how to create barcode in using c# The Neurologic Basis of Swallowing in Microsoft Office

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The Neurologic Basis of Swallowing
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The act of swallowing, like breathing, continues periodically through waking and sleep, largely without conscious will or awareness Swallowing occurs at a natural frequency of about once per
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minute while an individual is idle; it is suppressed during concentration and emotional excitement The fundamental role of swallowing is to move food from the mouth to the esophagus and thereby to begin the process of digestion, but it also serves to empty the oral cavity of saliva and prevent its entry into the respiratory tract Since the oropharynx is a shared conduit for breathing and swallowing, obligatory re exes exist to assure that breathing is held in abeyance during swallowing Because of this relationship and the frequency with which dysphagia and aspiration complicate neurologic disease, the neural mechanisms that underlie swallowing are of considerable importance to the neurologist and are described here The reader is also referred to other parts of this book for a discussion of derangements of swallowing consequent upon diseases of the lower cranial nerves (Chap 47), of muscle (Chap 48), and of the neuromuscular junction (Chap 53) Anatomic and Physiologic Considerations A highly coordinated sequence of muscle contractions is required to move a bolus of food smoothly and safely through the oropharynx This programmed activity may be elicited voluntarily or by re ex movements that are triggered by sensory impulses from the posterior pharynx Swallowing normally begins as the tongue, innervated by cranial nerve XII, sweeps food to the posterior oral cavity, and brings the bolus into contact with the posterior wall of the oropharynx As the food passes the pillars of the fauces, tactile sensation, carried through nerves IX and X, re exly triggers (1) the contraction of levator and tensor veli palatini muscles, which close the nasopharynx and prevent nasal regurgitation, followed by (2) the upward and forward movement of the arytenoid cartilages toward the epiglottis (observed as an upward displacement of the hyoid and thyroid cartilages), which closes the airway With these movements the epiglottis guides the food into the valleculae and into channels formed by the epiglottic folds and the pharyngeal walls The airway is closed by sequential contractions of the arytenoid-epiglottic folds, and below them, the false cords, and then the true vocal cords, which seal the trachea All of these muscular contractions are effected largely by cranial nerve X (vagus) The palatopharyngeal muscles pull the pharynx up over the bolus and the stylopharyngeal muscles draw the sides of the pharynx outward (nerve IX) At the same time, the upward movement of the larynx opens the cricopharyngeal sphincter A wave of peristalsis then begins in the pharynx, pushing the bolus through the sphincter into the esophagus These muscles relax as soon as the bolus reaches the esophagus The entire swallowing ensemble can be elicited by stimulation of the superior laryngeal nerve (this route is used in experimental studies) Re ex swallowing requires only medullary functioning and is known to occur in the vegetative and locked-in states as well as in normal and anencephalic neonates The integrated sequence of muscle activity for swallowing is organized in a region of brainstem that roughly comprises a swallowing center, located in the region of the NTS, close to the respiratory centers This juxtaposition ostensibly allows the re ned coordination of swallowing with the cycle of breathing Besides a programmed period of apnea, there is a slight forced exhalation after each swallow that further prevents aspiration The studies of Jean, Kessler and others (cited by Blessing), using microinjections of excitatory neurotransmitters, have localized the swallowing center in animals more precisely to a region adjacent to the termination of the superior laryngeal nerve
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Unlike the generators of respiratory rhythm, the entire re ex apparatus for swallowing may be located in the NTS There is, however, no direct connection between the NTS and the cranial nerve motor nuclei Therefore it is presumed that control must be exerted through premotor neurons located in adjacent reticular brainstem regions There have been few comparable anatomic studies of the structures responsible for swallowing in humans As to the cortical regions that are involved in swallowing, it appears from PET studies that the inferior precentral gyrus and the posterior inferior frontal gyrus are activated, and lesions in these parts of the brain give rise to the most profound cases of dysphagia Dysphagia and Aspiration Weakness or incoordination of the swallowing apparatus is manifest as dysphagia and, at times, aspiration The patient himself is often able to discriminate one of several types of defect: (1) dif culty initiating swallowing, which leaves solids stuck in the oropharynx; (2) nasal regurgitation of liquids; (3) frequent coughing and choking immediately after swallowing and a hoarse, wet cough following the ingestion of uids; or (4) some combination of these Extrapyramidal diseases, notably Parkinson disease, reduce the frequency of swallowing and cause an incoordination of breathing and swallowing, as noted below It is surprising how often the tongue and the muscles that cause palatal elevation appear on direct examination to act normally despite an obvious failure of coordinated swallowing In this regard, the use of the gag re ex as a neurologic sign is quite limited, being most helpful when there is a medullary lesion or the lower cranial nerves are affected In our experience, palatal elevation in response to touching the posterior pharynx only demonstrates that cranial nerves IX and X and the local musculature are not entirely dysfunctional; however, the presence of the re ex does not assure the smooth coordination of the swallowing mechanism and, more importantly, does not obviate the risk of aspiration It should also be emphasized that dif culties with swallowing may begin subtly and express themselves as weight loss or as a noticeable increase in the time required to swallow and to eat a meal Nodding or sideways head movements to assist the propulsion of the bolus, or the need to repeatedly wash food down with water, are other clues to the presence of dysphagia Sometimes recurrent minor pneumonias are the only manifestation of intermittent ( silent ) aspiration A defect in the initiation of swallowing is usually attributable to weakness of the tongue and may be a manifestation of myasthenia gravis, motor neuron disease, or, rarely, in ammatory disease of the muscle; it may be due to palsies of the 12th cranial nerve (metastases at the base of the skull or meningoradiculitis, carotid dissection), and to a number of other causes In all these cases there is usually an associated dysarthria with dif culty pronouncing lingual sounds The second type of dysphagia, associated with nasal regurgitation of liquids, indicates a failure of velopalatine closure and is characteristic of myasthenia gravis, 10th nerve palsy of any cause, or incoordination of swallowing due to bulbar or pseudobulbar palsy A nasal pattern of speech with air escaping from the nose is a usual accompaniment Viewed from a physiologic perspective, the causes of aspiration fall into four main categories: (1) weakness of the pharyngeal musculature due to lesions of the vagus on one or both sides; (2) a myopathy (myotonic and oculopharyngeal dystrophies) or neuromuscular disease (amyotrophic lateral sclerosis and myasthenia gravis); (3) a medullary lesion that affects the NTS or the cranial motor nuclei (lateral medullary infarction is the prototype) but
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