The document provides details about the anatomy and physiology of swallowing. It describes the four stages of swallowing as oral preparatory, oral, pharyngeal, and esophageal. Key points include that swallowing involves passage of food from mouth to stomach through coordinated voluntary and involuntary contractions. The pharynx and esophagus are described in terms of layers, segments, nerve supply, and functions during swallowing. Causes and characteristics of dysphagia in the oropharyngeal and esophageal regions are also summarized.

1. DR PRIYANKA SHASTRI

2. Definition- Normal deglutition involves a complex
series of voluntary and involuntary neuromuscular
contractions proceeding from the mouth to the
stomach and is commonly divided into
oropharyngeal and esophageal stages.
 Swallowing by definition involves passage of
bolus of food (solid / liquid) from the oral cavity to
stomach via the pharynx and esophagus, passing
over the entrance to laryngeal vestibule

4.  12-14cm
 4 layers :
 Mucous membrane : ciliated columnar in
nasopharynx, stratified squamous in the rest
 Pharyngeal aponeurosis : fibrous layer lining the
muscular layer
 Muscular
 Extrinsic : superior, middle and inferior constrictors
 Intrinsic : stylopharyngeus, salpingopharyngeus and
palatopharyngeus
 Buccopharyngeal fascia : lines outer surface.

5.  Nasopharynx : base
of skull to soft
palate, c1 vertebra
 Oropharynx :
junction of hard and
soft palate to floor of
vallecula, 2nd and 3rd
cervical vert
 Hypopharynx : floor
of vallecula to lower
border of cricoid
cartilage, 3rd, 4th, 5th
and 6th cervical vert

7.  Sensory Nerve Supply:
• Nasopharynx: Maxillary nerve
• Oropharynx: Glossopharyngeal nerve
• Laryngopharynx: Internal laryngeal branch of the vagus nerve
 Motor Nerve Supply:
• All the muscles of pharynx, except the stylopharyngeus, supplied by
the pharyngeal plexus
• The stylopharyngeus is supplied by the glossopharyngeal nerve
• Cricopharyngeus ms has additional supply frm external laryngeal N
& parasympathetic vagal fibres frm RLN ( relaxation ), postganlionic
sympathetic fibres frm sup cervical ganglion ( contrction ).

8.  Esophagus
 25cm long
 Layers : mucosa, submucosa, muscularis propria
and adventia
 Muscles : upper 1/3rd : skeletal
middle 1/3rd : mixed
lower 1/3rd : smooth
 LES : 2-4cm tonically contracted thickened
smooth muscle

9.  Teeth-grinding & reducing food
 Elevators & depressors of jaw helps in bolus
formation
 Tongue
 Intrinsic muscles-changes shape of tongue
 Extrinsic muscles-alters position of tongue
 Lips maintain a seal preventing spilling of food
 Buccinator returns food from the vestibule to the
oral cavity
 Soft palate prevents nasal regurgitation &
premature movement of food into oropharynx

10. 3 components
 Passage of bolus from oral cavity to stomach
 Airway protection
 Inhibition of air passing into stomach
4 stages
 Oral preparatory Phase-voluntary
 Oral phase - voluntary
 Pharyngeal Phase-reflexive
 Oesophageal Phase-reflexive

11.  Food is readied for swallowing by reducing & mixing
with saliva
 Jaw closed by jaw elevators masseter, temporalis &
medial pterygoid
 Chewing occurs with the help of both elevators &
depressors
 Lip maintains a tight seal under the action of orbicularis
oris
 Buccinator returns food from vestibule during
mastication
 Soft palate lowered by the action of palatoglossus &
palatopharyngeus which approximates the respective
arches to dorsal aspect of posterior part of tongue

12.  Lateral rolling of tongue
: most important ,
manipulation and
mastication of food
 At the end : tongue pulls
food together into a
bolus at the floor of
mouth or against hard
palate : preparation for
beginning of oral stage
 Respiration: normal
through the nose (mouth
closed

13.  Involves moving food from front of oral cavity to
the pharynx
 Tongue plays a vital role in this phase : shapes, lifts
and squeezes the bolus upward and backward along
the hard palate
 At this time lateral margins of tongue sealed
against alveolar ridge
 Soft palate elevated by tensor and levator veli palati
 When bolus crosses the tongue base : pharyngeal
swallowing reflex triggered.

