Mechanical Swallowing Disorders

Mechanical Disorders

Secondary to: Muscle loss Loss of motor and/or sensory innervation Peripheral structure loss

Oral Pharyngeal Esophageal

Frequently associated with cancerous processes

Clinical Manifestation

Can overlap with those observed in neurogenic dysphagia Sialorrhea Impaired mastication Collection in the oral cavity and pharynx Increased swallowing transit time Delayed swallow initiation Reduced pharyngeal peristalsis aspiration

Differential Diagnosis

Acute Inflammation Non-specific reactions to injury of the

oropharyngeal tissue Fungal Bacterial Viral Chemical Traumatic

May not be the primary cause of dysphagia, rather exacerbates an underlying compromise

Differential Diagnosis

Herpes Simplex Viral

Round lesions Lips Pharynx Buccal mucosa

Palatal and pharyngeal ulcers may cause pain during swallowing

Differential Diagnosis

Ludwig’s Angina: Most typical type of infection to impact swallowing Symptoms

Massive tongue swelling and displacement Red, tender floor of mouth May extend posteriorly and result in epiglottis Muffled voice Swelling in the suprahyoid area

Complications Asphyxia Aspiration pneumonia Lung abscess Tongue necrosis

Differential Diagnosis

Ludwig’s Angina (con’t); Treatment

IV antibiotics Surgery Drainage Airway maintenance

Condition is typically related to: Dental management

Abscess Post extrication infection

Ludwig’s Angina

Lingual Tonsillitis

Pts complain of pain in the throat in the medial pharynx Lump in the throat

Indirect laryngoscopy Examine the base of the tongue and pharynx Confirm diagnosis

Epiglotitis

Inflammation of the supraglottic structures Can result in acute respiratory stress

Airway obstruction Symptoms

Pain Dysphagia Respiratory difficulty Drooling stridor

Pharyngitis

Red inflammation of the oropharyngeal area Viral Bacterial May precede cold symptoms Dysphagia Mild fever Streptococcal- most common bacterial form

Untreated can lead to rheumatic fever

Streptococcal Pharyngitis

Lateral pharyngeal Space Infection

May be secondary to primary tonsillitis or pharyngitis Anterior presentation

Dysphagia Trismus High fever Mandibular swelling/hardening Systemic toxicity Bulging of the lateral pharyngeal wall

Lateral pharyngeal Space Infection (con’t) Anterior presentation

Treatment: Antibiotics Surgical drainage Airway management

Posterior presentation Sepsis Edema and swelling of the epiglottis Edema and swelling of the larynx Dyspnea Can lead to secondary infections

Sudden death syndrome myocarditis

Retropharyngeal and Prevertebral Infections Infections that occur in the

pharyngoesophageal wall and spine Retropharyngeal

Secondary to adjacent abscess or cervical trauma

Prevertebral Secondary to osteomyelitis

Infected hemotomas following vertebral fracture Complications

Meningitis Spontaneous rupture of the larynx

Fungal Inflammation

Candidiasis: most common (Thrush) Soft, white lesions frequently on the tongue Seen in immunosuppressed, debilitated pts Long-term antibiotic tx Those receiving irradiation tx Differ from leukoplakia

Can be scraped away http://www.ghorayeb.com/TongueGeographic

.html http://www.visualdxhealth.com/adult/oralCand

idiasisThrush.htm

Chemical Agents

Exposure to chemicals Can present as red or white lesions

Throat lozenges Excessive use = decreased sensation

Aspirin Gargles Lye ingestion

Most severe chemical burn Chemotherapy

Painful ulcerations

Pharyngoesophageal Diverticulum

Zenker’s diverticulum: weakness in muscle fibers that result in a “pouch” in which material can collect. Above or below the cricopharyngeal muscle Must be large to result in dysphagia symptoms

