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Physiology of Swallowing 
By- Vikas 
1
Introduction 
2 
 Swallowing involves co-ordinated activity of 
muscles of oral cavity, pharynx, larynx and 
esophagus 
...
3
Components of deglutition 
4 
 Deglution has 3 components 
 Passage of bolus from oral cavity to stomach 
 Protection o...
Deglutition - phases 
5 
Three stages have been traditionally described for 
the sake of convenience. They help in the bet...
Oral phase 
 In this phase food is 
prepared for swallowing 
 Tongue plays a vital role in 
this processThis phase is 
d...
Oral preparatory phase 
 This phase involves breaking 
down of food in the oral cavity 
 During this phase the food is 
...
oral preparatory phase (contd..) 
8 
 Tongue plays a vital role in bolus formation by the 
action of its intrinsic muscle...
oral preparatory phase (contd..) 
9 
Salivary Glands produce saliva which contains 
mucin. 
 Mucin binds the food togathe...
Bolus formation 
10 
 This is the most 
important function of 
preparatory phase 
 This involves repeated 
transfer of f...
Oral phase proper 
 During this phase the bolus 
is moved towards the back 
of the tongue 
 The contraction of soft 
pal...
 Tongue plays a vital role during this phase. 
 Its intrinsic muscles contracts and reduces its 
size, 
 while genioglo...
Pharyngeal phase (Pumping action of 
tongue & hypopharyngeal suction) 
 This phase of deglutition is 
reflexive in nature...
14 
 Contraction of diaphragm is inhibited making 
simultaneous breathing & swallowing impossible 
 Soft palate is eleva...
Functions of trigger points 
in oropharynx 
 Stimulation of trigger points 
present in the oropharynx 
starts off the pha...
16 
 Stimulation of these trigger points causes 
dilatation of pharynx due to relaxation of the 
constrictors, and elevat...
Importance of laryngeal elevation 
during pharyngeal stage 
 It narrows the laryngeal inlet 
 It ensures better sealing ...
Role of epiglottis in the pharyngeal 
phase 
 The movement of 
epiglottis occurs in two 
stages 
 The epiglottis moves f...
Esophageal stage 
 This is purely reflexive 
 In this phase 
cricopharyngeus 
relexses and the 
anterior superior 
movem...
20 
 The levator and tensor veli palatini relax lowering 
the soft palate. 
 The laryngeal vestibule opens, the hyoid dr...
Neural control of swallowing 
21 
 Two areas of brain are involved 
Cerebral cortex 
Brain stem
Neural control (initiation) 
22 
 Initiation of swallow is voluntary 
 Bilateral prefrontal, frontal and parietal cortic...
Neural control (initiation) 
23 
 Afferent nerve is the glossopharyngeal nerve 
 Nucleus tractus solitarius & spinal nuc...
Role of medulla 
24 
 There are two groups of neurons in the medulla 
while lie between the afferent and efferent system ...
Role of central pattern generator 
25 
 Central pattern generator are a set of neurons 
capable of initiating sequential ...
Phase of respiration & 
swallowing 
26 
 Swallowing occurs during expiratory phase of 
respiration 
 This helps in clear...
27 
Functional investigations of the 
upper gastrointestinal 
tract
Common principles 
28 
 A detailed history of onset and progression, 
specific symptoms and relief strategies. 
 Awarene...
29 
 Challenging the swallow during assessment by 
increasing the speed and bolus volume if 
necessary up to the safe lim...
Investigations 
30 
 Videofluroscopy 
 Barium swallow 
 Fibreoptic endoscopic evaluation of swallowing 
(FEES) 
 Manom...
RADIOLOGY 
31 
 There are two distinctly different barium swallows 
available 
 the traditional barium swallow, 
 video...
Barium swallow 
32 
 Includes both static and dynamic components to 
identify intrinsic disease (tumours, diverticula, 
w...
33 
 Both the oral and pharyngeal stages should be 
assessed even if the complaint is only 
oesophageal as 35 percent of ...
Videofluoroscopy 
34 
 Video fluoroscopy is a 
dynamic fluoroscopic 
imaging procedure 
 Advantageous for 
observing all...
PROCEDURE 
35 
 Patients are assessed in a sitting position 
 Boluses are given in increasing volume to 
minimize the ri...
36 
 Simultaneous viewing of the oral, pharyngeal and 
laryngeal areas should be included. 
 Images are recorded on vide...
ANALYSIS 
37 
 Subjective interpretation of video fluoroscopy by 
experienced clinicians provides descriptions 
about the...
38 
 Objective analyses of videofluoroscopy are called 
dynamic swallow study measurements or 
kinematics of swallowing. ...
Fluroscopic imaging of swallowing 
39
40
41
42
43
44
45
46
Video-abc VF 
47
vf 
48
ADVANTAGES 
49 
 All stages of the swallowing mechanism are seen. 
 Estimates of volume, depth and clearance of 
aspirat...
LIMITATIONS 
50 
 Radiation exposure to the patient, especially for 
repeated or lengthy studies.. 
 High cost of equipm...
51 
 Properties of barium are designed to coat 
structures, so liquid and food containing barium 
does not behave in the ...
CONTRAINDICATIONS 
52 
 Patients without a pharyngeal swallow, as 
aspiration of barium will almost certainly occur. 
 U...
53 
 If large volume aspiration is suspected, there 
should be a small volume « 5 mL) initial test 
swallow using water s...
