2. Normal swallowing process:
The swallowing movement of normal people can be divided into five stages: oral prophase, oral preparation stage, oral stage, pharyngeal stage and esophageal stage.
(1) Pre-oral period In the pre-oral period, people perceive food through sight and smell, and send food into their mouths with tableware, cups or fingers.
(2) Oral preparation refers to the process from food intake to chewing, which is the stage of preparation for swallowing. Food enters the mouth through the lips, teeth, chin, tongue, buccal muscles, hard palate and soft palate, and is chewed to form food balls. When food is processed in the oral cavity, the oral cavity presents a closed space, the front lip is closed, and the back tongue root is connected with the soft palate (tongue-palate connection) to prevent food from falling into the pharynx.
During this period, liquid diet does not need to be chewed, and the key lies in the control in the mouth; Semi-liquid and soft food can form food balls only through the squeezing movement of tongue and palate; However, solid food needs to be cut and ground through a complicated chewing process: the vertical and horizontal movements of the lower jaw, while the tongue stirs the food and mixes it with saliva, making it an easy-to-swallow food block.
(3) Oral phase refers to the short process of sending the chewed food balls to the pharynx. When the food piece moves from the mouth to the pharynx, the oral phase begins, and when the food piece passes through the pharyngeal gorge, it enters the pharyngeal phase. At the beginning of oral period, the tip of the tongue moves upward, and the contact surface between the tongue and the palate extends from front to back, pushing the food ball to the back of the mouth. Subsequently, the soft palate began to rise, the back of the tongue fell, the base of the tongue moved forward, and the food ball was pushed into the pharynx. At this time, the ascending soft palate is connected with the protruding posterior pharyngeal wall, blocking the gap between the upper pharynx and the middle pharynx, forming nasopharyngeal atresia.
(4) The stage in which the fast food ball moves from pharynx to esophagus through reflex motion. After the food ball enters the pharynx, it is surrounded by the tongue, soft palate and pharyngeal wall in the middle of the pharynx by the push of the root of the tongue. At this time, the larynx is raised, the laryngeal cavity is closed and the epiglottis is horizontal. With the contraction of the pharynx reaching the pharynx, the soft palate droops to close the pharyngeal isthmus, the hyoid bone and throat move forward and upward to the maximum extent, the epiglottis inclines downward, and the food mass enters the esophagus through the pharynx. Subsequently, the contraction of the pharynx enters the hypopharynx, and the food mass completely enters the esophagus. At this time, due to the close contact between the pharyngeal wall, the base of the tongue and the soft palate, the middle pharynx is completely closed and the throat is still closed. When the food mass is sent to the cervical esophagus, the position of each organ is restored and the respiratory tract is reopened. Under normal circumstances, swallowing reflex is completed within 1 sec.
(5) The esophageal phase begins when the food mass passes through the cricopharyngeal muscle. The esophagus produces a continuous peristaltic wave to push the food mass through the esophagus, and the lower esophageal sphincter located at the lower end of the esophagus relaxes, allowing the food mass to enter the stomach.
Normally, swallowing is controlled by the 5th (trigeminal nerve), 7th (facial nerve), 9th (glossopharyngeal nerve), 10 (vagus nerve), 1 1 (accessory nerve), 12 (hypoglossal nerve) and the first to third cervical nerves.
Therefore, any problem in any one of the five stages and pathological changes in related nerves may cause dysphagia.
3. Etiology:
(1) Etiology of functional dysphagia in oropharynx For young people, dysphagia in oropharynx is mainly caused by myositis, while for elderly patients, the main causes are central nervous system disorders, including stroke, Parkinson's disease and dementia.
A infection (such as retroperitoneal abscess), goiter, lymphadenopathy, Cenke diverticulum (such as diverticulum, the cause may be upper esophageal dysfunction), decreased muscle compliance (myositis, fibrosis), head and neck malignant tumor, neck osteophyte (rare), oropharyngeal malignant tumor and vegetation (rare).
B diseases of the central nervous system, such as stroke, Parkinson's disease, cranial nerve or bulbar palsy (such as multiple sclerosis and motor neuron disease), amyotrophic lateral sclerosis (ALS); Contraction dysfunction, such as cricopharyngeal spasm or myasthenia gravis.
50% patients with dysphagia are caused by stroke, and its severity is related to the severity of stroke.
C others such as dentition disorder, oral ulcer, dry mouth, long-term use of penicillin, etc.
(2) Etiology of esophageal functional dysphagia:
Mucosal diseases: ulcerative stenosis, esophagitis, esophageal tumor, chemical injury, radiation injury, infectious esophagitis and eosinophilic esophagitis secondary to gastroesophageal reflux disease.
B Mediastinal diseases: tumors (such as lung cancer and lymphoma), infections (such as tuberculosis and histoplasmosis) and cardiovascular diseases (auricular dilatation and vascular compression).
(3) Neuromuscular diseases: such as achalasia and scleroderma.
4. Clinical manifestations:
(1) Oral stage:
Weak lip muscles: food leaks from the mouth and drools.
B. Buccal muscle weakness: food mass formation disorder, food remains in the mouth after swallowing.
Soft palate weakness: aspiration before swallowing.
D sensory disturbance in the first 2/3 of the tongue: it affects the lifting and forming of food, which is characterized by chewing difficulty and forming food balls.
E food group recommendation obstacle: performance delay; Swallow in stages; Ineffective swallowing.
F. Look up and swallow: lack of swallowing reflex, food remains in the mouth.
G retrolingual 1/3 paralysis, tongue-palate connection disorder: aspiration before swallowing.
H chewing weakness.
(2) Pharyngeal stage:
A the soft palate can't touch the posterior pharyngeal wall normally: nasal reflux, nasal sound when speaking.
B Postlingual 1/3 muscle weakness: the ability to push food decreased and the pharynx prolonged.
C weakening of the upper and lower hyoid muscles: weak or unable to lift the larynx.
D. The upper pharyngeal sphincter cannot contract normally: food stays in the upper pharynx, and food nasal reflux occurs when swallowing is completed.
E pharyngeal sphincter weakness: food stays in the pharynx and is repeatedly swallowed to remove food in the pharynx, that is, repeated swallowing.
F in severe cases, the swallowing reflex is delayed or lacking, and the throat feels abnormal, so that the food cannot be effectively perceived after reaching the throat, resulting in delayed or lacking swallowing.
G epiglottis can't be folded completely or incompletely, and the movement of spoon cartilage is not smooth, which causes laryngeal insufficiency, cough when eating, difficulty in making sound or wet hoarseness.
H vocal cord paralysis: hoarseness and low tone.
Glottic insufficiency: aspiration when swallowing.
The compliance of J-ring muscle is reduced, and it can't be completely opened or not coordinated with the pharyngeal propulsion: food stays in the pharynx, food sticks to the pharynx, swallowing is difficult, and aspiration is caused after the airway is opened.
K the amount of one bite is reduced (normal 20ML).
L spontaneous cough is weakened: the risk of aspiration is increased.