Chapter 38

Dysphagia—difficulty with swallowing—refers to problems with the transit of food or liquid from the mouth to the hypopharynx or through the esophagus. Severe dysphagia can compromise nutrition, cause aspiration, and reduce quality of life. Additional terminology pertaining to swallowing dysfunction is as follows. Aphagia denotes complete esophageal obstruction, most commonly encountered in the acute setting of a food bolus or foreign body impaction. Odynophagia refers to painful swallowing, typically resulting from mucosal ulceration within the oropharynx or esophagus. It commonly is accompanied by dysphagia, but the converse is not true. Globus pharyngeus is a foreign body sensation localized in the neck that does not interfere with swallowing and sometimes is relieved by swallowing. Transfer dysphagia frequently results in nasal regurgitation and pulmonary aspiration during swallowing and is characteristic of oropharyngeal dysphagia. Phagophobia (fear of swallowing) and refusal to swallow may be psychogenic or related to anticipatory anxiety about food bolus obstruction, odynophagia, or aspiration.

### Physiology of Swallowing

Swallowing begins with a voluntary (oral) phase that includes preparation during which food is masticated and mixed with saliva. This is followed by a transfer phase during which the bolus is pushed into the pharynx by the tongue. Bolus entry into the hypopharynx initiates the pharyngeal swallow response, which is centrally mediated and involves a complex series of actions, the net result of which is to propel food through the pharynx into the esophagus while preventing its entry into the airway. To accomplish this, the larynx is elevated and pulled forward, actions that also facilitate upper esophageal sphincter (UES) opening. Tongue pulsion then propels the bolus through the UES, followed by a peristaltic contraction that clears residue from the pharynx and through the esophagus. The lower esophageal sphincter (LES) relaxes as the food enters the esophagus and remains relaxed until the peristaltic contraction has delivered the bolus into the stomach. Peristaltic contractions elicited in response to a swallow are called primary peristalsis and involve sequenced inhibition followed by contraction of the musculature along the entire length of the esophagus. The inhibition that precedes the peristaltic contraction is called deglutitive inhibition. Local distention of the esophagus anywhere along its length, as may occur with gastroesophageal reflux, activates secondary peristalsis that begins at the point of distention and proceeds distally. Tertiary esophageal contractions are nonperistaltic, disordered esophageal contractions that may be observed to occur spontaneously during fluoroscopic observation.

The musculature of the oral cavity, pharynx, UES, and cervical esophagus is striated and directly innervated by lower motor neurons carried in cranial nerves (Fig. 38-1). "Oral cavity muscles are innervated by the fifth (trigeminal) and seventh (facial) cranial nerves; the tongue by the twelfth (hypoglossal) cranial nerve. Pharyngeal muscles are innervated by the ninth (glossopharyngeal) and tenth (vagus) cranial nerves.

###### Figure 38-1

Sagittal and diagrammatic views of the musculature involved in enacting oropharyngeal swallowing. ...

Sign in to your MyAccess Account while you are actively authenticated on this website via your institution (you will be able to tell by looking in the top right corner of any page – if you see your institution’s name, you are authenticated). You will then be able to access your institute’s content/subscription for 90 days from any location, after which you must repeat this process for continued access.

Ok

## Subscription Options

### AccessMedicine Full Site: One-Year Subscription

Connect to the full suite of AccessMedicine content and resources including more than 250 examination and procedural videos, patient safety modules, an extensive drug database, Q&A, Case Files, and more.