Regurgitation Halitosis Fullness Weight loss Nocturnal cough with aspiration

Zenker’s Diverticulum

Dysphagia Associated with Cancer

Cancer Tumor Staging

Stage TNM System

I T1 N0 M0

II T2 N0 M0

III T3 N0 M0

T1 or T3 N1 M0

IV T4 N0 or N1 M0

Any T N2 or N3 M0

Any T any N M1

T = tumor size N = nodal status M = presence or absence of metastasis

Dysphagia Associated with Cancer

Constitute the largest group of people with mechanical disorders Organ(s) involved Adjacent structures Not the size of the lesion, rather the area that

is excised Sensation innervation

Oral lesions

Anterior tongue Floor of the mouth Submental structures Mandible Maxilla One or more of these structures may be

partially (or totally) removed http://www.ghorayeb.com/Pictures.html

Clinical Manifestations

Impairments in: Mastication Formation of the bolus Retention of the bolus Anteroposterior propulsion of the bolus Premature penetration of the bolus, or

particles of the bolus into the pharynx Impaired sequence of movements

Glossectomy

Partial or total glossectomy Interferes with the oral phases of deglutition

Even total glossectomy pts are able to eat Dependent upon the resection; if adjacent structures were

involved Age Preoperative health Size and position of primary tumor Lymph node involvement

1/3 glossectomy good prognosis Unless combined with mandibular resection

Usually oral candidates (PO trials) around 1month post surgery

Multiple Oral Structure Resection

Tongue, neck, floor of the mouth, and mandible Multiple structure resection involves varying symptoms

Mastication Bolus manipulation Bolus transit Posterior propulsion Protecting the airway

Surgery can result in scar tissue contractures, TMJ pain

Oropharyngeal Resections

Lesions involving the posterior tongue, soft palate, tonsils, superior and lateral pharynx.

Clinical manifestations Nasal regurgitation Aspiration PE segment dysfunction Impaired transit Altered pressure relationships

Use of reconstructive flaps No sensory/innervation

Partial Laryngectomy

Attempt to control malignant growth but preserve voice and deglutition Hemilaryngectomy

Unilateral resection of the TVF, VF, the ventricle, the SLN with preservation of the epiglottis

Mixed results in the literature

Partial Laryngectomy

Supraglottic laryngectomy Resection of both vestibular and aryepiglottic

folds and unilateral or bilateral transection of the SLNs

Immediate dysphagia symptoms postoperatively Varying results due to nonstandard definitions for

the procedure Resection without bilateral transection of the SLN

has good prognosis Extension of the resection of the resection results in

moderate to severe symptoms in approximately ½ of patients.

Partial Laryngectomy

Supraglottic laryngectomy Predictors for improved deglutition

Mobile tongue base Laryngeal elevation to the tongue base Resected hyoid Competent closure of the glottis.

Total Laryngectomy

Surgical separation of the respiratory and digestive tracts Still at risk for dysphagia

Postoperatively Malfunctioning CP (sphincter) Impaired pharyngeal function Recurrent neoplasm Stricture Fistulas

Irradiation procedures May negatively impact deglutition

Mixed results

Tracheoesophageal Puncture

Tracheoesophageal fistula that is surgically created either during or after the primary surgery

Implications for deglutition Aspiration saliva/food (two small or not fit correctly) Aspiration of voice prosthesis Stenosis Stoma/fistula infection Spasm Enlargement

TEP

Irradiation

Impaired saliva flow Implications for reduced saliva

Mucositis Inflammation of the mucosa

Dissipates following the termination of the tx

Osteoradionecrosis Mucosal destruction

Fibrosis Decreased blood flow

Can invade the bone

Irradiation

Trismus Fibrosis of mastication muscles

Loss of taste/appetite Effects of radiation

Decreased ability to taste, smell, chew, and swallow

Nausea Modified diet

Weight loss malnutrition

Miscellaneous Etiologies

Cervical Spine Disease Osteophytes – bony growth from spine

Nasogastric tubes Large vs. small bore Excess salivation Depressed cough reflex Laryngopharyngeal injuries GERD Tube placement

Tracheostoma tubes Limits laryngeal movement Still have larynx but can’t breath well.