54 
 Oesophageal motility is assessed with multiple 
single swallows in different positions, 
 including recumbent (unli...
CT & MRI 
55 
 These techniques each show structural lesions, for 
example the intracranial disease causing 
neurogenic d...
Fibreoptic endoscopic evaluation of 
swallowing (FEES) 
56 
 Also known as video endoscopic 
evaluation of swallowing (VE...
Fibreoptic endoscopic Evaluation of 
swallowing with sensory testing 
(FEESST) 
57 
 This is extended technique 
 Quanti...
PROCEDURE 
58 
 The patient sits upright, the nostrils are examined 
to detect any septal deviation. 
 topical anaesthes...
Four different views allow observation of anatomy and physiology during swallowing 
as follows: 
59 
1. Nasal 
passage for...
Equipment 
60 
 Includes a flexible 
nasendoscope, with 
camera for video or digital 
(including auditory) 
recording and...
ADVANTAGES 
61 
 Good views of any alterations in the anatomy and of 
muscular function in the nasopharynx, oropharynx 
a...
62 
 Ability to assess swallow without giving food or drink 
to those patients who are nil by mouth. 
 Observation of sw...
LIMITATIONS 
 No view for evaluation of bolus management in the 
oral cavity. 
 Loss of view ('whiteout') during the swa...
CONTRAINDICATIONS 
64 
 Unsuitable patients (e.g. those who are unable to 
maintain a stable position, drowsy, uncooperat...
Risks 
65 
 The potential complications listed below are 
extremely rare, however, awareness of the risks is 
important f...
66 
 Laryngospasm is less likely to occur in patients with 
pooling and aspiration of secretions who also have 
poor tact...
Video- FEES 
67
MANOMETRY 
68 
 Directly measures:- 
 amplitude and 
duration of contraction 
and relaxation 
pressures in the 
pharynx,...
Oesophageal Manometry 
69 
 The oesophageal peristaltic wave pressure rises 
slowly to approximately 50 mmHg, and falls r...
Pharyngeal Manometry 
Pressure changes in the oropharynx and UOS are 
required for effective bolus transit and UOS opening...
71 
 Closure of the UOS with increased pressure (90 
mmHg) ; 
 Return to an UOS tonic (resting) pressure of 
approximate...
LIMITATIONS 
72 
 Conventional pharyngeal manometry involves using a 
catheter with a limited number (three or four) of p...
 Upward movement of the UOS during swallowing due 
to laryngeal movement. Consequently the sensor 
may be left in the ope...
74 
 The barrier formed by LOS tonic pressure is lower 
after meals and tighter at night. 
 Similar to the UOS, measurem...
High-resolution manometry 
75 
 Recent advance over conventional manometry for 
taking measurements of the oesophagus and...
76 
 It removes the need for the time-consuming station 
pull through procedure and facilitates the accurate 
positioning...
77 
 Computer technology allows the large data set 
acquired by HRM to be analysed and presented 
in realtime. 
 Concurr...
High-resolution manometry video 
78
79
Manofluoroscopy 
80 
 Pharyngeal manometry is rarely the first or sole 
study used to evaluate swallowing function, 
beca...
Advantages 
81 
 Manofluoroscopy aids clinical decisions about 
the need for medical procedures: 
 It provides informati...
Procedure 
82 
 Standard methodology for oropharyngeal 
manometry is needed because of the technical and 
subject variabl...
Equipment 
83 
Sensor type 
 Catheters with miniature strain gauge pressure 
transducer sensors are required for pharynge...
 Patients can be tested 
in a normal upright 
position, unlike the 
supine position with 
water perfused 
catheters. 
 A...
85 
Catheter 
 The diameter should be small (3 mm or less) both 
for comfort and to avoid the reactive increase in 
UOS t...
86 
 Catheters need to be 100 cm long for oseophageal 
manometry. 
 A short (4 cm) malleable section of the catheter 
sh...
87 
Sensor spacing and placement in conventional 
manometry 
 One sensor each should be placed in three (or four) 
locati...
 Correct placement of the UOS sensor can be seen 
during swallowing by production of a waveform that 
has a negative nadi...
89 
 The techniques of station pull through (SPT) or rapid 
pull through (RPT) are used to position the catheters 
accura...
METHODOLOGY 
90 
Salassa et al. also suggest that methodology 
guidelines are still needed in order to 
standardize: 
 Bo...
Recordings 
91 
 A computerized 
mulitchannel recording 
device is used to collect 
store and display the 
pressure readi...
92 
 Computer recordings are accurate, quick and 
unbiased. 
 Automatic data collation into a database gives 
faster ana...
Calibration 
93 
 Regular calibration of the equipment is necessary 
before the equipment is used. 
 The measurement of ...
94 
CONTRAINDICATIONS 
 Patients suspected of having a perforated 
gastrointestinal tract. 
 Same as Endoscopy.
Analysis 
95 
 UOS tonic (resting) pressures, and variations 
in pressure in the pharynx, UOS and 
oesophagus during swal...
96 
 Measurements made include: 
1. maximum and minimum pressures; 
2. duration of contraction with the sequence, and 
re...
OTHER INVESTIGATIONS 
97 
Respiration 
 The oropharyngeal tract is the same anatomical 
channel for swallowing and breath...
Ultrasound 
98 
 The ultrasound transducer with high frequency 
sounds ( > 2 MHz) is placed sub mentally to 
produce dyna...
