Pathophysiology

The fetus is capable of swallowing amniotic fluid in utero, indicating that the motor program for swallowing functions before gestation is complete.

However, oral feeding is not initiated in preterm infants before 32 weeks of postconceptional age, partly because the coordination of sucking,

Table 15.1 Differential diagnosis in dysphagia (adapted from reference 5)

Prematurity

Upper airway obstruction Nasal and nasopharyngeal cohanal atresia, stenosis, septal deflections and abscess, infections, tumors, sinusitis Oropharynx defects of lips and alveolar processes, cleft lip or palate, hypopharyngeal stenosis, craniofacial syndromes or sequences (e.g. Cruzon, Treacher-Collins syndrome, Pierre Robin sequence) Laryngeal laryngeal cleft and cyst, laryngomalacia, subglottic stenosis and paralysis

Congenital defects of the larynx, trachea and esophagus Laryngotracheoesophageal cleft

Tracheoesophageal fistula with associated esophageal atresia Esophageal anomalies (e.g. strictures, webs) Vascular anomalies aberrant right subclavian artery double aortic arch right aortic arch with left ligamentum

Acquired anatomic defects Trauma external trauma, intubation, endoscopic, foreign body Chemical ingestion

Neurological disorders Central nervous system trauma hypoxia and anoxia cortical atrophy, hypoplasia, agenesis infections (meningitis, brain abscess)

Peripheral nervous system disease Trauma

Congenital defects

Neuromuscular disorders Guillain-Barre syndrome Poliomyelitis (bulbar paralysis) Myasthenia gravis Myotonic muscular dystrophy

Anatomic and functional defects Crycopharyngeal dysfunction Esophageal achalasia Esophageal spasm Paralysis of the esophagus

Associated atresia-tracheoesophageal fistula, nerve defect

Peptic and eosinophilic esophagitis

Riley-Day syndrome (Dysautonomia)

Brain stem compression (e.g. Chiari malfomation, tumor)

Anatomic considerations 235

swallowing and respiration is not established.6 Even at 34 weeks, the minute ventilation during sucking decreases more than that of infants at 36-38 weeks. Therefore, the co-ordination between swallowing and breathing is not yet fully organized at 34 weeks of postconceptional age.7,8

Anatomic structures, which are essential to competent feeding skills, undergo growth that changes their physical relationship to one another and consequently affects their function. The swallowing mechanism, by which food is transmitted to the stomach and digestive organs, is a complex action involving 26 muscles and five cranial nerves. The neurophysiological control involves sensory afferent nerve fibers, motor efferent fibers, paired brainstem swallowing centers, and supra-bulbar neural input. Structural integrity is essential to the development of normal feeding and swallowing skills.9

Deglutition is generally divided into phases of swallowing, based on anatomic and functional characteristics: pre-oral, pharyngeal and esophageal.10,11

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