The process of swallowing food in humans. When swallowing, the soft palate closes. Neuromuscular components of normal swallowing

Swallowing is a natural process of the body during food intake. During the act of swallowing, the throat muscles make more than hundreds of movements throughout the day. It is one of those processes that you barely notice until disturbances occur. During swallowing, the circular muscle in the upper esophagus, called the sphincter, relaxes. This process moves the contents of the mouth through the throat and into the digestive system. This process proceeds smoothly in the absence of tension and fear. In these emotional states, spasms occur in the throat. Swallowing problems or dysphagia accompanied by pain and unpleasant sensations in the throat. This serious disruption of the body's natural reflexes must be treated.

Causes of swallowing disorders

The causes of swallowing disorders can be mainly divided into mechanical And functional. The first arise as a result of a discrepancy between the size of a piece of food and the lumen of the esophagus. Functional ones occur when peristalsis is impaired. It must be taken into account that impaired swallowing results in exhaustion of the body, weight loss, and coughing. Pneumonia may also develop.

A narrowing of the esophagus can also be a swallowing problem. It can occur as a result of:

• edema (sore throat, stomatitis);
• stenosis (food and pharyngeal);
• scars (burns, post-operative);
• healthy tumors (esophageal cancer);
• benign formations (polyps, sore throats).

There may also be external pressure on the esophagus, as a result of:

• increase thyroid gland;
• cervical spondylitis;
• diverticulum;
• ostephyte.

Functional disorders Swallowing is associated with muscle dysfunction due to:

• tongue paralysis;
• damage to the glossopharyngeal nerve;
• diseases of the muscles of the pharynx and esophagus (stroke);
• damage to the smooth muscles of the esophagus (neuropathy, myopathy, alcoholism).

Approximately 50% of people with swallowing problems have had a stroke. Can also be quite rare causes swallowing disorders, namely:

• Parkinson's disease;
• multiple sclerosis;
• cerebral paralysis;
• chronic inflammation lungs;
• systemic scleroderma (connective tissue diseases);
• esophagitis (inflammation of the esophageal mucosa).

Associated factors of swallowing disorders

It is necessary to understand that swallowing disorders are also associated with the following factors:

• pain and shortness of breath;
• cough during and after swallowing;
• feeling of lack of air while swallowing.

"Lump in the throat" syndrome

The feeling of a lump in the throat is a common complaint of patients when visiting an otolaryngologist. There are several reasons for this feeling:

• There is an object in the throat that interferes with the act of swallowing;
• reflux disease;
• chronic pharyngitis;
• psychological factors.

Reflux- This is the backflow of stomach contents into the esophagus and further into the throat. Muscle spasm in the throat, which causes the feeling of a “coma,” is provoked by gastric contents (the acidic contents of the stomach burn the mucous membrane of the esophagus and throat). Quite often, the appearance of the “coma in the throat” syndrome is facilitated by stressful situations, a state of strong excitement or fear.

Consequences of swallowing disorders

Elimination of the causes of the disease should be taken seriously, as complications can be serious. In severe cases, you may experience:

• Esophagitis (inflammation of the esophagus);
• development of esophageal cancer;
• aspiration pneumonia;
• lung abscesses;
• pneumosclerosis.

Prevention of swallowing disorders

To avoid problems with swallowing, you need to eat a rational and balanced diet and stop smoking. It is also important to monitor with a doctor and treat throat diseases in a timely manner. In some cases, swallowing disorders can be caused in children by swallowing small toys and parts. It is necessary to monitor them and not purchase toys with too small parts.

Treatment of swallowing disorders

Treatment primarily depends on the cause of the swallowing problem. Today, swallowing disorders do not pose a serious threat to the patient’s life if you consult a specialist in time. The doctor will help determine the cause and eliminate it. If the patient has tumors that cause swallowing problems, additional consultation with an oncologist is necessary. For neurological causes of swallowing disorders, a consultation with a psychotherapist is carried out. The attending physician prescribes a special medication for the patient diet, Almost all products are consumed in puree form so as not to irritate the esophagus. If the patient is not able to eat independently, feeding occurs through a tube or intravenously. In case of muscle dysfunction, special exercises are prescribed, and sometimes the esophagus is dilated. Massage for dysphagia is also effective. In case of gastroesophageal reflux or esophagitis, the prescribed medications will reduce stomach acidity.

