Swallowing Head NeckWord下载.docx

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oMucosalinjury

oMuscularweakness

oSensorydeficits

oConnectivetissuefibrosis

oBonyandsofttissuemasses

oRespiratorydisorders

oNeuralpathwaydisorders

Introduction

Normaldeglutitionrequiresacomplexandcoordinatedinteractionofmanyheadandneckstructures.Abnormalitiesanddisordersoforopharyngealanatomyandphysiologyatanylevelwillleadtosomeperceptibledysphagia.Normalhumanswallowisacombinationofvolitionaleventsandinvoluntaryreflexes.

Thisreviewdiscussesseveralofthediseasesanddisordersoftheheadandneckthatcanaffectswallowfunction.Themostclinicallyrelevantmethodoforganizationisbydiseasecategory,allowingforamoreglobalcharacterizationofthedysphagiainducedbyeachdisorder.Otherresourcesareprovidedforanin-depthunderstandingofthenormalanatomyandphysiologiceventsthatoccurduringanormalswallow.Specifically,thisreviewaddressesanatomicabnormalities,includingcongenital,postsurgical,ortumor-relatedchangesinoropharyngealanatomy;

neurologicandneuromotorabnormalitiesthatinterferewithboththereflexiveandvoluntarymotorfunctionsrequiredforanormaloropharyngealswallow;

infectiousdiseasesresultinginoropharyngealdysphagia;

iatrogenic,pharmacologic,andpsychiatriccausesofdysphagia;

andgastroesophagealrefluxdiseaseanditsprobableroleinoropharyngealdysphagia（Table1）.

Table1:

Majorcategoriesofheadandneckdisorderscausingdysphagia

Anatomic

Cricopharyngealdysfunction

Tumorsandmalignancy

Neurologic

Autoimmune,thyroidandsalivarydiseases

Infectiousdisorders

Pharmacologic

Laryngopharyngealreflux

Idiopathic/psychogenic

AnatomicAbnormalitiesInducingHeadandNeckSwallowingDisorders

Anatomicabnormalitiesintheheadandneckresultingindysphagiacanbegroupedintothreecategories:

congenitalabnormalities,traumaticinjuries,andsurgicalinsults.TheprimarycongenitalabnormalitiesassociatedwithdysphagiaarelistedinTable2.Thesedisordersmanifestthemselvesinallcasesduringinfancy.Traumaticabnormalitiesarecausedbydirectinjury,surgicalscaring,radiationtherapy,thermalinjury,orcausticingestion.Thecomplexanatomicproblemsassociatedwithheadandneckcanceranditstreatmentswillbediscussedseparately.

Table2:

Swallowingdysfunctionsduetocongenitalanatomicabnormalities

Cleftlipandpalate

Choanalatresia

Laryngomalacia

Laryngealclefts

Tracheoesophagealfistula/esophagealstenosis

Congenitaldisordersassociatedwithmicrognathia

Isolatedmicrognathia

PierreRobinsyndrome

Goldenhar'

ssyndrome

Vascularabnormalities

CongenitalAbnormalities

CleftLipandPalate

Cleftlipwithresultingoralincompetenceandcleftpalatewithresultingvelopharyngealincompetencecanleadtodysphagia.Thesecraniofacialabnormalitiesmayoccurindependentlyorincombinationwithotheranatomicabnormalitiesandcanbeassociatedwithothersyndromes.Acleftpalatecanprecludeaninfantfromcreatingappropriateintraoralnegativepressureduringsuckling.Theresultingdysphagiamayrequiremechanicalassistanceintheformofamodifiednipple,orevenatemporarytubefeeding.Earlysurgicalinterventionisnowcommonlythecase,withtherepairofboththecleftlipandpalateperformedoftenwithinthefirstyearoflife.1,2

Choanalatresiaandlaryngomalaciacanalsoleadtoswallowingdisordersinnewborns.Inbothcases,theswallowingdisordersaretheresultofrespiratorydifficultyduringfeeding.Choanalatresia,partialorcomplete,disruptsbreathingduringfeedingasthechildcannotmoveairthroughthenoseandnasopharynx.Laryngomalaciaisprimarilyarespiratorydisorder,butwhensevereitcandisruptfeedingowingtotheworkofbreathingandanassociationwithgastroesophagealreflux.

LaryngealCleftsandTracheoesophagealFistula

Laryngealcleftsarecategorizedbytheextentofclefting,rangingfromtype1,whichinvolvestheinterarytenoidspace,totype4,whichextendsdownintoandbeyondthethoracicinlet,involvingthetracheaandupperesophagus（Figure1）.3Largelaryngealcleftsareincompatiblewiththenormalswallowasaspirationoccurswithallswallowedand/orrefluxedmaterials.Surgicalclosureisrequiredpriortooralalimentation.Ontheotherhand,atracheoesophagealfistulamaymanifestasasubtle,difficulttodiagnose,smallfistuloustractpresentingwithrecurrentpneumoniasintheinfant.4Otherassociatedabnormalitiesmayincludetrachealstenosisandesophagealatresia.4

Figure1:

Laryngealcleftsclassification.