Oesophageal pH monitoring 
99 
 Prolonged (24-hour ambulatory) pH monitoring is 
the most reliable method of diagnosing g...
Scintigraphy 
100 
 This procedure tracks movement of the bolus 
over time, and quantifies the residual bolus in the 
oro...
Lingual pressure recording 
101 
 Recently, three-bulb linear manometric sensor 
arrays (Kay Elemetrics Workstation) have...
Electromyography 
 Surface electromyography (sEMG) measures the 
amplitude (voltage) of swallowing muscle activity 
(from...
Thank You 
103
104
Double contrast image of 
pharynx 
105
Examination of oesophagus 
106
Dc image of gastro oesophageal 
junction 
107
asymmetry 
108
Stasis 
109
Cricopharyngeal dysfunction 
110
111
112
113
114
115
116
Aspiration 
117
Web 
118
119 
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swallowing, deglutition, dysphagia. physiology, investigations, manometry, fluroscopy, HRM, FEES, FEESST,

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Physiology swallowing & functional investigations of upper git

  1. 1. Physiology of Swallowing By- Vikas 1
  2. 2. Introduction 2  Swallowing involves co-ordinated activity of muscles of oral cavity, pharynx, larynx and esophagus  The whole process is partly under voluntary control & partly reflexive in nature  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.  Voluntary control of Swallowing involves control of jaw, tongue, degree of constriction and length of pharynx and closure of laryngeal inlet.
  3. 3. 3
  4. 4. Components of deglutition 4  Deglution has 3 components  Passage of bolus from oral cavity to stomach  Protection of airway  Inhibition of air entry into the stomach
  5. 5. Deglutition - phases 5 Three stages have been traditionally described for the sake of convenience. They help in the better understanding of the physiological process involved.  Oral  Pharyngeal  Esophageal
  6. 6. Oral phase  In this phase food is prepared for swallowing  Tongue plays a vital role in this processThis phase is divided into 6  oral preparatory phase and  oral phase proper  This phase is vital in all land animals which don’t swallow their food as a whole  This phase is under
  7. 7. Oral preparatory phase  This phase involves breaking down of food in the oral cavity  During this phase the food is chewed and mixed with saliva making it into a bolus which can be swallowed  The elevators of lower jaw play an important role in bolus preparation 7
  8. 8. oral preparatory phase (contd..) 8  Tongue plays a vital role in bolus formation by the action of its intrinsic muscles which alters its shape.  extrinsic muscles changes its position within the oral cavity thereby helping in chewing the food by dental occlusion  Occlusal action of the lips help in creating an effective seal preventing the bolus from dribbling out of the oral cavity.  The action of buccinator muscle helps in pushing the bolus out of the vestibule into the oral cavity proper
  9. 9. oral preparatory phase (contd..) 9 Salivary Glands produce saliva which contains mucin.  Mucin binds the food togather and helps in bolus formation
  10. 10. Bolus formation 10  This is the most important function of preparatory phase  This involves repeated transfer of food from oral cavity to oropharyngeal surface of tongue  Bolus accumulates on the oropharyngeal surface of tongue due to repeated cycles of upward & downward movement of the tongue
  11. 11. Oral phase proper  During this phase the bolus is moved towards the back of the tongue  The contraction of soft palate prevents nasal regurgitation, also prevents premature movement of bolus into the oropharynx  Once the bolus is of suitable consistency the transit from mouth to oropharynx just takes a couple of seconds 11
  12. 12.  Tongue plays a vital role during this phase.  Its intrinsic muscles contracts and reduces its size,  while genioglossus muscle elevates the tongue towards the palate  The elevation of the mandible plays a vital role here When the mandible is elevated the suprahyoid muscles raises the hyoid bone
  13. 13. Pharyngeal phase (Pumping action of tongue & hypopharyngeal suction)  This phase of deglutition is reflexive in nature  during this phase Ventilatory and alimentary streams cross each other. Dynamic separation of these streams is possible due to the co-ordination of reflex phase that occurs  It just takes a second for the bolus to traverse the 13 pharynx and reach the cricopharyngeal area
  14. 14. 14  Contraction of diaphragm is inhibited making simultaneous breathing & swallowing impossible  Soft palate is elevated in order to seal off the nasopharynx (T. palatini & L. palatini)  Vocal cords adduct protecting the airway  As the bolus passes the palatoglossal & palatopharyngeal folds the act of swallowing becomes reflexive
  15. 15. Functions of trigger points in oropharynx  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 wall  innervated by glossopharyngeal nerve 15
  16. 16. 16  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
  17. 17. Importance of laryngeal elevation during pharyngeal stage  It narrows the laryngeal inlet  It ensures better sealing of the laryngeal inlet by the downturned epiglottis  Laryngeal elevation also contributes to dilatation of pharynx  The laryngeal inlet is closed due to the actions of interarytenoid, aryepiglottic 17 and thyroepiglottic muscles
  18. 18. Role of epiglottis in the pharyngeal phase  The movement of epiglottis occurs in two stages  The epiglottis moves from vertical – horizontal position  The upper third of epiglottis moves below the horizontal to a slightly lower level to cover the narrowed laryngeal inlet 18
  19. 19. Esophageal stage  This is purely reflexive  In this phase cricopharyngeus relexses and the anterior superior movement of the laryngohyoid complex acts to open the upper oesophageal sphincter.  The bolus passes through the sphincter and moves along the 19 esophagus by peristalsis.
