1. Mechanical Swallowing Disorders

2. Mechanical Disorders Secondary to: Muscle loss
Loss of motor and/or sensory innervation
Peripheral structure loss
Oral
Pharyngeal
Esophageal
Frequently associated with cancerous processes

3. Clinical Manifestation
Can overlap with those observed in neurogenic dysphagia
Sialorrhea
Impaired mastication
Collection in the oral cavity and pharynx
Increased swallowing transit time
Delayed swallow initiation
Reduced pharyngeal peristalsis
aspiration

4. Differential Diagnosis
Acute Inflammation
Non-specific reactions to injury of the oropharyngeal tissue
Fungal
Bacterial
Viral
Chemical
Traumatic
May not be the primary cause of dysphagia, rather exacerbates an underlying compromise

5. Differential Diagnosis
Herpes Simplex
Viral
Round lesions
Lips
Pharynx
Buccal mucosa
Palatal and pharyngeal ulcers may cause pain during swallowing

6. Differential Diagnosis
Ludwig’s Angina: Most typical type of infection to impact swallowing
Symptoms
Massive tongue swelling and displacement
Red, tender floor of mouth
May extend posteriorly and result in epiglottis
Muffled voice
Swelling in the suprahyoid area
Complications
Asphyxia
Aspiration pneumonia
Lung abscess
Tongue necrosis

7. Differential Diagnosis
Ludwig’s Angina (con’t);
Treatment
IV antibiotics
Surgery
Drainage
Airway maintenance
Condition is typically related to:
Dental management
Abscess
Post extrication infection

8. Ludwig’s Angina

9. Lingual Tonsillitis
Pts complain of pain in the throat in the medial pharynx
Lump in the throat
Indirect laryngoscopy
Examine the base of the tongue and pharynx
Confirm diagnosis

10. Epiglotitis Inflammation of the supraglottic structures
Can result in acute respiratory stress
Airway obstruction
Symptoms
Pain
Dysphagia
Respiratory difficulty
Drooling
stridor
Dangerous in infants

11. Pharyngitis Red inflammation of the oropharyngeal area Viral Bacterial
May precede cold symptoms
Dysphagia
Mild fever
Streptococcal- most common bacterial form
Untreated can lead to rheumatic fever

12. Streptococcal Pharyngitis

13. Lateral pharyngeal Space Infection
May be secondary to primary tonsillitis or pharyngitis
Anterior presentation
Dysphagia
Trismus
High fever
Mandibular swelling/hardening
Systemic toxicity
Bulging of the lateral pharyngeal wall

14. Lateral pharyngeal Space Infection (con’t)
Anterior presentation
Treatment:
Antibiotics
Surgical drainage
Airway management
Posterior presentation
Sepsis
Edema and swelling of the epiglottis
Edema and swelling of the larynx
Dyspnea
Can lead to secondary infections
Sudden death syndrome
myocarditis

15. Retropharyngeal and Prevertebral Infections
Infections that occur in the pharyngoesophageal wall and spine
Retropharyngeal
Secondary to adjacent abscess or cervical trauma
Prevertebral
Secondary to osteomyelitis
Infected hemotomas following vertebral fracture
Complications
Meningitis
Spontaneous rupture of the larynx

16. Fungal Inflammation Candidiasis: most common (Thrush)
Soft, white lesions frequently on the tongue
Seen in immunosuppressed, debilitated pts
Long-term antibiotic tx
Those receiving irradiation tx
Differ from leukoplakia
Can be scraped away

17. Chemical Agents Exposure to chemicals
Can present as red or white lesions
Throat lozenges
Excessive use = decreased sensation
Aspirin
Gargles
Lye ingestion
Most severe chemical burn
Chemotherapy
Painful ulcerations

18. Pharyngoesophageal Diverticulum
Zenker’s diverticulum: weakness in muscle fibers that result in a “pouch” in which material can collect.
Above or below the cricopharyngeal muscle
Must be large to result in dysphagia symptoms
Regurgitation
Halitosis
Fullness
Weight loss
Nocturnal cough with aspiration
Small are not problematic. Large ones need surgury.