Liquid from the oral cavity, if it is not retained by volitional effort, immediately passes into the stomach. Solid food is crushed. Grinding food, the act of chewing and mixing food with the secretion of the salivary glands occur both reflexively and voluntarily, which especially affects the duration of chewing, although it can be canceled by voluntary effort. Voluntary processes are possible due to the participation in their regulation of the so-called chewing center of the brain; there is a bilateral representation of chewing movements at the level of the cerebral cortex.

The activity of the masticatory muscles is divided into isometric and isotonic phases. Cycles of repeated movements are combined into the chewing period. The temporal and quantitative indicators of its constituent phases depend on the properties of the food: consistency, composition, taste. The habit of chewing for a long time or, on the contrary, swallowing pieces of food practically without chewing arises in the process of learning in childhood and throughout adult life. Thus, in case of chewing disorders, in the absence of teeth, or poorly made dentures, they often prefer to swallow food without thoroughly crushing it. Physiologically, chewing is not absolutely necessary for normal digestion. Pieces of food, if it is possible to swallow them, during digestion successfully undergo digestion processes in the stomach and small intestine, and the transmembrane transfer of nutrients is carried out according to its own laws. The position that has become the property of textbooks and popular literature that grinding and chopping food in the oral cavity does not at all serve as a guarantee of subsequent successful digestion and absorption (this occurs especially demonstratively in predatory animals) is probably not yet a final conclusion for human physiology. Grinding food, and perhaps even its very presence in the oral cavity, causes the secretion of saliva; if not complete mixing of food with saliva, then enveloping it in the secretion of the salivary glands allows the secretion of the salivary glands to enter the stomach. This is not indifferent to subsequent gastric and intestinal digestion, since it has been established that the secretion of the salivary glands, rich in kallikrein, probably contains other substances that cause a delay in the evacuation of food from the stomach and at the same time facilitate the subsequent assimilation of carbohydrates. Food in the oral cavity serves as a source of stimulation of numerous receptors (chemoreceptors, thermoreceptors, baroreceptors). Then the flow of afferent excitation goes along the trigeminal and glossopharyngeal nerve, branches of the vagus nerves, branches of the superior cervical sympathetic ganglion and other nerve pathways. In addition to excitation of the “swallowing center” of the medulla oblongata, electrical responses of neurons in various parts of the cerebral cortex (inferior frontal gyrus, pre-central gyrus) and subcortical formations (amygdala complex and other formations) were established.

However, to all the popular arguments about the usefulness of thoroughly chewing food, it should be added that the secretion of the salivary glands contains a range of biologically active substances that perform a regulatory role in the organs of the digestive system, and information signals for the nervous system, both autonomic and central. nervous system. The functional state of the central nervous system is reflected in turn on the secretion of the salivary and gastric glands, up to a change in the quantitative indicators of the substances that make up the secretion, or on the appearance of additional products in it.

The act of swallowing, having once begun voluntarily (oral phase), then proceeds as an involuntary complex reflex process (pharyngeal, involuntary, fast and esophageal, slow phases). The end of one reflex serves as the beginning of the next: a huge number of receptor formations located in the mucous membrane along the digestive tube control the chain of reflex acts until food leaves the cavity of the esophagus. Here, in this section of the digestive apparatus, mechanisms for controlling functions, performed both by the cerebral cortex and automatically, are inseparably connected.

through the implementation of complex reflex acts with the participation of the central and autonomic nervous systems. About 13 muscle groups are involved in the act of swallowing.

When swallowing, movement of the tongue, velopharyngeal muscles of the larynx, vocal cords, epiglottis, and esophagus occurs, which ensures that the communication between the nasal and oral cavities and larynx is blocked. The pressure in the mouth, pharynx, and esophagus changes, and breathing stops. The act of swallowing, to describe it briefly, consists of several stages. In the oral cavity, a food bolus with a volume of 5-15 cm 3 is separated from the rest of the mass and, by moving the tongue towards the hard palate, moves towards the pharynx. This is followed by a change in the cavity of two sections of the pharynx; posterior wall of the pharynx: the upper and lower parts approach the anterior wall, the distal half of the tongue fills the space of the oral cavity, the movement of the soft palate complements this action of the tongue, displacing the bolus of food into the pharynx. Intraoral pressure increases. The next moment, the epiglottis blocks the entrance to the larynx. The bolus of food passes through the upper esophageal sphincter, which is accompanied by completion of the closure of the middle and lower part of the pharynx, its back wall.