  20. 20. 20  The levator and tensor veli palatini relax lowering the soft palate.  The laryngeal vestibule opens, the hyoid drops and the vocal cords open  This opening of the glottis at the very end of oropharyngeal swallow sequence is part of the airway protection mechanism.
  21. 21. Neural control of swallowing 21  Two areas of brain are involved Cerebral cortex Brain stem
  22. 22. Neural control (initiation) 22  Initiation of swallow is voluntary  Bilateral prefrontal, frontal and parietal cortices are involved  Swallowing is initiated when food comes into contact with certain trigger areas like fauces / mucosa of posterior pharyngeal wall
  23. 23. Neural control (initiation) 23  Afferent nerve is the glossopharyngeal nerve  Nucleus tractus solitarius & spinal nucleus of trigeminal nerve play a vital role  Efferents involve several cranial nerve nuclei which include nucleus ambiguus (muscles of palate, pharynx and larynx), hypoglossal nucleus supplying the muscles of the tongue, motor nuclei of trigeminal and facial nerves supplying the muscles of face, jaws and lips.
  24. 24. Role of medulla 24  There are two groups of neurons in the medulla while lie between the afferent and efferent system  First group lie in the dorsal medulla above the nucleus of the solitary tract  The second group lie in the ventral medulla around nucleus ambiguus  These groups of neurons are named as lateral & medial medullary swallowing centers
  25. 25. Role of central pattern generator 25  Central pattern generator are a set of neurons capable of initiating sequential swallow  These neurons act like a cardiac pacemaker  Since the process of swallowing and breathing are interlinked there is a certain degree of central co ordination taking place
  26. 26. Phase of respiration & swallowing 26  Swallowing occurs during expiratory phase of respiration  This helps in clearing food material left in the vestibule. Thus it should be considered to be a protective phenomenon  The rhythm of respiration is reset after a successful swallow
  27. 27. 27 Functional investigations of the upper gastrointestinal tract
  28. 28. Common principles 28  A detailed history of onset and progression, specific symptoms and relief strategies.  Awareness of adverse situations during assessment.  Recording clinical observations, instructions, bolus volumes and consistencies given.  Accurate recording of penetration (material entering the larynx but remaining above the vocal folds) or aspiration (below the level of the vocal folds).  Assessing patients in their usual feeding position.  Awareness of multifactoral risks for developing pneumonia.
  29. 29. 29  Challenging the swallow during assessment by increasing the speed and bolus volume if necessary up to the safe limit.  Both single mouthful and continuous swallowing should be recorded.  Sterilizing equipment from contamination of nasal mucus and blood, due to the semi-invasive nature of nasendoscopy and manometry.  A team approach, including speech and language therapists, radiologists, otolaryngologists, gastroenterologists, neurologists and psychiatrists, etc., as required.
  30. 30. Investigations 30  Videofluroscopy  Barium swallow  Fibreoptic endoscopic evaluation of swallowing (FEES)  Manometry  Oesophageal manometry  Pharyngeal manometry  High-resolution manometry  Manofluoroscopy  Other investigations
  31. 31. RADIOLOGY 31  There are two distinctly different barium swallows available  the traditional barium swallow,  video fluoroscopy (aka modified barium swallow or dynamic swallowing study).
  32. 32. Barium swallow 32  Includes both static and dynamic components to identify intrinsic disease (tumours, diverticula, webs and dysmotility) and extrinsic disease (cervical osteophytes, enlarged thyroid gland).  The oesophageal lumen is distended with liquid barium, or coated in thick barium and distended by gas to show intrinsic irregularities and extrinsic impressions.  Static imaging with plain radiographs provides information on structural abnormalities (e.g. Zenker's diverticulum, cervical osteophytes), but little contribute to the investigation of dysphagia.
  33. 33. 33  Both the oral and pharyngeal stages should be assessed even if the complaint is only oesophageal as 35 percent of patients have simultaneous disorders of the pharynx and oesophagus and the level of the lesion does not necessarily correspond to the site of the patient's symptoms.
  34. 34. Videofluoroscopy 34  Video fluoroscopy is a dynamic fluoroscopic imaging procedure  Advantageous for observing all stages of swallowing, estimating the amount of aspiration, and identifying structural or anatomical abnormalities as well as the physiological abnormalities causing dysphagia.
  35. 35. PROCEDURE 35  Patients are assessed in a sitting position  Boluses are given in increasing volume to minimize the risk of aspiration of large amounts of barium, often starting with 1 mL to coat oral structures.  All consistencies are given (liquid, semi-solid and solid) using video fluoroscopic specific contrast material.  These are designed to optimize bolus visualization using standard viscosities and to minimize adherence and coating on mucosa.
  36. 36. 36  Simultaneous viewing of the oral, pharyngeal and laryngeal areas should be included.  Images are recorded on videotape or digitally, in the lateral and anterior-posterior views for later analysis and interpretation.  If dynamic measurements of distance and area are to be calculated, then a metal ring of known diameter (e.g. coin) is taped in the midline to the underside of the chin for calibration.
  37. 37. ANALYSIS 37  Subjective interpretation of video fluoroscopy by experienced clinicians provides descriptions about the bolus flow, reactions to a misdirected bolus and variations from the normal anatomy and physiology.  Rating scales attempt to standardize observations over time or between clinicians, for parameters of oral transit, pharyngeal transit and laryngeal valving and for penetration and aspiration.
