inflammatory bowel disease (balsalazide
  disodium), and GERD (esomeprazole, omeprazole and
  pantoprazole.

23
IatrogenicMedication Induced

• These medications are capable of causing
  potentially permanent side effects which may
  range from dramatic and debilitating to very
  subtle.
• Symptoms may be reversible if identified early
  and the medication changed to newer medications
  which do not produce these symptoms.

24
Iatrogenic--Surgery Induced

• Surgery involving the neck, such as cervical
  spine surgery and carotid endarterectomy, may
  produce dysphagia generally owing to manipulation
  of cranial nerves.
• The anterior approach frequently used with
  cervical fusion results in dysphagia more
  frequently than a posterior approach.
• Dysphagia, which often co-occurs with
  postoperative dysphonia, results from retraction
  and stretch injury of cranial nerves.

25
Iatrogenic--Surgery Induced

• Generally damage to the pharyngeal plexus may
  occur with anterior cervical fusion.
• Injury of the VII, X, and XII cranial nerves may
  occur with carotid endarterectomy, as these
  nerves are close to the carotid bifurcation.
• Postoperative edema may also contribute to the
  dysphagia.

26
DegenerativeProgressive Course with Dementia

• Dementia is characterized by a decline in one or
  more major cognitive domains accompanied by
  impairment in memory.
• There are multiple causes of dementia.
• Patients with dementia not only have problems
  with swallowing but also with feeding.
• They may have limb apraxia affecting their
  ability to use eating utensils or an agnosia that
  affects their ability to recognize and accept
  food.

27
DegenerativeProgressive Course with Dementia

• Deficits in transfer of the bolus in the oral
  cavity are also prominent.
• Because of the progressive nature of these
  disease processes, one is never certain at what
  point in the progression the dysphagic symptoms
  occur.
• Some patients complain of dysphagia as the
  initial symptom of the disease, whereas others
  may never complain of dysphagia.
• In general, as disease severity increases, so
  does dysphagia.

28
Alzheimers Disease

• Alzheimer's disease (AD) is the most common type
  of dementia.
• Neuritic plaques and neurofibrillary tangles are
  the neuropathologic hallmarks of AD and result in
  severe brain atrophy with widened sulci and gyri
  shrinkage.
• Initial symptoms include decreased recent memory
  and anomia.
• As the disease progresses, symptoms include
  inability to complete activities of daily living,
  agitation, and mutism.

29
Frontotemporal Dementia

• Frontotemporal dementia (FTD) is associated with
  severe atrophy of the frontal and temporal lobes
  with prominent changes in behavior.
• As with AD, the occurrence of FTD is primarily
  sporadic, but familial occurrence due primarily
  to the tau gene mutation is also evident.
• FTD may co-occur also with amyotrophic lateral
  sclerosis.

30
Frontotemporal Dementia

• Symptoms of FTD include
• personality changes
• mental rigidity
• decreased language
• stereotyped behavior
• hyperorality
• decreased ability to perform ADLs.

31
Lewy Body Dementia

• Lewy body dementia, like AD and FTD, is typically
  sporadic but may also be familial.
• Many patients with Lewy body dementia have
  first-degree relatives with Parkinson's disease
  or dementia.
• Neurologic characteristics include fluctuating
  cognitive ability, visual hallucinations,
  spontaneous parkinsonism, sleep disturbance, and
  reduced ability to perform activities of daily
  living.

32
Vascular Dementia (VD)

• Vascular dementia may result from multiple
  cortical or lacunar infarcts, a single
  strategically placed infarct, or microvascular
  disease.
• Characteristics include a slow, stepwise, and
  fluctuating progression with memory frequently
  mildly affected.
• Dysfunction in executive control is evident early
  and is characterized by disorganized thought,
  behavior, and emotion.
• Gait is frequently disturbed.

33
DegenerativeProgressive Course with Movement
Disorders

• Movement disorders constitute a group of
  degenerative metabolic disorders of the CNS
  involving the extrapyramidal and cerebellar
  pathways, which are characterized by disordered
  movement that allows for their easy clinical
  recognition.
• These progressive neurological diseases commonly
  give rise to dysphagia as well.

34
DegenerativeProgressive Course with Movement
Disorders

• Such disorders include Parkinsons disease (PD)
  and its variants progressive supranuclear palsy
  (PSP) amyotrophic lateral sclerosis (ALS)
  Huntingtons disease (HD) multiple sclerosis
  (MS) myasthenia gravis (MG) and systemic
  rheumatic diseases, such as dermatomyositis,
  polymyositis, rheumatoid arthritis, scleroderma,
  and Sjogrens syndrome.