14.  Bolus accumulates in
the oropharyngeal
surface of tongue due
to repeated cycles of
upward and downward
movement of tongue
Time taken
 Bolus preparation-
variable
 Oral phase proper : 1-
2sec

15.  This phase is reflexive in nature
 Ventilatory & alimentary streams cross each other
during this phase
PROTECTION OF AIRWAY
 Inhibition of diaphgramatic contraction making
swallow & breathing impossible simultaneously
 Soft palate elevation closing the nasopharynx by
the action of tensor & levator veli palatini
 Closure of larynx

16. Opening of cricopharyngeal sphincter
Airway closure
Pharyngeal closure to clear residues
Tongue base retraction to propel bolus through pharynx
Velopharyngeal closure
Pharyngeal swallow triggered

17. ELEVATION OF SOFT PALATE
ELEVATION OF LARYNX
CLOSURE OF LARYNX-3 TIER MECHANISM
*EPIGLOTTIS & ARYEPIGLOTTIC FOLDS
*FALSE CORDS
*TRUE CORDS

18. Pharyngeal closure
Food passes the tongue base
Immediately tongue base
retracts, moves backwards
Increase in pressure in
pharynx
Lateral and ppw move
inward( constrictor action )

19. Cricopharyngeus relaxes at
the time when pharyngeal
contraction occus
Allow food bolus to pass
Immediately closes to
prevent reflux of food into
pahrynx

20.  Time: 1 second
 Respiration: briefly
halted (apneic
moment)

21. 21
 Stimulation of trigger
points present in the
oropharynx starts off the
pharyngeal reflexive
stage of swallowing
 present at the faucial
arches & mucosa of the
posterior pharyngeal wal
 innervated by
glossopharyngeal nerve
 Stimulation of these
trigger points causes
dilatation of pharynx due
to relaxation of the
constrictors, and elevation
of pharynx & larynx due
to contraction of
longitudinal muscles
 The pharynx constricts
behind the bolus thereby
propelling it
 Contraction of the inferior
constrictor moves the
bolus towards the
oesophagus

22.  Involuntary in nature
 Starts with the relaxation of cricopharyngeus
 The anterosuperior movement of laryngohyoid
complex opens the upper oesophageal sphincter
 Bolus is then conducted from oesophagus to
stomach

23. Primary peristalsis
 Continuation of peristalatic wave initiated in pharynx
Secondary peristalsis
 Initiated due to distension of oesophagus with food
 These waves will continue till all the food is emptied into stomach
 Produced due to intrinsic neural circuits and partly by vagal reflex
Tertiary peristalsis
 Irregular, non propulsive contractions involving long segments
which occur during emotional stress.
 Time taken-
7-8sec (solids)
3sec (liquids)

26.  Swallow is initiated in trigger area. Afferent is the
glossopharyngeal nerve
 Efferents involve several cranial nuclei which
include
 Nucleus ambiguus supplying muscles of palate,
pharynx & larynx
 Hypoglossal nucleus supplying muscles of tongue
 Motor nuclei of trigeminal nerve & facial nerve
which supply muscles of face,jaw & lips

27. Nucleus tractus solitarius, Trigeminal nuclei, Afferents from jaw,
muscles of mastication, lips and tongue
Triggering of swallow reflex
Pharynx
Food bolus in oral cavity

28. Muscles of pharynx and esophagus
Cranial nerve motor nuclei
Nucleus ambiguus : muscles of palate, pharynx and larynx
Hypoglossal : muscles of tongue
Motor nuclei of trigeminal and facial for muscles of jaws and lips
Medulla( dorsal and ventral group of neurons )
Dorsal : convergence of sensory input
Vnetral : output to cranial motor nuclei
Frontal cortex through ventral and lateral corticobulbar tracts

30.  DYSPHAGIA{Greek:dys-difficulty, phagia-to eat}
Refers to difficulty in swallowing affecting any part
from mouth to stomach
 ODYNOPHAGIA
Painful swallowing
 GLOBUS HYSTERICUS
Sensation of a lump lodged in throat
 PHAGOPHAGIA
Fear of swallowing as in rabies, tetanus, pharyngeal
paralysis due to fear of aspiration
 PRESBYDYSPHAGIA
Refers to swallowing difficulties due to ageing