  38. 38. 38  Objective analyses of videofluoroscopy are called dynamic swallow study measurements or kinematics of swallowing.  These involve capturing and manipulating digital images with computer technology to make exact timing measures of bolus flow and movement of structures, as well as spatial measurements of distance and area against reference points.
  39. 39. Fluroscopic imaging of swallowing 39
  40. 40. 40
  41. 41. 41
  42. 42. 42
  43. 43. 43
  44. 44. 44
  45. 45. 45
  46. 46. 46
  47. 47. Video-abc VF 47
  48. 48. vf 48
  49. 49. ADVANTAGES 49  All stages of the swallowing mechanism are seen.  Estimates of volume, depth and clearance of aspiration can be made.  A full range of consistencies can be tested.  Anatomical abnormalities can be detected (pouches, diverticulae, fistulae).  Biofeedback to patients
  50. 50. LIMITATIONS 50  Radiation exposure to the patient, especially for repeated or lengthy studies..  High cost of equipment and involvement of several staff.  Patient intolerance of procedure.  Difficulties with seating some patients within the confined space.
  51. 51. 51  Properties of barium are designed to coat structures, so liquid and food containing barium does not behave in the same way as normal liquids or food.  Limited information is gained about mucosa and secretions, sensation, inter-bolus pressure, and details of glottic closure.  Greater standardization of the procedure, with higher interjudge reliability between experienced clinicians,is required before it is truly a 'gold standard' technique.
  52. 52. CONTRAINDICATIONS 52  Patients without a pharyngeal swallow, as aspiration of barium will almost certainly occur.  Unsuitable patients (e.g. those who are unable to maintain a stable position, drowsy, uncooperative, nil by mouth for reasons other than dysphagia, have adverse reactions to contrast media, should avoid unnecessary exposure to radiation).  Caution needs to be taken when  patients are suspected of large volume aspiration, or  have a history of respiratory distress/arrest due to aspiration.
  53. 53. 53  If large volume aspiration is suspected, there should be a small volume « 5 mL) initial test swallow using water soluble contrast materials such as nonionic isotonic agents (e.g. Omnipaque or Gastromiro).  Aspiration of barium can be assessed with a chest radiograph to document the pattern and extent of aspiration, before suction and physiotherapy.  Repeated or prolonged radiation exposure.
  54. 54. 54  Oesophageal motility is assessed with multiple single swallows in different positions,  including recumbent (unlike in a videofluoroscopy assessment of oropharyngeal dysphagia) , to assess peristalsis without the effect of gravity.  Continuous and single swallows are observed separately as a second swallow obliterates peristalsis of the first. The oesophageal stage lasts for 8-20 seconds.
  55. 55. CT & MRI 55  These techniques each show structural lesions, for example the intracranial disease causing neurogenic dysphagia ?  More recently, high speed MRI has been used for dynamic analysis of the pharyngeal phase of swallowing, where the oral, pharyngeal and laryngeal musculature can be evaluated during movement.  experimental and costly, and patients need to be supine - which does not reflect the true physiology of swallowing.
  56. 56. Fibreoptic endoscopic evaluation of swallowing (FEES) 56  Also known as video endoscopic evaluation of swallowing (VEES). Or 'milk nasendoscopy.  Trans-nasal insertion of the nasendoscope provides assessment of pharyngeal and laryngeal anatomy and physiology at rest and in the pre-and post -swallow stages of dry (saliva) and bolus swallows, using normal food and drink.
  57. 57. Fibreoptic endoscopic Evaluation of swallowing with sensory testing (FEESST) 57  This is extended technique  Quantitatively measures sensory loss in the supraglottic larynx and pharynx by sending air pulses of differing intensity, duration and frequency through an additional port in the endoscope.  it is an important development as reduced or absent laryngeal sensation found in endoscopy correlates with silent aspiration and thus the risk of aspiration pneumonia.
  58. 58. PROCEDURE 58  The patient sits upright, the nostrils are examined to detect any septal deviation.  topical anaesthesia is applied to the nasal passages (sparingly to avoid desensitizing the pharynx and larynx).  Dry and bolus swallows of coloured liquid and food (using food colouring), are given in measured volumes.
  59. 59. Four different views allow observation of anatomy and physiology during swallowing as follows: 59 1. Nasal passage for elevation of the dorsal side of the velum. 2. Nasopharynx for nasal reflux and lateral and posterior pharyngeal walls. 3. Oropharynx for base of tongue, epiglottis and Larynx. 4. Hypopharynx for pyriform fossae, vocal folds and upper
  60. 60. Equipment 60  Includes a flexible nasendoscope, with camera for video or digital (including auditory) recording and slow motion playback facilities, with an additional colour monitor for immediate biofeedback with the patient.  Developments include reducing the scope diameter, picture clarity and size, light source strength and portability.  For FEESST, a specially designed scope and pulse generator are needed to deliver quantifiable air Pulses .
  61. 61. ADVANTAGES 61  Good views of any alterations in the anatomy and of muscular function in the nasopharynx, oropharynx and hypopharynx.  Quantitative objective assessment of pharyngeal and laryngeal sensitivity with FEESST.  Assessment of initiation and maintenance of airway protection.  Visualization of secretions and any pooling of secretions, thus helping overall management.