35
Parkinsons Disease (PD)

• Parkinson's disease (PD) is the most prevalent of
  the movement disorders.
• It is a degenerative disorder involving
  dopaminergic neuronal loss in the striatal tract
  of the basal ganglia.
• Onset of PD typically occurs between the ages of
  55 and 65.
• Onset and progression of symptoms is gradual and
  initially asymmetric.

36
Parkinsons Disease (PD)

• Neurologic symptoms initially include resting
  tremor, bradykinesia, and rigidity.
• As the disease progresses, symptoms may include
  autonomic disturbances and cognitive and
  behavioral changes.
• Dysphagia occurs in about 50 of those
  individuals with PD.
• The prevalence of dysphagia is probably higher in
  those patients with PD who also have significant
  dementia.

37
Parkinsons Disease (PD)

• Common dysphagic manifestations include
• Abnormal lingual peristalsis
• Reduced pharyngeal peristalsis
• Delayed swallow response and
• CP dysfunction.

38
Progressive Supranuclear Palsy

• Progressive supranuclear palsy (PSP) is a rare,
  generally sporadic, rapidly progressive disease
  involving the basal ganglia, frontal lobes,
  midbrain, and brainstem.
• Onset typically occurs between the ages of 50 and
  60 years.
• Symptoms include vertical ophthalmoplegia, axial
  rigidity, pseudobulbar palsy, and dementia.

39
Olivopontocerebellar (OPC) Atrophy

• Olivopontocerebellar atrophy is one of a group of
  degenerative diseases involving multiple system
  atrophy, with atrophy concentrated in the
  cerebellum, pons, and inferior olivary nuclei.
• The variants of OPC atrophy include genetic
  (autosomal dominant and recessive) and sporadic
  forms.
• Onset of OPC atrophy occurs generally within the
  sixth decade.
• Neurologic symptoms include gait disturbance,
  dysarthria, dysphonia, and dysphagia.

40
Huntingtons Disease (HD)

• Huntington's disease (HD) is a hereditary
  degenerative autosomal dominant disease.
• It involves a preferential loss of ?-aminobutyric
  acid (GABAergic) neurons, yielding diffuse
  atrophy and concentrated cell loss in the caudate
  and the putamen.
• Onset occurs between the ages of 30 and 50 years.
  
• Neurologic symptoms include gait disturbance,
  dysarthria, dysphonia, and dysphagia.

41
Wilsons (WD)

• Wilson's disease is a rare hereditary
  degenerative autosomal recessive disease
  resulting in a disorder of copper metabolism.
• Symptoms include liver disease, tremor, rigidity,
  dystonia, ataxia, dysarthria, and psychiatric
  disturbances.
• Symptoms of liver disease occur in childhood,
  with approximately half of Wilson's disease
  patients presenting with neurologic symptoms
  during adolescence.

42
Amyotrophic Lateral Sclerosis (ALS)

• Amyotrophic lateral sclerosis (ALS) is a
  progressive disorder affecting both the upper and
  lower motor neurons.
• The disease is always fatal, with death generally
  occurring within 2 to 5 years of diagnosis of
  corticobulbar ALS.
• Some estimates suggest that FTD may occur in
  approximately 5 of patients with ALS.
• Between 5 and 10 of cases are believed to be
  the result of an autosomal dominant mutation.

43
Amyotrophic Lateral Sclerosis (ALS)

• Onset is generally around the age of 60 but may
  occur in patients as young as 20 years of age.
• ALS can affect predominately the corticobulbar or
  corticospinal tracts.
• The spinal presentation generally includes
  reduced dexterity, limb weakness, and spasticity.
• The bulbar presentation includes dysarthria,
  dysphonia, dysphagia, sialorrhea, muscle atrophy,
  and fasciculations.

44
Amyotrophic Lateral Sclerosis (ALS)

• Approximately 25 of ALS patients will have
  bulbar-related symptoms at onset.
• When ALS affects the bulbar (pontine)
  musculature, dysphagia may be one of the first
  symptoms of the disease.
• In the early stages of ALS, oral phase problems
  are due to either a dysfunction in the transport
  of the bolus at the anterior part of the tongue,
  or in the holding of the bolus at the posterior
  part of the tongue (Kawai, Tsukuda, Mochimatsu,
  Enomoto, Kagesato, Hirose, Kuroiwa, Suzuki,
  2003)

45
Amyotrophic Lateral Sclerosis (ALS)

• Aspiration is more often associated with impaired
  holding function at the posterior part of the
  tongue, than to transport dysfunction.
• There is almost no delay in swallowing at the
  pharyngeal level, nor problems with esophageal
  peristalsis.