Type1:

supraglotticinterarytenoidcleft.Type2:

partialcricoidcleft.Type3:

totalcricoidcleft.Type4:

laryngoesophagealcleft.（Source:

BenjaminandInglis,3withpermissionfromAnnalsPublishingCo.）

Micrognathia（MandibularHypoplasia）

IsolatedmicrognathiaandmicrognathiaassociatedwithdisorderssuchasaPierreRobinsequence（micrognathia,glossoptosis,andcleftpalate）resultindysphagiasecondarytoposteriortonguedisplacement.Thisanatomicabnormalitycanleadtopoororopharyngealintakeanddifficultieswithupperairwaymaintenance.Infantsoftenrequireintervention.Nasogastrictubefeedingorevengastrostomytubefeedingmaybeneededtoprovidethechildwiththenecessarynutritiontosustainlife.Earlyairwayinterventionwithmandibulardistractionortracheostomyhasbeendescribedtoachieveasafeairway.

VascularAbnormalities

Vascularabnormalitiesofthegreatvesselshavebeendescribed,leadingtoprimarilyesophagealobstruction.Themostcommonlyidentifiedincludecompressivevascularringssecondarytoright-sidedaorticarchordoubleaorticarch,orcompressionsecondarytoaberrantrightsubclavianartery（dysphagialusoria）.Thesedisordersareeasilydiagnosedwithcontrastradiology.Severesymptomsrequiresurgicalinterventionwithresectionoftheaberrantrightsubclavianarteryandvascularrerouting.5

TraumaticandPostsurgical

Thedynamicnatureofswallowingrequiresmobilityofstructures.Laryngotrachealelevationandpharyngealcontractureoccurduringanormalswallow.Limitationorimpairmentofmobilityleadstodysphagia.Thepresenceofatracheotomy,scarring,fibrosis,ormucosaltraumafromingestionofcausticmaterialscanimpedenormalmovementandresultindysphagia.AlatersectioncoverscricopharyngealdysfunctionandZenker'

sdiverticulum.

Tracheotomy

Theassociationbetweentracheotomyanddysphagiahasbeensomewhatcontroversial.Athree-tieredprocessleadstoasafeswallowandpreventionofaspiration.Laryngealclosurewithlaryngealelevationundertheoverlyinghyoidanddownfoldingoftheepiglottisoverthetopofclosedvocalfoldsprotectstheairwayduringswallowing（Figure2）.6Tetheringofthetracheatotheskinbyatracheotomycanpreventthisfinalepiglotticdownfolding,leadingtobolustransporttowardaclosedglottiswithsecondaryaspirationuponopening.7Tracheotomiesmaynotonlytetherthelarynxinaninferiorposition,butalsointerferewiththenormalrespiratoryeventsthatsurroundswallow,includingthecreationofsubglotticpressureandinterferencewiththepatient'

sabilitytoproduceanadequatecough.Incaninestudies,thepresenceofanopentracheotomyaffectsthesensory,motor,andreflexactivitiesofthelarynx.8However,thegreatmajorityofpatientswithatracheotomyowingtoairwaydisorderssuchasglotticstenosis,subglotticstenosis,orsleepapneaareabletocompensateadequatelyandproduceanessentiallynormalswallow.Intheacutepatientsetting,nocausalrelationshipwasfoundbetweentracheotomyandaspiration.9

Figure2:

Mechanismofepiglotticdownfolding.

a:

Pre-swallowpositionforlarynxandhyoid.b:

Firstsuperiormovementoflaryngealelevationbelowhyoid.c:

Secondmovementoflarynxanteriorwithepiglottictipinferiordeflection.（Source:

VanDaeleetal.,6withpermissionfromBlackwellPublishing.）

IntrapharyngealScars

Intrapharyngealscarringproducedbylyeingestionsorthermalinjuriescanresultinsignificantobstructivedysphagia（Figure3）.Inseverecasessuperficialscarringatthelevelofthepyriformsinusandcervicalesophagusleadstocompleteinletobstruction.Thetreatmentforthistypeofscarformationisinmostcasesdilatationofthescarredregion.Inseverecases,theobstructedlevelmustbebypassed.Techniquesareavailableforcompletepharyngealandesophagealbypassprocedures,whichallowpatientstoresumeanearlynormaldiet,aslongastheirpharyngealmusculatureisintactandtheyareabletoproduceadequateboluspropulsionpressures（Figure4）.10

Figure3:

Pharyngeallyeinjection.

PharyngealLyeinjection.a:

Lateraltonguewithmucosalinjury.b:

Hypopharynxwithseveremucosalinjury.

Figure4:

Radialarteryforearmfreeflapreconstructionofcervicalesophagus.

Initialstageofreconstructionwithradialforearmfreeflappharyngealreconstructionopenontoanteriorchestwall.b:

Aftercoloninterpositionandattachmentofreconstructedpharynx.

CervicalSpineApproachesandOsteophytes

Dysphagiaassociatedwithcervicalosteophyteshasbeenreportedbymanyindividuals.TheassociationisprimarilywithlargelesionsbelowthelevelofC3.Itisnotcompletelyunderstoodwhetherthedysphagiaisowingtotheobstructionofthecervicalesophagusfromthemassoftheos