  62. 62. 62  Ability to assess swallow without giving food or drink to those patients who are nil by mouth.  Observation of swallowing with a range of normal food and drink.  Lengthy or repeated assessments without radiation exposure. This enables assessment throughout a meal (to evaluate swallow fatigue, effective of cumulative bolus residue, delayed reaction to aspiration and effectiveness of coughing).  Real time and repeated biofeedback to the patient for evaluating the effectiveness of therapeutic manoeuvres.  Portable and easy implementation at the bedside and in the clinic.
  63. 63. LIMITATIONS  No view for evaluation of bolus management in the oral cavity.  Loss of view ('whiteout') during the swallow due to pharyngeal constriction around the endoscope lens.  Quantitative measures of structure displacement are not possible.  Limited ability to estimate amount of aspirated material. 63
  64. 64. CONTRAINDICATIONS 64  Unsuitable patients (e.g. those who are unable to maintain a stable position, drowsy, uncooperative) .  Predisposition to risk factors (history of bronchospasm or laryngospasm, severe heart disease, recent respiratory distress, allergies) .  Lack of appropriate medical and nursing support. Physical obstruction to passing the scope (e.g. extreme deviation of septum, oedematous mucosa, hypersensitivity) .  Obscured view (e.g. large epiglottis, thick secretions)  Maxillary and other supraglottic resections.
  65. 65. Risks 65  The potential complications listed below are extremely rare, however, awareness of the risks is important for those performing FEES.  Aspiration – (suction equipment should be readily available).  Vasovagal responses of hypotension, bradycardia or cardiac dysrhythmia. These risks are minimized by local anaesthesia of the nasal mucosa and care manipulating the scope in the hypopharynx.
  66. 66. 66  Laryngospasm is less likely to occur in patients with pooling and aspiration of secretions who also have poor tactile sensitivity of the larynx, and who therefore usually need sensation testing. Probing of the hypopharynx and larynx should be cautious in those who swallow normally, are asymptomatic of aspiration, with an adequate cough reflex.  Nose bleeds can be avoided by the use of topical decongestant and lubrication of the scope.  Adverse reactions to the topical anaesthetic are rare, but take an adequate case history, adhere to recommended doses and have resuscitation measures available.
  67. 67. Video- FEES 67
  68. 68. MANOMETRY 68  Directly measures:-  amplitude and duration of contraction and relaxation pressures in the pharynx, UOS, oesophagus and lower oesophageal sphincter (LOS).  Measurements are taken at rest and during swallowing.
  69. 69. Oesophageal Manometry 69  The oesophageal peristaltic wave pressure rises slowly to approximately 50 mmHg, and falls rapidly.  Secondary peristaltic waves arise locally in response to distension, needed for more solid bolus transportation.  Tertiary oesophageal contractions are irregular, nonpropulsive contractions involving long segments of the oesophagus.  The 3 cm long LOS behaves like the UOS, but with a lower tonic (resting) contraction pressure of 10-30 mmHg relative to intragastric pressure.  It remains closed except for relaxation when the bolus and peristaltic wave arrive, as swallowing induces inhibition of lower oesophageal sphincter tone activity.
  70. 70. Pharyngeal Manometry Pressure changes in the oropharynx and UOS are required for effective bolus transit and UOS opening during swallowing. UOS opening involves:  Cricopharyngeal muscle relaxation, preceding opening by 0.1 second;  Hyoid and laryngeal elevation, pulling the UOS open;  Pharyngeal and tongue base pressure (up to 90 mmHg) on the bolus further pushing open the UOS;  Cricopharyngeal elasticity allowing the UOS to stretch open for larger boluses; 70
  71. 71. 71  Closure of the UOS with increased pressure (90 mmHg) ;  Return to an UOS tonic (resting) pressure of approximately 45 mmHg.  The UOS remains closed with increased tonic pressure with each inspiration to avoid aerophagy.
  72. 72. LIMITATIONS 72  Conventional pharyngeal manometry involves using a catheter with a limited number (three or four) of pressure sensors spanning the oropharynx and hypopharynx (including the UOS), in a unidirectional or multidirectional orientation.  Susceptible to technical difficulties with accurate sensor placement, and inter- and intra subject variation.  Radial asymmetry of the UOS, as anterior-posterior pressures are two or three times greater than those recorded laterally because contraction of the cricopharyngeus muscle compresses the UOS against the trachea into an oval slit-like aperture.  Longitudinal (axial) asymmetry of the UOS, with larger anterior pressures closer to the pharynx and larger posterior pressures closer to the oesophagus, especially in men;
  73. 73.  Upward movement of the UOS during swallowing due to laryngeal movement. Consequently the sensor may be left in the open oesophageal lumen without recording UOS relaxation.  Sensitivity of UOS to diameter size requires the smallest diameter catheter possible (e.g. 3 mm or less) to avoid inaccurate and increased UOS tonic pressure readings;  UOS tonic pressure increases with stress and decreases during sleep;  Over 60 years of age, tonic pressures decline and pharyngeal pressures during swallowing increase as a result of reduced compliance of the UOS, thus requiring greater force to push large boluses through a less stretchable sphincter 73
  74. 74. 74  The barrier formed by LOS tonic pressure is lower after meals and tighter at night.  Similar to the UOS, measurement of the LOS tonic pressure is complicated by radial asymmetry and a respiratory pressure fluctuation.  Because of the differences in anatomy and physiology and the frequency of recordings, catheters with miniature strain gauge pressure transducer sensors are required.