The vocal cords close the glottis and insulate the trachea. When the food bolus reaches the pharynx, it is accompanied by contraction of the anterior arches of the soft palate, which, together with the root of the tongue, covers the proximal part of the cavity. Contraction of the pharyngeal muscles increases pressure. The latter is driving force for the passage of food bolus to the esophagus. The muscles of the upper esophageal sphincter relax, allowing the bolus to pass through, and contract again. After these complex movements, the food bolus moves toward the stomach with petal movements of the esophagus. The speed of propagation of petaltic waves in humans is about 2-4 cm/s.

To study the act of swallowing and motor function of the esophagus, X-ray cinematography, balloonography, tensometry, the open catheter method (when determining intracavitary pressure), electromyography, endoscopy, etc. were used. On X-ray cinema frames, individual stages of the movement of the tongue, palatal folds, narrowing of the pharynx and esophagus, etc. were used. There is no need to give a lot of details here inclusion in the act of swallowing of various structures of the oral cavity, nasopharynx, esophagus, larynx, soft palate, epiglottis and other formations, the coordinated work of which ensures the movement of the food bolus to the stomach. In the “Guide to the Physiology of Digestion” (1974), in the chapter “Digestion in the oral cavity,” information about the physiology of the salivary glands and mechanical processes in the oral cavity, the function of the esophagus and the cardial part of the stomach is presented in sufficient detail.

Coordination of the sequence and completion of individual elements in a complex combination of muscle movements involved in the act of swallowing is carried out by nerve cells of the brain located in the reticular formation of the brain stem, which is called the swallowing center. The afferent pathways from the pharynx to the swallowing center constitute a reflex arc, followed by signals that cause the activity of the center, but its activation simultaneously causes the activity of other centers (breathing, speech). Efferent flows along one or another nerve in the proximal-distal direction excite the longitudinal and circular layers of striated and smooth muscles. This sequence of signals to a certain extent explains the nature of the coordination of contractions of numerous muscle groups of the mouth, pharynx and esophagus. Shutting down (including surgically) the swallowing center inevitably leads to disruption of the pharyngeal components of swallowing.

Swallowing is an important part of food intake. Swallowing is the sum of motor reactions that move food from the mouth through the esophagus to the stomach. The swallowing reflex is an innate reflex. Normally, 22 muscles of the maxillofacial and sublingual regions and pharynx take part in the act of swallowing (Doty, Bosma, 1956). The initiation of swallowing is controlled by the central nervous system.

Further consistent, coordinated work of the muscles is carried out with the participation of certain ganglion areas of the central nervous system, which during the entire period of swallowing are under the influence of impulses coming from the corresponding peripheral receptors (K.M. Bykov et al., 1955; G. Ya. Priyma, 1958; I. S. Rubinov, 1958; Netter, 1959).

The swallowing center is located in the medulla oblongata, at the bottom of the fourth ventricle. Near the swallowing center are the respiratory center and the center that regulates cardiac activity. The function of these three centers is interconnected, which is expressed in a slight increase in heart rate (Meltzer, Werttheimer, Meyer. Quote from Binet 1931) and inhibition of excitation of the respiratory center, leading to a reflex cessation of breathing during swallowing (Binet, 1931). Swallowing sharply reduces the electrical activity of the stomach, i.e., it reflexively inhibits motility and relaxes the tone of its muscles (M.A. Zlotnikov, 1969).

Destruction of the swallowing center makes it impossible. It is also impossible if the mucous membrane of the pharynx is lubricated with cocaine (Wassilieff, 1888), i.e., the reflexogenic zone of the mucous membrane of the soft palate, the posterior wall of the pharynx is turned off from the reflex chain, or if the nerves innervating the muscles of the pharynx and esophagus are cut (Nolf, Jurica. Cited . according to Binet, 1931).

The swallowing mechanism undergoes certain changes after the birth of a child. As Bosma (1963) points out, the child is born with a well-developed swallowing mechanism and sufficient activity of the tongue, especially its tip. At rest, the tongue is freely located between the gingival ridges and sometimes extended forward, which ensures its readiness for work. Thanks to contractions of the muscles of the lips, cheeks, tongue, as well as positive pressure in the mother's mammary gland and negative pressure in the baby's mouth, milk enters the mouth. The contracted labial and buccal muscles provide support for the tongue, which, spreading between the gingival ridges and pushing off from this support, directs milk into the oropharynx. Usually, contraction of the tongue's own muscles forms a groove on the back of the tongue through which milk flows.

The infantile type of swallowing is observed from birth to 2.5-3 years. During this period, the child does not chew, but sucks, so during swallowing the tongue is pushed away from the closed lips.