46
Multiple Sclerosis (MS)

• Multiple sclerosis is an autoimmune disease
  caused by an inflammatory demyelinating process
  that affects multiple white matter tracts within
  the CNS.
• Symptom onset is generally between the ages of 25
  and 30 years.
• Clinical features are varied in MS, reflecting
  the multifocal areas of the CNS and may include
  bilateral internuclear ophthalmoplegia, sensory
  impairment, heat sensitivity, and fatigue
  involvement.

47
Multiple Sclerosis (MS)

• Similar to ALS, not all patients with MS will be
  dysphagic unless bulbar musculature is involved.
• Because of the diseases tendency to produce
  ataxic symptoms, the coordination of deglutition
  and breathing may predispose these patients to
  dysphagia, as well as to oral and pharyngeal
  muscle weakness and incoordination.
• Hartelius and Svensson (1994) found that more
  than 33 of patients with MS had either chewing
  or swallowing problems.

48
Multiple Sclerosis (MS)

• Other common dysphagic manifestations include
  aspiration
• before the swallow due to reduced lingual
  control
• before the swallow due to a delayed swallow
  response
• during the swallow due to reduced laryngeal
  closure
• after the swallow due to reduced pharyngeal
  peristalsis and
• after the swallow due to CP dysfunction.

49
Myasthenia Gravis (MG)

• In selected populations of patients with MG,
  approximately one third are dysphagic.
• The prevalence of dysphagia largely depends on
  the extent of muscle fatigue.
• A recent study by Dolton-Hudson, Koopman, Moosa,
  Smith, Bach and Nicolle (2002) found that 45 had
  oral preparatory phase dysphagia, 65 had oral
  phase dysphagia, and 100 had pharyngeal phase
  dysphagia.

50
Myasthenia Gravis (MG)

• Specific oral preparatory phase problems included
  poor bolus formation and extended chewing with
  reduced buccal tension leading to spillage of
  material into the lateral sulci.
• Oral phase problems included slow bolus
  transports, piecemeal deglutition, and poor
  retro-oral seal of the tongue and palate, leading
  to residue on the tongue base and soft palate.

51
Myasthenia Gravis (MG)

• Pharyngeal phase dysphagia included delayed
  swallow response and reduced tongue base
  retraction toward the pharyngeal wall, resulting
  in residue in the valleculae and pyriform
  sinuses.
• Aspiration occurred in about 1/3 of the patients,
  with the majority aspirating during the swallow.

52
Systemic Rheumatic Diseases

• Systemic rheumatic diseases, such as
  dermatomyositis, polymyositis, rheumatoid
  arthritis, scleroderma, and Sjogrens syndrome
  are rarer than PD or MS, but deserve
  consideration in a discussion of dysphagia and
  neurologic disease.
• Dermatomyositis and polymyositis are
  characterized by inflammation of the proximal
  skeletal muscles.

53
Systemic Rheumatic Diseases

• Thus muscles of the pharynx are often affected
  but the smooth muscles of the esophagus are
  spared.
• On VFSS, there is usually prominence of the CP
  muscle, decreased epiglottic tilt, and moderate
  to severe pharyngeal residue (Murray Carrau,
  2001).
• About 67 of patients with myositis have
  demonstrable delayed transit through the cervical
  esophagus.

54
Systemic Rheumatic Diseases

• Rheumatoid arthritis (RA) is a chronic relapsing
  inflammatory arthritis, usually affecting
  multiple diarthrodial joints.
• Women are more commonly affected than men, with a
  ratio of 31.
• RA is associated with xerostomia, TMJ syndrome,
  cervical spine arthritic disease, and decreased
  peristaltic amplitude in the proximal esophagus,
  all contributing to swallowing problems.

55
Systemic Rheumatic Diseases

• Rheumatic laryngeal involvement may result in
  cricoarytenoid joint fixation, affecting
  laryngeal closure.
• A study by Ekberg, Redlund-Johnell, and Sjoblom
  (1987) found that 65 of patients with RA had
  pharyngeal dysfunction.
• Scleroderma is a disorder characterized by
  progressive fibrosis and vascular changes.

56
Systemic Rheumatic Diseases

• As many as 90 of patients with scleroderma have
  complaints related to swallowing.
• Dysphagia is first noticed while swallowing
  solids due to poor motility through the inferior
  2/3 of the esophagus.
• Secondary effects on the oral and pharyngeal
  stages have been reported.

