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DYSPHAGIA. 3:236. 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

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Dysphagia

DYSPHAGIA

3:236



Esophagus1

Esophagus

A. Empty tube approx.

20 cm in length

(See Figure 2-4, page 15 in Kahrilas)


Esophagus cont

Esophagus (cont.)

B. Two muscle layers

1. Inner circular layer

2. Outer longitudinal layer


Esophagus cont1

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 cont2

Esophagus (cont.)

D. Innervation -Vagus Nerve

1. Meissner's plexus - "submucosal" between muscularis mucosa and circular muscle layer



Esophagus cont3

Esophagus (cont.)

D. Innervation -Vagus Nerve (cont.)

2. Auerbach's plexus - "myenteric" between circular and longitudinal muscle layers



Esophagus cont4

Esophagus (cont.)

E. Esophageal Peristalsis

1. Onset with bolus entry through Upper Esophageal Segment

2. Moves from striated to smooth



A sensory input

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

A. Sensory Input (cont.)

2. Posterior 1/3 of tongue (cont.)

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


A sensory input cont1

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

B. Motor is from theInnervation

1. Glossopharyngeal (IX)

2. Vagus (X)

3. Hypoglossal (XII).


C central swallow center

C. CENTRAL SWALLOW CENTER? is from the

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


C central swallow center1

C. CENTRAL SWALLOW CENTER? is from the

1. Medullary Reticular Formation

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


C central swallow center2

C. CENTRAL SWALLOW CENTER? is from the

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 center3

C. CENTRAL SWALLOW CENTER? is from the

1. Medullary Reticular Formation

c. Sends excitatory motor output via anterior and lateral reticulospinal tract


Schematic of theoretical model of neural control of swallowing
Schematic of Theoretical Model of Neural Control of Swallowing

Cerebral Cortex

Corticoreticular

Pathway

Dorsal and Ventral

Trigeminal Lemniscus

MOTOR

PATHWAYS

SENSORY

PATHWAYS

Medullary Reticular

Formation

Reticulospinal

Pathway

Spinal Trigeminal

Neucleus and Tract

CN Motor Nuclei

V, IX, X, XII

Spinal Motor Neurons

CN Sensory Nuclei

VI, VII, X


C central swallow center4

C. CENTRAL SWALLOW CENTER? Swallowing

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 RESPONSE (HOWEVER, DAMAGE TO PRECENTRAL GYRUS HAS BEEN ASSOCIATED WITH ORAL PHASE IMPAIRMENT)

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.) (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

Swallow Response Neurophysiology (cont.) (cont.)

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


D. Sequence of muscle contraction events (cont.)

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


D sequence of muscle contraction events 2 leading complex activation

D. Sequence of muscle contraction events (cont.)

2. "Leading complex" activation


2. "Leading complex" activation (cont.)

a) Posterior tongue

b) Superior constrictor

c) Palatopharyngeus

d) Stylohyoid

e) Geniohyoid


D. Sequence of muscle contraction events (cont.)

3. Pharyngeal constrictors fire in overlapping order

4. Cricopharyngeal dilation

5. Esophageal peristalsis (velocity between 2-4 cm sec)


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