31.  Lack of coordination or strength of muscles
 Mechanical obstruction
 If contractions fail to develop progress bolus
distends the oesophageal lumen & causes
discomfort
 Low amplitude of primary & secondary peristaltic
activity is insufficient to clear oesophagus as in
elderly individuals

32.  Mechanical narrowing of oesophageal lumen
obstructs passage of bolus despite adequate
contractions
 Minimal obstructing lumen; large bolus
 Lesions occluding lumen; liquids & solids
 Abnormal sensory perception in oesophagus may
cause sensation of dysphagia even after bolus is
cleared

33.  Oropharyngeal
 Difficulty in preparing
and transfferring food
bolus through oral
cavity
 Difficulty in initiation
of swallow
 Aspiration/
nasopharyngeal
regurgitation
 Oesophageal
dysphagia
 patients complain of
food sticking in their
lower throat, neck,
retro-sternal
discomfort or
epigastrium

34.  Inability to initiate the act of swallowing.
 It is a transfer problem caused by
 impaired ability to transfer food from mouth to upper
esophagus
 impaired oral preparatory phase
 Clinical presentation:
 food sticking in the throat
 difficulty initiating a swallow
 nasal regurgitation
 coughing during swallowing
 They may also complain of
 dysarthria
 nasal speech because of associated muscle weaknesses
 Other Neurological clinical findings

35. STRUCTURAL-intrinsic STRUCTURAL-extrinsic NEUROMUSCULAR
CONGENITAL-
stenosis,web,atresia,TO
fistula,diverticulum,cleft
lip&palate,vascular rings
Retropharyngeal
parapharyngeal abscess or
mass,ludwig’s angina
Amyotropic lateral
sclerosis,multiple sclerosis,
parkinson’s d/s
TRAUMATIC-Foreign
body,sticture(postoperative,c
orrosive,postradiation)
Laryngeal
malignancies,lymphatic
metastasis of neck
Myasthenia gravis,post polio
syndrome, myotonic
dystrophy
INFLAMMATORY-Acute
tonsillitis,
Peritonsillar
abcsess,stomatitis,pharyngiti
s,epiglottitis
Enlarged Thyroid gland,
large thymus
Idiopathic UES
Dysfunction,thyroid
dysfunction
NEOPLASTIC
Benign-Leiomyoma,
Lipoma, Angioma
Malignant- Squamous cell
Ca, Adenocarcinoma,
Lymphoma, Melanoma

36.  Likely causes: reflux, certain cancers
 Characteristics:
 Structural abnormalities in esophagus
 Decreased esophageal motility or contraction
 Inadequate opening of lower esophageal sphincter
(bolus cannot move into stomach)
 Excessive opening of the lower esophageal sphincter,
allowing backward flow of contents from stomach to
esophagus (reflux)

37. NEUROMUSCULAR
DISORDERS
STRUCTURAL
PRIMARY
Achalasia cardia,Diffuse esophageal
spasm,Nutcracker
esophagus,Hypertensive LES
SECONDARY
Chaga’s disease,reflux related
dysmotility,sclerodrema & other
rheumatological disorders
INTRINSIC
Diverticula,eosiniphilic
esophagitis,foreign body,esophageal
rings & webs,lower esophageal
ring(schatzki’s),stricture(peptic,corro
sive)
EXTRINSIC
Mediastinal mass,spinal
osteophytes,vascular compression

38. HISTORY
 Age
 Complaints-onset, duration, progression & severity
 Type of food
 Associated symptoms;-nasal regurgitation, aspiration,
hoarseness, otalgia
 h/o surgeries, h/o medications
 CLINICAL EXAMINATION
 Examination of oral cavity & oropharynx
 IDL-to inspect pharynx, larynx & pooling of saliva
 Lymph node examination neck
 Thyroid Examination
 Cranial nerve function

39. Before
swallow
• Reduced
tongue
control
• Delayed or
absent
pharyngeal
swallow
During
swallow
• Inadequate
airway
closure
After swallow
• Reduced
laryngea;
elevation
• Decreased
tongue base
contraction
• Decreased
pharyngeal
contraction