57
Systemic Rheumatic Diseases

• Sjogrens syndrome (SS) is an autoimmune disorder
  that produces dryness of the eyes, nose, and
  mouth.
• Xerostomia, oral pain, glossodynia, and dysgeusia
  are prominent features of SS.
• As many as 75 of patients diagnosed with SS have
  dysphagia, which has the potential to involve all
  stages of swallowing function.

58
Structural Disorders of Swallowing

• The largest group of patients with structural
  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 are
  involved.
• The general rule for predicting significant
  dysphagic episodes following surgical excision is
  the 50 rule.

59
Structural Disorders of Swallowing

• If less than 50 percent of an area or organ
  concerned with deglutition is removed, this will
  not interfere seriously or permanently with
  swallowing function. 
• The 50 percent rule can also apply if the
  structure in question is rearranged, or if
  adjacent structures are rearranged.
• Usually procedures on adjacent structures carry a
  more negative prognosis for deglutitory recovery
  than does loss of mobility of these structures.

60
Structural Disorders of Swallowing

• Total or partial loss of sensation, or
  interruption of the neurologic sensory controls
  in the oropharynx can be precipitated by surgical
  procedures.
• The use of tissue flaps to close surgical defects
  interferes with the normal sensation that
  provides adequate sensory guidance of the bolus
  needed to affect a normal swallow.

61
Structural Disorders of Swallowing

• An additional complication is radiation, pre- or
  post-operatively, which may produce side effects
  that may farther compromise swallowing.
• The 50 rule is only a guide individual
  differences should not be overlooked.
• In fact, individual differences among patients
  who have had cancerous lesions and subsequent
  resections may not be related to the amount of
  the structure removed.

62
Structural Disorders of Swallowing

• Factors such as preoperative and postoperative
  health, psychological reaction to the disability,
  and the ability to learn adaptive swallowing
  techniques often have more adverse affects than
  the cancer surgery itself.

63
Oral Surgical Resection/Reconstruction

• Cancers in the oral cavity may involve the
  tongue, floor of the mouth, tonsils, soft palate,
  mandible, and maxilla.
• Many times, more than one of these structures is
  involved.
• It is not unusual to have parts of the tongue,
  mandible, and floor of the mouth resected.

64
Oral Surgical Resection/Reconstruction

• In general, patients with resected oral
  structures have difficulty with mastication,
  formation and retention of a bolus, and anterior
  to posterior lingual transport.
• Major resections of parts of the mandible can
  significantly alter the relationships among oral,
  pharyngeal, and laryngeal structures, resulting
  in disturbance of the sequential movements
  involved in swallowing.

65
Oral Surgical Resection/Reconstruction

• For example, loss of the occlusal jaw
  relationships after partial removal of the
  mandible can interfere with mastication in such a
  way as to lengthen the oral phase of eating.
• This can result not only in delayed and therefore
  poorly timed propulsion, but in premature
  attempts at swallowing because the delay is not
  well tolerated by most patients.

66
Partial Tongue Resection

• Patients whose surgical resection is small (less
  than 50) and limited to the tongue with no other
  tissue involved, and whose reconstruction is by
  primary closure will have swallowing difficulties
  of a relatively temporary nature.

67
Partial Tongue Resection

• Initially, edema may cause the patient to
  experience a sense of clumsiness with their
  tongue in both speech and swallowing, and may
  contribute to some short-lived difficulties in
  triggering the swallow reflex.
• When resection has included 50 or more of the
  tongue, lingual peristalsis and control of the
  material in the mouth will be severely reduced.

68
Partial Tongue Resection

• The patient will be unable to contact the
  remaining tongue segment to the palate and thus
  control the movement of the food.
• If the resection is limited to the tongue, and
  the pharyngeal and laryngeal aspects of the
  swallow normal, the patient will be able to
  tolerate a backward tilted head posture without
  increasing the chances of aspiration.

69
Anterior Floor of the Mouth Resection

• Tumor found in anterior floor of mouth.
• Dotted lines indicate resection of oral cavity to
  remove the tumor

70
Anterior Floor of the Mouth Resection

• After anterior floor of mouth resection, the oral
  phase of the swallow may be impaired but
  pharyngeal transit will be normal because the
  surgical defect does not extend posteriorly.
• Because the remaining tongue segment is mobile,
  and the inferior rim of the mandible has been
  left to maintain its contour, lingual peristalsis
  is good, and lingual control of the bolus in the
  oral cavity is essentially normal.