19. Zenker’s Diverticulum

20. Dysphagia Associated with Cancer

21. Cancer Tumor Staging Stage TNM System I T1 N0 M0 II T2 N0 M0 III
T1 or T3 N1 M0 IV
T4 N0 or N1 M0
Any T N2 or N3 M0
Any T any N M1
Just need to know what the letters mean. T4 is a BIG tumor. N- how many surrounding lyphnodes.
Metastasis – spread of cancer. MO means no spread of cancer
T = tumor size
N = nodal status
M = presence or absence of metastasis

22. Dysphagia Associated with Cancer
Constitute the largest group of people with mechanical disorders
Organ(s) involved
Adjacent structures
Not the size of the lesion, rather the area that is excised
Sensation
innervation

23. Oral lesions Anterior tongue Floor of the mouth Submental structures
Mandible
Maxilla
One or more of these structures may be partially (or totally) removed

24. Clinical Manifestations
Impairments in:
Mastication
Formation of the bolus
Retention of the bolus
Anteroposterior propulsion of the bolus
Premature penetration of the bolus, or particles of the bolus into the pharynx
Impaired sequence of movements

25. Glossectomy Partial or total glossectomy
Interferes with the oral phases of deglutition
Even total glossectomy pts are able to eat
Dependent upon the resection; if adjacent structures were involved
Age
Preoperative health
Size and position of primary tumor
Lymph node involvement
1/3 glossectomy good prognosis
Unless combined with mandibular resection
Usually oral candidates (PO trials) around 1month post surgery

26. Multiple Oral Structure Resection
Tongue, neck, floor of the mouth, and mandible
Multiple structure resection involves varying symptoms
Mastication
Bolus manipulation
Bolus transit
Posterior propulsion
Protecting the airway
Surgery can result in scar tissue contractures, TMJ pain

27. Oropharyngeal Resections
Lesions involving the posterior tongue, soft palate, tonsils, superior and lateral pharynx.
Clinical manifestations
Nasal regurgitation
Aspiration
PE segment dysfunction
Impaired transit
Altered pressure relationships
Use of reconstructive flaps
No sensory/innervation

28. Partial Laryngectomy
Attempt to control malignant growth but preserve voice and deglutition
Hemilaryngectomy
Unilateral resection of the TVF, VF, the ventricle, the SLN with preservation of the epiglottis
Mixed results in the literature

29. Partial Laryngectomy Supraglottic laryngectomy
Resection of both vestibular and aryepiglottic folds and unilateral or bilateral transection of the SLNs
Immediate dysphagia symptoms postoperatively
Varying results due to nonstandard definitions for the procedure
Resection without bilateral transection of the SLN has good prognosis
Extension of the resection of the resection results in moderate to severe symptoms in approximately ½ of patients.

30. Partial Laryngectomy Supraglottic laryngectomy
Predictors for improved deglutition
Mobile tongue base
Laryngeal elevation to the tongue base
Resected hyoid
Competent closure of the glottis.

31. Total Laryngectomy
Surgical separation of the respiratory and digestive tracts
Still at risk for dysphagia
Postoperatively
Malfunctioning CP (sphincter)
Impaired pharyngeal function
Recurrent neoplasm
Stricture
Fistulas
Irradiation procedures
May negatively impact deglutition
Mixed results
Two separate tracts

32. Tracheoesophageal Puncture
Tracheoesophageal fistula that is surgically created either during or after the primary surgery
Implications for deglutition
Aspiration saliva/food (two small or not fit correctly)
Aspiration of voice prosthesis
Stenosis
Stoma/fistula infection
Spasm
Enlargement

33. TEP

34. Irradiation Impaired saliva flow Mucositis Osteoradionecrosis
Implications for reduced saliva
Mucositis
Inflammation of the mucosa
Dissipates following the termination of the tx
Osteoradionecrosis
Mucosal destruction
Fibrosis
Decreased blood flow
Can invade the bone

35. Irradiation Trismus Loss of taste/appetite
Fibrosis of mastication muscles
Loss of taste/appetite
Effects of radiation
Decreased ability to taste, smell, chew, and swallow
Nausea
Modified diet
Weight loss
malnutrition
Trismus – lock jaw.

36. Miscellaneous Etiologies
Cervical Spine Disease
Osteophytes – bony growth from spine
Nasogastric tubes
Large vs. small bore
Excess salivation
Depressed cough reflex
Laryngopharyngeal injuries
GERD
Tube placement
Tracheostoma tubes
Limits laryngeal movement
Still have larynx but can’t breath well.