41. OVERVIEW
 LABORATORY EVALUATION
 RADIOLOGICAL STUDIES
 SPECIAL TECHNIQUES

42.  Haemoglobin-anemia
 Peripheral smear-plummer vincent syndrome
(cricopharyngeal web causing dysphagia)
 Serum ferritin,TIBC
 Total WBC count,Differential count-infections,TB
 ESR,C-Reactive protein-malignancy,TB,rheumatic
disease
 Thyroid function test-thyroid dysfunction
 Creatine kinase levels-myopathies

43.  Plain X-Ray
 Barium swallow
 CT & MRI
 Videofluroscopy

44. X-RAY SOFT TISSUE NECK
 Lateral view
 AP view
LATERAL VIEW(taken in full inspiration with neck
extn)
 Examine patency of airway
 Examine soft tissues of neck
 Examine the cervical vertebra
 Foreign body

45. AP VIEW
 For glottic & subglottic areas
CHEST X-RAY
 PA View
 Lateral View
To detect general conditions of lung
 Rule out aspiration,chest infection,pulmonary
neoplasm,achalasia cardia
 Patency of airway

47. Prevertebral abscess Foreign body

48.  PROCEDURE
 Patient is given liquid barium(barium sulfate)to
swallow while bolus is followed fluroscopically
 COMPONENTS
 Static: Provides information on structural
abnormalities eg-zenker’s diverticulum, cervical
osteophytes
 Dynamic: Oesophageal motility assesed with multiple
single swallows in different positions(including
recumbent)

49.  Continuous & single swallows are observed
separately as second swallow obliterates the
peristalsis of first swallow
 Look for
 Filling defects
 Obliterative lesions
 Spill over
 Extrinsic compression

50.  BARIUM SUPHATE
Contrast used in barium studies
ADVANTAGES:
 Inert
 Suspendable in water
 very minimal absorption in GIT
DISADVANTAGES:
 Outside the lumen of GIT acts as foreign body
 Contrast leak in mediastinum leads to
inflammatory reaction

52. ACHALASIA CARDIA DIFFUSE ESOPHAGEAL SPASM

56. ADVANTAGES DISADVANTAGES
WIDELY AVAILABLE
COST EFFECTIVE
IRRADIATION
DOCUMENTED ON PLAIN
FILM,NO VIDEOTAPE
AVAILABLE

57. Performed like barium swallow but with addition
of effervescent granules to barium
Advantages:
 Better anatomical details especially edge contrast
Disadvantages:
 Irradiation
 Documented on plain film

58. Normal Fungal Plagues

59. Definition
Dynamic fluoroscopic imaging procedure that
enables visualization of rapid & integrated
movements involved in all phases of deglutition
Equipment
 X-Ray screening facility
 Digital/video recorder with microphone & timer
Personnel
 Radiologist, radiographer, speech & language
therapist, otolaryngologist

60. 60

61. Procedure
 Bolus(Barium sulfate) of all consistencies (liquid,
semi-solid, solid) incorporated with special
contrast materials in increasing volume to
minimize risk of aspiration.
 Patient in upright position
 Start with 1 ml
 Simultaneous viewing of oral, pharyngeal &
laryngeal areas
 Images recorded on videotapes in lateral & AP
views

62. Analysis
Subjective
 Flow, misdirection & residue of bolus
 Aspiration
Objective
 Kinematics of swallowing
 Capturing & manipulating digital images to make
exact timing of bolus flow & movements of
structures
 Spatial measurement of distance & area

64. ADVANTAGES DISADVANTAGES
ALL STAGES OF SWALLOWING
ASSESSED COMPREHENSIVELY
ANATOMY OF STRUCTURES
BETTER UNDERSTOOD
DIFFERENT POSITIONS
ASSESSED
ALL RANGE OF CONSISTENCIES
TESTED
DIAGNOSING SILENT
ASPIRATION SYMPTOMS
ESTIMATING THE AMOUNT OF
ASPIRATION
EASY TO VIDEOTAPE
IRRADIATION
HIGH COST
PATIENT INCOMPATIBILITY
LIMITED INFERENCE ABOUT
SENSATION,MUCOSA,GLOTTIC
CLOSURE,INTER BOLUS
PRESSURE

65.  Contraindictations :
 Patients without a pharyngeal swallow
 Uncooperative, drosy patient
 h/o adverse reactions to contrast media
 Caution in pts with h/o respiratiory distress/ arrest
due to aspiration