71
Anterior Floor of the Mouth Resection

• There may, however, be an initial period when
  post-surgical edema delays oral transit time.
• This can easily be compensated for by placing the
  food more posteriorly on the tongue.
• If, however, the floor of the mouth is closed by
  suturing the tongue into the surgical defect, the
  patient will be unable to control the bolus,
  utilize normal lingual peristalsis or masticate.

72
Anterior Floor of the Mouth Resection

• Because the tongue is sutured down, its anterior
  range of motion is reduced, and the patients
  ability to cup and hold material in the anterior
  mouth in preparation for the swallow is severely
  affected.
• Again, this can be compensated for by positioning
  the food more posteriorly, but because the
  patient is unable to chew, food will have to be
  restricted to liquids or pastes.

73
Anterior Floor of the Mouth Resection

• Some voluntary airway protection may have to be
  instructed for loose material may fall over the
  immobile tongue, before a swallow is actually
  initiated.

74
Lateral Floor of the Mouth Resection

• Patients who have had resection in the lateral
  floor of the mouth, tonsil, and base of the
  tongue area, have potential difficulties in both
  the oral and pharyngeal stages of the swallow.

75
Lateral Floor of the Mouth Resection

• Because the tongue and other oral structures are
  involved in the resection, the oral stage of the
  swallow will be affected.
• Patients will also have problems with the
  pharyngeal phase of swallow, because of resection
  to the faucial arches and a portion of the
  pharynx.

76
Lateral Floor of the Mouth Resection

• Some of these problems may include, mild to
  severe disturbances in oral transit time,
  impaired lingual propulsion of the bolus, food
  pocketing in the lateral sulci or on the hard
  palate, delayed swallow response, reduced
  pharyngeal peristalsis, and possible decreased
  sensation due to scar tissue.
• Usually, unless a fistula has developed in the
  healing process, laryngeal control of the swallow
  is normal.

77
Laryngeal Surgical Resection/ Reconstruction

• As with resections of the oral cavity, every
  patient's surgical resection and reconstruction
  will be different depending on the areas of
  involvement.
• Generally speaking, approximately 60 of
  malignant laryngeal tumors occur at the level of
  the glottis 35 occur in the supraglottic area
  and 5 occur in the subglottic region.

78
Laryngeal Surgical Resection/Reconstruction

• Partial laryngectomy is a general category of
  surgical resection of the pharyngeal and
  laryngeal regions that seeks to control a
  malignancy while preserving vocal function and
  deglutition.
• These procedures are principally supra-glottic
  laryngectomy and hemi-laryngectomy.

79
Supraglottic Laryngectomy

• A supraglottic laryngectomy is the usual
  treatment for small lesions on the supraglottic
  larynx, predominantly involving the epiglottis,
  the aryepiglottic fold or the false vocal folds.

80
Supraglottic Laryngectomy

• The typical extent of the resection generally
  includes the hyoid bone and the epiglottis
  superiorly, and the aryepiglottic folds, and the
  false cords inferiorly.

81
Supraglottic Laryngectomy

• This procedure clearly removes the two upper
  sphincters providing airway protection during
  swallowing the epiglottis with its
  aryepiglottic folds, and the false vocal folds.

82
Supraglottic Laryngectomy

• This leaves the true vocal folds as the only
  protective mechanism.
• In reconstruction, the surgeon generally elevates
  the remaining larynx and tucks it under for
  additional protection during the swallow.
• Also a cricopharyngeal myotomy is usually
  performed during the surgical procedures to
  facilitate swallowing.

83
Supraglottic Laryngectomy

• Sometimes, the surgical procedure may extend
  either inferiorly or superiorly, depending on the
  exact location and size of the tumor.
• If the tumor invades the anterior surface of the
  epiglottis and extends into the base of the
  tongue, the supraglottic laryngectomy procedure
  may extend up onto and into the base of the
  tongue.

84
Supraglottic Laryngectomy

• These patients will experience a more precipitous
  drop off the tongue into the airway.
• Thus, food or liquid will tend to fall onto the
  closed true vocal cords, so the closure of the
  larynx at the level of the true vocal folds must
  be very strong.

85
Supraglottic Laryngectomy

• Some patients may be affected by reduced lingual
  movement and control of the bolus.
• In addition, reduced laryngeal sensation may
  occur because of the need to sacrifice one of the
  branches of the superior laryngeal nerve, which
  may affect the cough reflex or the swallow
  response.

