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DYSPHAGIA

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Esophagus

Esophagus
A. Empty tube approx.
20 cm in length
(See Figure 2-4, page 15 in
Kahrilas)

Esophagus (cont.)
B. Two muscle
layers
1. Inner circular layer
2. Outer longitudinal
layer

Esophagus (cont.)
C. Muscle Type
1. Upper 1/4 striated (similar
to pharyngeal muscles)

2. Middle 1/4 mixed


striated & smooth
3. Lower 1/2 smooth
(similar to gastric muscles)

Esophagus (cont.)
D. Innervation -Vagus Nerve

1. Meissner's plexus "submucosal" between


muscularis mucosa and
circular muscle layer

Meissner's plexus

Esophagus (cont.)
D. Innervation -Vagus Nerve
(cont.)
2. Auerbach's plexus "myenteric" between
circular and longitudinal
muscle layers

Auerbach's plexus

Esophagus (cont.)
E. Esophageal Peristalsis
1. Onset with bolus
entry through Upper
Esophageal Segment
2. Moves from striated to
smooth

Swallow Response
Neurophysiology

A. Sensory Input
1. Anterior 2/3 of tongue (cont.)
a) General Sensation Trigeminal (V) (Lingual
nerve)
b) Taste - Facial nerve (VII)
(chorda tympani)

A. Sensory Input (cont.)

2. Posterior 1/3 of tongue


(cont.)
a) Glossopharyngeal (IX) for
Gen. Sensation & Taste

A. Sensory Input (cont.)

3. Pharynx (gen sens.)


a) Vagus (X) (via SLN &
Pharyngeal Branch)
b) Glossopharyngeal(IX)

Primary Afferent input


controlling the swallowing
response is from the

Superior Laryngeal
Nerve.
(Kahrilas Figure 2-5, page 17)

B. Motor Innervation
1. Glossopharyngeal (IX)
2. Vagus (X)
3. Hypoglossal (XII).

C. CENTRAL
SWALLOW CENTER?
1. Medullary Reticular
Formation - most ventral
(toward belly) part of the
reticular formation extending
rostrally through the pons and
midbrain

C. CENTRAL SWALLOW CENTER?

1. Medullary Reticular
Formation
a. Receives sensory input
for swallowing from Vagus
(primarily superior laryngeal
nerve) and Glossopharyngeal
nerves.

C. CENTRAL SWALLOW CENTER?


1.

Medullary Reticular Formation

b. Receives excitatory
motor input from structures
involved in motor control
including the motor and
premotor cerebral cortex via
cortico reticular pathway

C. CENTRAL SWALLOW CENTER?


1.

Medullary Reticular Formation

c Sends excitatory motor

output via anterior and


lateral reticulospinal tract

Cerebral Cortex
Corticoreticular
Pathway

MOTOR
PATHWAYS

Dorsal and Ventral


Trigeminal Lemniscus

Medullary Reticular
Formation

Reticulospinal
Pathway
CN Motor Nuclei
V, IX, X, XII
Spinal Motor Neurons

SENSORY
PATHWAYS
Spinal Trigeminal
Neucleus and Tract

CN Sensory Nuclei
VI, VII, X

C. CENTRAL SWALLOW CENTER?


1.

Medullary Reticular Formation

d. Only one side of the


medullary swallowing center
is necessary to coordinate a
swallow response.

NOTE: CORTICAL INPUT IS


NOT NECESSARY FOR
NORMAL SWALLOW
RESPONSE (HOWEVER,
DAMAGE TO PRECENTRAL
GYRUS HAS BEEN
ASSOCIATED WITH ORAL
PHASE IMPAIRMENT)

C. Sequence of events from


CNS to cranial nerves
1 . Appropriate sensory
stimulation activates the
swallow center
2. "...the entire behavior of
swallowing results from
activation of the center." (p. 17)

C. Sequence of events from


CNS to cranial nerves (cont.)

3. A bilateral sequence of
excitation and inhibition
occurs involving
approximately 2 dozen
motoneuron pools scattered
throughout the brainstem.

C. Sequence of events from CNS


to cranial nerves (cont.)

4. Efferent signal activates


portions of the nucleus
ambiguous and nuclei of
cranial nerves V, VII, and
XII (associated with oral
phase)

C. Sequence of events from


CNS to cranial nerves (cont.)

5. Once stimulated, the


entire pharyngeal
swallowing response is
generated (CN X)

C. Sequence of events from


CNS to cranial nerves (cont.)

6. An apneic pause of .5 to 3.5


sec. accompanies swallowing.
The swallow center inhibitory
influence overrides respiratory
centers competing for access to
the same motoneurons.

Swallow Response
Neurophysiology (cont.)
D. Sequence of muscle
contraction events
(observed
experimentally, Doty &
Bosma, 1956)

D. Sequence of muscle contraction events

1. Mylohyoid contraction
(first detectible action,
precedes other muscular
contraction by 30-40 ms)

D. Sequence of muscle contraction events

2. "Leading complex"
activation

2. "Leading complex"
activation
a) Posterior tongue
b) Superior constrictor
c) Palatopharyngeus
d) Stylohyoid
e) Geniohyoid

D. Sequence of muscle contraction events

3. Pharyngeal constrictors
fire in overlapping order
4. Cricopharyngeal dilation
5. Esophageal peristalsis
(velocity between 2-4 cm
sec)