  75. 75. High-resolution manometry 75  Recent advance over conventional manometry for taking measurements of the oesophagus and upper and lower oesophageal sphincters.  It has been made possible by the development of micro-manometric water-perfused assemblies and miniaturized solid-state pressure sensors.  The presence of closely spaced recording sensors in HRM (up to one pressure sensor per cm) provides several procedural advantages over conventional manometry.
  76. 76. 76  It removes the need for the time-consuming station pull through procedure and facilitates the accurate positioning of the catheter.  For pharyngeal and UOS measurements, a solid state high-resolution manometry catheter can have a total of 36 pressure sensing elements.  Sensors are spaced at 1 cm intervals; with each sensor detecting pressure changes over a length of 2.5 mm and consisting of 12 circumferentially dispersed smaller sensing elements.  The pressure recorded at each axial location is the mean pressure measured from the 12 elements.
  77. 77. 77  Computer technology allows the large data set acquired by HRM to be analysed and presented in realtime.  Concurrent video fluoroscopy images displayed in the same record as HRM allow simultaneous analysis,  HRM detects segmental abnormalities of oesophageal function and predicts the success of bolus transport more accurately than conventional oesophageal manometry, and identifies clinically important abnormalities not detected by other investigations
  78. 78. High-resolution manometry video 78
  79. 79. 79
  80. 80. Manofluoroscopy 80  Pharyngeal manometry is rarely the first or sole study used to evaluate swallowing function, because of the limitations , particularly when using conventional manometry.  More information is provided when it is performed simultaneously with videofluoroscopy, termed manofluoroscopy or videomanometry.  Shows a simultaneous image with pressure readings so that clinicians gain information about bolus flow relative to anatomical movements.  Radio-opaque metal housing around each pressure sensor gives accurate information about the placement and position of the sensors during movement to ensure.
  81. 81. Advantages 81  Manofluoroscopy aids clinical decisions about the need for medical procedures:  It provides information to distinguish between UOS opening with and without relaxation of the cricopharyngeal musculature.  Where adequate UOS relaxation is occurring, manofluoroscopy can help to differentiate between poor opening of the UOS secondary to weak pharyngeal and tongue forces; poor elevation of the hyoid; and decreased elasticity of the cricopharyngeus muscle.  Videofluoroscopy alone without manometry cannot make the above distinctions.
  82. 82. Procedure 82  Standard methodology for oropharyngeal manometry is needed because of the technical and subject variables.  To date, Normal and dysphagic results are not directly or numerically comparable because of different equipment and procedures.  Salassa et al. have proposed catheter standards for pharyngeal manofluoroscopy, which aim to enable comparison of the same patient over time; to establish normal ranges for all parameters; and to evaluate abnormal results in relation to the diagnosis, treatment, outcome and effectiveness of treatments.
  83. 83. Equipment 83 Sensor type  Catheters with miniature strain gauge pressure transducer sensors are required for pharyngeal and UOS measurements for the following reasons.  Striated muscle contractions are quicker in the oropharyngeal area, producing altering pressures of higher frequency and amplitude, compared with the slower smooth muscle contractions in the oesophagus.  The pharyngeal pressure 'wave' travels at a speed of 9-25 cm per second (requiring a recording frequency of over 50 Hz), whereas the slower oesophageal wave travels at 4 cm per second (requiring a recording frequency of 5 Hz).
  84. 84.  Patients can be tested in a normal upright position, unlike the supine position with water perfused catheters.  Although less expensive, water perfused catheters are usually slower to set up and use, and they also introduce water into the pharynx, so causing unwanted swallows and poor tolerance. 84
  85. 85. 85 Catheter  The diameter should be small (3 mm or less) both for comfort and to avoid the reactive increase in UOS tonic pressure.  Catheters with fibreoptical 'sensors' are available, and these provide circumferential readings without increasing the catheter diameter.  An ovoid shaped catheter helps to maintain correct orientation, (as UOS radial pressures are asymmetrical).  Clear markings in centimetres, with the distal sensor marked at 0 cm, indicates anterior and posterior orientation, and helps with the inter-subject variation in pharyngeal length and UOS high pressure zone length.
  86. 86. 86  Catheters need to be 100 cm long for oseophageal manometry.  A short (4 cm) malleable section of the catheter should extend past the most distal sensor to enable easier naso-pharyngeal insertion  Also to allow some of the catheter to pass into the oesophagus to provide catheter stability laterally and horizontally during manometry recordings
  87. 87. 87 Sensor spacing and placement in conventional manometry  One sensor each should be placed in three (or four) locations, which are level with  the tongue base,  hypopharynx,  UOS (and upper cervical oesophagus); (with 2 and 3 cm between the sensors in the order stated above)  Unidirectional in-line sensors, orientated posteriorly, capture readings of maximum amplitude.  The advantage of circumferential sensors is that radial asymmetries can be averaged, and readings are not affected by unwanted changes in the orientation of the catheter.
  88. 88.  Correct placement of the UOS sensor can be seen during swallowing by production of a waveform that has a negative nadir, preceded and followed by an elevated pressure wave and clearing wave.  A pressure transducer too high in the nasopharynx should be avoided in case the readings record the soft palate against the posterior pharyngeal wall. 88
  89. 89. 89  The techniques of station pull through (SPT) or rapid pull through (RPT) are used to position the catheters accurately. Each sensor passes the DOS in Turn.  In HRM, the above procedural difficulties are overcome by the large number of circumferentially placed and closely spaced sensors.