86
Supraglottic Laryngectomy

• Sometimes the supraglottic laryngectomy extends
  inferiorly to include part of one vocal cord and
  the arytenoid cartilage.
• Chances for recovery of normal swallowing without
  significant chronic aspiration during the swallow
  are diminished because this final valve is lost.

87
Hemilaryngectomy

• Tumors located on the free margin of one vocal
  fold with only local extension are usually
  treated with the hemilaryngectomy.

88
Hemilaryngectomy

• As the name suggests, the hemilaryngectomy
  involves the removal of one vertical half of the
  larynx (see b and c)
• This resection includes one false vocal fold, one
  ventricle, and a true vocal fold, excluding the
  arytenoid cartilage, as well-as a portion of the
  thyroid cartilage on the side of the resection.

89
Hemilaryngectomy

• The hyoid bone and epiglottis are left intact.
• Few swallowing difficulties should be experienced
  by an individual having this procedure, as some
  tissue bulk is reconstructed on the operated
  side, against which the unoperated side can
  attain normal laryngeal closure during
  swallowing.
• However, the reconstructed side must be at the
  same level as the normal vocal fold.

90
Hemilaryngectomy

• Location of the tumor may require that the
  hemilaryngectomy procedure be extended either
  anteriorly or posteriorly.
• This lesion is located anteriorly on one vocal
  fold.

91
Hemilaryngectomy

• The surgical resection will need to include part
  or all of the anterior commissure of the larynx.
• In this case the hemilaryngectomy becomes a
  fronto-lateral laryngectomy including
  approximately one-third of the anterior portion
  of the larynx on both sides.

92
Hemilaryngectomy

• If the lesion is located even more anteriorly,
  the hemilaryngectomy may be extended to include
  one-half of the other side of the larynx.
• This becomes a three-fourths laryngectomy.
• These patients will still have both arytenoid
  cartilages, a normal epiglottis, and hyoid bone.

93
Hemilaryngectomy

• Tissue bulk is placed on the operated
• If there is sufficient constriction at the level
  of the true cords and at the epiglottic level,
  aspiration can be prevented.

94
Hemilaryngectomy

• The hemilaryngectomy may also be extended
  posteriorly to include
• the arytenoid cartilage if the location of the
  tumor so dictates.

95
Hemilaryngectomy

• When the arytenoid cartilage is included in the
  resection, the patient's chances of returning to
  normal swallowing with no aspiration are greatly
  decreased.

96
Hemilaryngectomy

• With any hemilaryngectomy, tipping the patient's
  head forward will increase the vallecular space
  between the base of the tongue and the
  epiglottis.
• This usually provide sufficient added airway
  protection to eliminate all aspiration.

97
Laryngectomy

• Large lesions or lesions involving more than one
  region of the larynx usually require total
  laryngectomy.
• Patients who have undergone total laryngectomy,
  resulting in a physical separation of the
  gastrointestinal tract from the respiratory
  tract, do not usually run the risk of aspiration
  of food or liquid.

98
Laryngectomy

• There are however, two types of swallowing
  problems that may accompany total laryngectomy.
  
• The first is the formation of a pseudo epiglottis
  formed by a band of scar tissue that develops at
  the base of the tongue.
• During swallowing, the peristaltic action of the
  pharyngeal constrictor muscles pulls the scar
  tissue band posteriorly.

99
Laryngectomy

• This widens the gap at the base of the tongue and
  forms a large pocket where food can collect.
• This structure looks deceptively small on mirror
  examination of the base of the tongue at rest,
  but it can widen to essentially occlude the
  pharynx and prevent material from passing when
  the patient attempts to swallow.

100
Laryngectomy

• Some total laryngectomees, then, are restricted
  to liquid food consistency because of this
  problem.
• Treatment is generally surgical resection of the
  scar tissue band.
•  The second type of problem which can occur in
  the total laryngectomee relates to the tightness
  of the surgical closure.

101
Laryngectomy

• Patients with lesions in the pyriform sinus or
  extending into the laryngopharynx will require
  more extensive resection of pharyngeal mucosa as
  a part of their total laryngectomy.
• This necessitates a tighter closure.
• Some patients will form scar tissue strictures in
  the esophagus after surgery.

102
Laryngectomy

• The strictures narrow the esophagus sufficiently
  to prevent any large amount of material or
  material of thick consistency from passing
  through the esophagus.
• Lately, a procedure, developed by Singer and
  Blom, called a pharyngo-esophageal myotomy after
  total laryngectomy, releases this scar
  tissue stricture and permits more normal
  swallowing.