66.  CT used to stage the disease in malignant
dysphagia-both intrinsic & extrinsic
 MRI used to detect intracranial lesions and
vascular abnormalities
Disadvantages
 Expensive
 Patient has to be in supine which does not reflect
stages of swallowing

67.  MANOMETRY
 MANOFLUROSCOPY
 DIRECT PHARYNGOSCOPY
 ENDOSCOPY
 BOLUS SCINTIGRAPHY
 24 HR OESOPHAGEAL PH MONITORING

68. Definition
Technique used to measure intraluminal pressure &
coordination of pressures in 3 regions
 Lower esophageal sphinchter(LES)
 Oesophageal body
 Upper esophageal sphinchter(UES)
 To assess oesophageal peristalsis & oesophageal
motor dysfunction

69. Technique
 Performed with water
infusion catheters
 They contain several
small caliber lumens
perfused with water
 These are inserted into
oesophagus via nares

70. Mechanism
Oesophageal contraction occludes catheter
Water pressure builds in catheter exerting a
force,conveyed to external transducer
Electrical signals from transducers reflected in
computer which produces graphic record

71. Catheter advanced to approx.60cm to enter the
stomach
Patient placed in left supine position & catheter
calibrated
Catheter slowly withdrawn through LES,oesophagus
& UES

72. Basal LES pressure 10-45mm Hg
LES relaxation with swallow Complete
Wave progression Peristalsis
Distal wave amplitude 30-180 mm Hg

73.  High resting LES Pressure
 Absent or incomplete LES
Relaxation
 Loss of peristalsis

74. Peristalsis with 20% simultaneous
contractions
Distal wave amplitude is high

75. Advantages Disadvantages
Actual test of pressure wave
pathology
Assessment of pressur events only
Due to movement of larynx difficult
to reading from middle transducer
measuring cricopharyngeus muscle
activity

76.  Solid probe with 36 sensors
spaced at 1cm intervals,
having12 circumferential sectors
measuring pressure over 2.5mm
length
 Average of pressure detected by
each sensor taken
Advantage
 Simple
 Precise
 Accurate
 Faster

77. Similar to videofluroscopy & manometry
Advantages
 Combines pressure & bolus information
simultaneously
Disadvantages
 Not widely used
 Costly

78.  Done under general anaesthesia
 Used to visualize the pharynx & upper oesophagus
 To take biopsy and staging tumors of pharynx &
upper oesophagus
 To examine postcricoid area

79.  Done in acute stages of dysphagia
 Persistent dysphagia
 Assesment of pharyngeal and laryngeal anatomy
and physiology with normal food and drink
Equipment
 Flexible nasal endoscope, camera, monitor,
digital/video recorder, microphone

80. Procedure
 Patient sits upright,nose examined for any septal
deviation
 Decongestants & lubrication of nasal passages
along with topical anaesthesia
 Scope passed between inferior turbinate & floor of
nose
 Examine nasopharynx for nasal reflux, oropharynx
and hypopharynx

83. Advantages Disadvantages
Good view of anatomical variations
Visualization of secretion & pooling
of secretions
Observation of swallowing with a
range of normal food and drink
Can assess swallow when patient is
nil orally
Lengthy assessments-enables
assessment throughout meals
Portable
No view of oral phase
Loss of view due to pharyngeal
constriction around endoscope lens
Cannot measure structure
displacement
Cannot measure the amount of
aspirate

84.  Short lived isoptope mixed with single swallow bolus
 Gamma camera registers the radiation
 Bolus transit & aspiration assessed
Advantages
 Aspiration assessed
Disadvantages
 Oropharyngeal anatomy not assessed
 Cannot perform multiple swallows
 Technical expertise needed

86.  Submental transducers used to image
 Structures
 Mobility of bolus transit
 Vallecular status
Advantages
 Avoids irradiation
 Normal food used(no barium)
Disadvantages
 Cannot be used to visualize larynx & pharynx due
to skeletal interference
 Not effective for esophageal phase

87. 24hrs ambulatory Ph monitoring –reliable for GERD
Procedure
 Proximal probe placed below UES
 Distal probe placed 5cm above LES(position
detected by manometry)
 Reflux measured along entire length of esophagus
Disadvantage
 Invasive
 Provokes relux