  90. 90. METHODOLOGY 90 Salassa et al. also suggest that methodology guidelines are still needed in order to standardize:  Bolus volumes, consistencies and temperatures;  Duration of swallow intervals;  Single or multiple swallow analysis;  Methods to obtain and values of pressure recordings to analyse;  Comparable software analysis systems.
  91. 91. Recordings 91  A computerized mulitchannel recording device is used to collect store and display the pressure readings.  A channel is needed for each transducer pressure reading, and these are displayed in graph form with amplitude (x axis) against time (Y axis).
  92. 92. 92  Computer recordings are accurate, quick and unbiased.  Automatic data collation into a database gives faster analysis and interpretation.  The frequency by which pressure reading data is recorded needs to be standardized.  Each laboratory needs to decide whether to average all the readings taken at the UOS) and for this to be a constant in recorded values over time and between patients.
  93. 93. Calibration 93  Regular calibration of the equipment is necessary before the equipment is used.  The measurement of UOS pressure is usually expressed relative to intrapharyngeal zero baseline, (equivalent to atmospheric pressure).  Sensors are zeroed to an accurate baseline of atmospheric pressure) then a known pressure (e.g. 200 mmHg) is applied to calibrate) before readings are taken.
  94. 94. 94 CONTRAINDICATIONS  Patients suspected of having a perforated gastrointestinal tract.  Same as Endoscopy.
  95. 95. Analysis 95  UOS tonic (resting) pressures, and variations in pressure in the pharynx, UOS and oesophagus during swallowing are the main measurements. Large numbers of swallows per subject are needed due to intra-subject variability.  Two types of pressure can be analysed, and both are seen within one pressure wave shape : 1. Bolus pressure on the sensors as they are surrounded by fluid, also called intra-bolus or luminal or cavity pressure, and usually small in amplitude. 2. Contact pressure from contraction of the lumen walls on the sensors during
  96. 96. 96  Measurements made include: 1. maximum and minimum pressures; 2. duration of contraction with the sequence, and relative timing of contractions and relaxations.
  97. 97. OTHER INVESTIGATIONS 97 Respiration  The oropharyngeal tract is the same anatomical channel for swallowing and breathing, resulting in the need for deglutition apnoea and the potential risk of aspiration.  Respiratory recordings can measure the duration and timing of deglutition apnoea, direction and rate of airflow and thus a more complete picture of the physiology of swallowing.  Continuous recordings of oxygen saturation by pulse oximetry have also been investigated as a possible marker of aspiration with conflicting results.
  98. 98. Ultrasound 98  The ultrasound transducer with high frequency sounds ( > 2 MHz) is placed sub mentally to produce dynamic images of the soft tissue in the oral cavity and parts of the oropharynx, and the motion of the hyoid can be tracked.  It is noninvasive and risk free.  Quality of the tongue image, for measuring tongue movements, is not easy to interpret.  The pharyngeal stage of swallowing cannot be viewed.
  99. 99. Oesophageal pH monitoring 99  Prolonged (24-hour ambulatory) pH monitoring is the most reliable method of diagnosing gastro-oesophageal reflux, especially atypical presentations.  The distal oesophageal pH probe is placed 5 cm above the LOS (position determined by manometry) and the proximal one below the UOS, thus any reflux is measured along the entire length of the oesophagus.  However, the invasive technique prevents some patients from undertaking activities that provoke reflux during the investigation, so underestimating their problems?
  100. 100. Scintigraphy 100  This procedure tracks movement of the bolus over time, and quantifies the residual bolus in the oropharynx, larynx and trachea, using radio nuclide material with liquid or food, and a gamma camera.  Although it detects aspiration and reflux, it does not have a significant advantage over other functional investigations as it does not image anatomy and physiology, nor does it image the biomechanics of swallowing, and the cause of aspiration cannot be determined.
  101. 101. Lingual pressure recording 101  Recently, three-bulb linear manometric sensor arrays (Kay Elemetrics Workstation) have been used to evaluate the timing and pressure patterns of the tongue during the oral phase of swallowing.  The small strain gauge pressure sensors are attached to the palate).
  102. 102. Electromyography  Surface electromyography (sEMG) measures the amplitude (voltage) of swallowing muscle activity (from the submental muscle group) from electrodes placed on the throat, and is a method for identifying the onset of swallowing only.  Activity is recorded from any or all of the submental muscles during swallowing, and they are variable in their order of activation both within and between subjects. 102
  103. 103. Thank You 103
  104. 104. 104
  105. 105. Double contrast image of pharynx 105
  106. 106. Examination of oesophagus 106
  107. 107. Dc image of gastro oesophageal junction 107
  108. 108. asymmetry 108
  109. 109. Stasis 109
  110. 110. Cricopharyngeal dysfunction 110
  111. 111. 111
  112. 112. 112
  113. 113. 113
  114. 114. 114
  115. 115. 115
  116. 116. 116
  117. 117. Aspiration 117
  118. 118. Web 118
  119. 119. 119 THANK YOU
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swallowing, deglutition, dysphagia. physiology, investigations, manometry, fluroscopy, HRM, FEES, FEESST,

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