103
Mechanical Disorders of Swallowing

• Patients with mechanical swallowing disorders
  evidence difficulty with swallowing behaviors
  secondary to the loss of sensory guidance of the
  structures necessary to complete a normal
  swallow.
• Nonetheless, their central and most of their
  peripheral neurological controls of deglutition
  are intact.

104
Irradiation and Radiotherapy

• It is not infrequent for patients who undergo
  surgical resections for carcinoma to also receive
  preoperative or postoperative radiotherapy.
• These treatment may produce some side effects
  that may further compromise swallowing.
• Side effects may include
• oral and pharyngeal inflammation
• pain in the soft tissues and bone

105
Irradiation and Radiotherapy

• drying of the mucosal tissues
• diminished volume and thicker consistency of
  saliva
• changes in taste sensation and
• loss of appetite.

106
Loss of Saliva Flow (Xerostomia)

• If radiotherapy is directed towards the salivary
  glands, patients will experience marked reduction
  in saliva flow.
• This is called xerostomia and can be permanent
  and irreversible.
• When the salivary glands can no longer produce a
  normal mixture of serous and mucous saliva,
  deglutition is affected by

107
Loss of Saliva Flow (Xerostomia)

• increased dental caries due to loss of the
  natural defense against decay and accumulation
  of stringy mucous that has lost its lubricating
  abilities.
• Dental caries create pain during mastication if
  left untreated.
• Decay can begin on any tooth and progress rapidly
  toward destruction of the dental crown.
• Accumulation of thick mucous can in itself
  mechanically interfere with swallowing.

108
Mucositis

• Radiotherapy can produce significant inflammatory
  changes in the mucous lining, resulting in
  tenderness and burning not unlike a severe sore
  throat.
• A more marked form of these complaints may
  surface as mucositis.
• When the pain spreads to the pharyngeal mucosa,
  swallowing can be difficult.
• This discomfort may be antagonized by coarse and
  highly seasoned foods.

109
Mucositis and Osteoradionecrosis

• Mucositis gradually improves over time.
• Osteoradionecrosis can result from oral mucosal
  destruction at the primary site of radiation.
• Developing fibrosis and reduction of blood supply
  result in the formation of necrotic ulcers that,
  if left untreated, can invade bony structures
  through infectious processes.

110
Osteoradionecrosis

• Ulcers can develop two to three months after
  radiotherapy or any time thereafter.
• The resultant pain can impair oral feeding
• actions and swallowing to the point at which
  patients are unable to take nutrition orally.
• Patients are most vulnerable to
  osteoradionecrosis of the jaws during the two
  years following irradiation.

111
Trismus

• Trismus is a form of tonic spasms affecting the
  muscles of mastication.
• It usually occurs during or following
  radiotherapy.
• Jaw excursion becomes quite painful and limited.
  
• This is thought to be secondary to masticatory
  muscle fibrosis.

112
Loss of Taste

• A common complaint among at least a little better
  than half of all irradiated patients is loss of
  appetite either during or shortly after
  treatment.
• Some patients experience a loss of taste which
  causes them to be less interested in food.
• Others experience a feeling of nausea and general
  dissatisfaction with their diets.

113
Loss of Taste

• Somewhere after 4 months of termination of
  radiotherapy, the sense of taste acuity should
  return, although some specific losses of sweet,
  salt, and bitter tastes may be noted.
• Aversions to meat and vegetable proteins have
  also been noted.
• Such aversions can lead to loss of appetite,
  disinterest in food, and eventually, to poor
  nutrition.

114
Loss of Taste and Inflammations

• Severe loss of proteins, calories,
• vitamins, and minerals can lead to a nutritional
  deficiency type of stomatitis (inflammation of
  the mouth).
• Acute inflammatory processes that produce or
  exacerbate dysphagia are nonspecific reactions to
  injury of the oropharyngeal tissue secondary to
  bacterial or viral agents, chemical irritants, or
  traumatic insults.

115
Herpes Simplex

• Viral in origin, this herpetic infection is
  characterized by round vesicles that break to
  form shallow ulcers surrounded by a zone of
  inflammation.
• Typically, they are on the lips however, the
  pharynx and buccal mucosa may be involved.
• Palatal and pharyngeal ulcers create significant
  pain and discomfort on
• swallowing.

116
Fungal Inflammation

• One of the most common fungal inflammations is
  candidiasis/moniliasis (thrush).
• Most frequently seen on the tongue, the lesions
  appear as soft, white, slightly elevated plaques.
• If left untreated, the lesions cause associated
  pain and difficulty swallowing.

