Disorders of Swallowing

Chapter 98

Disorders of Swallowing

Phonation and coordinated movement of liquid and food are the result of complex, integrated, and intact neuromuscular function. When a person’s swallowing function is abnormal because of a structural anomaly, neuromuscular deficit, or postsurgical change, a swallowing function study can be performed. Most swallowing disorders in infants and children are a result of neurologic abnormalities, of which cerebral palsy is the most common.1,2

General Examination Principles

Specialized radiographic studies of deglutition can be performed in the radiology department in association with occupational therapists or speech pathologists, depending on the institution. Usually a videofluoroscopic swallow study (VFSS) is performed.

The history related to feeding and associated clinical conditions of the patient must be detailed and should include data about the acuity of the clinical complaint, the child’s feeding history, the ability to suck, the use of utensils, positioning and irritability during and after feeding, usual appetite, and signs of fatigue during feeding.

The initial step in the swallowing evaluation is to assess the competence of the velopharyngeal mechanism. First, the patient is observed during quiet breathing and phonation. During feeding, the patient is placed in the true lateral position and is fed contrast material of varying thickness with a bottle with a nipple initially, while swallowing is evaluated in real time with video fluoroscopy, including examination from the mouth to the carina. Either a single image or a sweeping image down to the carina and back to the mouth may be obtained.36 Imaging in the frontal projection using a basal or Towne view6 may be performed after lateral imaging; this view permits evaluation of lateral wall movement and correlation with nasopharyngoscopy (e-Fig. 98-1).3,7

If the infant will not take contrast material from the nipple, the contrast material can be introduced into the baby’s mouth carefully with a blunt-tipped syringe (between the cheek and the lateral aspect of the teeth or gums), or a feeding tube can be inserted through the nipple into the baby’s mouth and contrast material can be introduced in a controlled manner under fluoroscopic guidance to initiate swallowing (e-Fig. 98-2). The contrast medium is mixed with increasingly thicker food mixtures, beginning with thin liquids and progressing to solid food if such food is age appropriate. Evaluation of the patient’s ability to handle food with different textures aids in planning an appropriate diet to meet nutritional needs and in planning future therapy. If the patient requires a special diet or only eats certain foods, this food can be brought to the examination and used for the study.

Causes of Swallowing Dysfunction

The most common causes of swallowing dysfunction in pediatric patients include central neurologic dysfunction, congenital anomalies with anatomic abnormalities and mechanical interference in the swallowing apparatus, congenital and acquired retropharyngeal processes, and connective tissue disorders.

Central Neurologic Dysfunction

Overview: Cerebral palsy is the most common cause of swallowing dysfunction in infants and children. Other neuromuscular disorders are brainstem dysfunction, cranial nerve abnormalities, intracranial neoplasms, meningomyelocele, muscular dystrophies, and myasthenia gravis. Familial dysautonomia (Riley-Day syndrome) leads to autonomic dysfunction with esophageal dysmotility and frequent aspiration pneumonias. Abnormality of the neuromuscular mechanism elevating the soft palate may lead to reflux of contrast material into the nasopharynx, with subsequent pooling of contrast in the pharynx and potential airway aspiration. Abnormalities of other muscle groups lead to defective function of the epiglottis and upper esophageal sphincter, with aspiration into the airway being common1 (Fig. 98-3; Videos 98-1 and 98-2).

Etiology: Swallowing dysfunction is related to dysfunction in one or more of the three phases of swallowing: the oral phase, with the inability to deliver food into the mouth (e.g., poor suck); the pharyngeal phase, with failure to move the food through the pharynx, elevate the soft palate, and close the epiglottis; and/or the upper esophageal phase, with abnormal coordination of relaxation and contraction of the upper esophageal sphincter.1 Swallowing coordination is mediated through the cranial nerves responsible for both sensation and motor function, as well as osseous and muscular structures supplied by both the autonomic and voluntary nervous system. Thus swallowing dysfunction may be due to a large number of conditions that affect any of the mechanical and functional processes necessary for normal swallowing and phonation.

Clinical Presentation: The severity of disordered swallowing and the resultant degree of aspiration will vary with the level of neurologic deficit. Depending on the specific neurologic defect, any or all components of the swallowing mechanism may be affected. Symptoms include nasopharyngeal regurgitation, gagging, coughing and choking during feedings, recurrent pneumonia, malnutrition, and failure to thrive.1,8

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Dec 20, 2015 | Posted by in PEDIATRIC IMAGING | Comments Off on Disorders of Swallowing

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