117
Fungal Inflammation

• They are more common in debilitated patients, in
  those who are undergoing extensive antibiotic
  therapy, and in patients receiving irradiation
  treatments.

118
Chemical Inflammation

• Chemically-induced inflammation can result from
  prolonged use of phenol (toothache drops).
• Other drugs that precipitate mucosal burns
  include aspirin, which causes irritation to the
  cheek lining, some gargles, and anesthetic throat
  lozenges when used excessively.

119
Chemical Inflammation

• Anesthetic throat lozenges reduce oral sensation
  and invite traumatic lesions from persons who
  unknowingly bite their oral mucosa.
• Mucosal burns can be red or white but represent a
  change in the normal pinkish mucosal lining.
• More severe inflammations have a whitish slough
  covering an intensely reddened area.

120
Chemical Inflammation

• The most severe form of chemical burn, lye
  ingestion, can cause severe blistering of the
  entire digestive tract.
• Drugs commonly used in chemotherapy, such as
  doxorubicin (Adriamycin), methotrexate, and
  cyclophosphmide (Cytoxan) can cause oral
  mucositis and the development of painful
  ulcerations.

121
Tracheostomy and Nasogastric Tubes

• Tracheostomy with or without ventilator
  dependency are frequently seen in patients with a
  variety of neuromuscular pathologies.
• Damage to the CNS, specifically, the cerebrum,
  brainstem, and/or spinal cord, due to head
  trauma, infarction, glioma, and/or a high
  cervical lesion may necessitate the need for a
  temporary and/or permanent airway assistance.

122
Tracheostomy and Nasogastric Tubes

• Damage to the PNS, specifically the lower motor
  neuron and/or cranial nerve, from poliomyelitis,
  ALS, or Guillain Barre syndrome may also result
  in the need for a temporary and/or permanent
  airway assistance.
• Finally, damage at the neuromuscular junction,
  due to botulism, MG, or muscular dystrophy, may
  comprise the airway.

123
Tracheostomy and Nasogastric Tubes

• Tracheostomy tubes create a mechanical
  interference to swallowing by restricting normal
  laryngeal elevation.

124
Tracheostomy and Nasogastric Tubes

• Loss of elevation compromises glottal protection
  and invites aspiration, by fixing the larynx
  anteriorly and preventing its axial rotation.
• Lack of this movement may also interfere with
  relaxation of the CP.

125
Tracheostomy and Nasogastric Tubes

• Patients who have cuffed trach tubes that are
  over inflated run the risk of esophageal
  obstruction from the pressure on the
  tracheo-esophageal wall.

126
Tracheostomy and Nasogastric Tubes

• The obstruction keeps nutrition from entering the
  esophagus easily, creating spillover and possible
  aspiration.

127
Tracheostomy and Nasogastric Tubes

• Between 20-70 of patients with chronic
  tracheostomy experience at least one episode of
  aspiration every 48 hours.

128
Tracheostomy and Nasogastric Tubes

• A tracheo-esophageal fistula can also develop
  which can lead to food leakage from the esophagus
  into the trachea.

129
Tracheostomy and Nasogastric Tubes

• An additional complication is that the presence
  of the tube, especially if unfenestrated,
  prevents expiratory air from being shunted
  superiorly.
• This results in a decrease of expired air needed
  to clear the larynx after swallowing.
• A reduction in the ability to clear the airway
  because of such mechanical interference may
  impede rehabilitation.

130
Tracheostomy and Nasogastric Tubes

• Nasogastric feeding tubes also interfere with
  normal swallowing by altering sensations in the
  pharynx and deflecting the bolus.
• A tube passing transnasally may force the patient
  to breathe from the mouth, thus drying the mucosa
  and additionally impairing normal reflexes.

131
Tracheostomy and Nasogastric Tubes

• From the standpoint of patient comfort and fewer
  complications, the smaller size (10 French) is
  preferred.

132
Tracheostomy and Nasogastric Tubes

• Patients with larger feeding tubes (16 to 18
  French) tend to suffer more frequently from
  esophageal ulceration, especially if they are
  employed for an extensive length of time.
• The most frequent complication of nasogastric
  feeding is aspiration of food or gastric contents.

133
Tracheostomy and Nasogastric Tubes

• Symptoms of aspiration include increased
  respiratory rate with labored breathing,
  pulmonary congestion with decreased breath
  sounds, cyanosis, and sweating.
• These patients may also manifest a persistent
  low-grade fever.
• Continuous feeding with NG tube raises gastric pH
  to 4 instead of the normal 2.2
• Bacteria grows up the esophagus and then invades
  the lungs.