At 5 - 6 months of age, with the appearance of the first teeth, the process of swallowing restructuring gradually begins. From this period, the transformation of the infantile type of swallowing into the somatic one occurs. This is the so-called period mixed type swallowing. The tip of the tongue meets support on the incisors, although its lateral parts continue to occupy the space between the areas of the gingival ridges that do not yet have teeth. With the eruption of the lateral teeth, the formation of a new way of swallowing ends. The somatic type of swallowing normally appears between the ages of 2.5 and 3 years, i.e., after the primary teeth are established in the bite. During this period, the child moves from sucking to chewing, so during swallowing the tongue is pushed away from the closed dentition and the palatine vault.

When studying age characteristics swallowing using fariography and electromyography of the masticatory muscles and the hypoglossal-laryngeal muscle complex B.K. Kostur (1972) found that children aged 1, 3, 5 and 9 years swallow 15 ml of water in several doses and that the younger the children, the more sips they take, i.e., swallowing improves with age.

Due to various reasons sometimes there is no change in the way of swallowing and the child, having become an adult, continues to rest his tongue on the lips or cheeks for the starting push. This is the main difference between the infantile and somatic methods of swallowing.

Magendie conventionally divides the act of swallowing into phases: oral, pharyngeal and esophageal. Kroncher sees only two phases in the act of swallowing: oro-pharyngeal and esophageal, and Ranvie identifies another phase, during which the bolus of food enters the stomach. Barclay (1930, 1931), who studied in detail the normal mechanism of swallowing, found it possible to distinguish eight phases. G.Ya. Priyma (1958) considers swallowing as a chain of reflexes consisting of 7 phases corresponding to the reflexogenic fields along which the food bolus passes to the stomach.

Straub (1951) and Whitman (1951) suggested the most convenient division of swallowing into the following three stages: the first - voluntary and conscious, during which food is brought to the exit into the oropharynx; the second - almost involuntary, poorly conscious, when the food bolus, if desired, can still be returned from the oropharynx; the third is involuntary, during which food enters the upper esophagus and then moves into the stomach. These three stages of swallowing occur within 0.5-0.2 s.

According to Barclay (1934), Frenckner (1948), the time for swallowing solid food is approximately 0.5 s, and for liquid food it is less than 0.25 s.

According to the observations of Winders (1958, 1962), a person performs swallowing movements on average 1200-1600 times during the day, and according to Kunvara (1959) and Straub (1961), 2400 times. Swallowing saliva occurs on average 2 times per minute, and during sleep - 2 times per hour.

The swallowing process is carried out as follows. After the food is chewed and moistened with saliva, the tongue, cheeks and lips form it into a bolus, which fits into a groove on the back of the tongue (Cannon, 1911; Johnstone, 1942; Whillis, 1946; Ardan and Kemp, 1955). At this time, the lips (m. orbicularis oris) are closed, the lower jaw is brought to the upper jaw until the teeth contact in central occlusion (abbreviation mm. masseter, temporalis, pterigoidea medialis). The lower jaw is held in this position throughout the swallowing process. Thus, the tongue appears to be in a rigid cavity, capable of serving as a support for pushing when moving the food bolus into the oropharynx.

Abbreviated mm. mylohyoidei and m. hyoglossus, the tongue lifts the food bolus upward and presses it tightly, with the entire back, to the palate. The tip of the tongue rests on the rugae palatinae and presses upward and backward. The movements of the tongue give the correct direction to the lump. tip and side surfaces tongues, resting on the hard palate and tightly closed teeth, prevent food from slipping forward and to the cheeks, and the lump has only a path backwards.

As soon as the food bolus touches the anterior wall of the soft palate, irritation of the receptors in this area causes a reflex contraction mm. levator and tensor palatini, hyo and salpingopharyngeus, palatopharyngeus, palato-thyreoideus, stylopharyngeus, contributing to the closure of the posterior wall of the pharynx with the edge of the raised and stretched soft palate (G. Ya. Priyma, 1958; Negus, 1948). Due to this, the nasal airways - the nasopharynx and internal auditory openings - are closed. Immediately, the root of the tongue, the epiglottis and the sphincter of the larynx (m. crycoarythenoideus m. thyreoarythenoideus) close the entrance to the larynx.

Isolation of all four air holes helps create negative pressure, which helps suction (promotion) of the food bolus. It occurs in the back of the oropharynx, growing to 20 cm 3 of water. Art., and in the esophagus it increases to 35 cm 3 water column. and more. At the same time, mm palatini stylohyoidei digastrici hyoidei contracts, as a result of which the hyoid bone, larynx and esophagus rise, the entrance to which expands due to the contraction mm. pterygoideus interna. Then there is a sharp, piston-like movement of the root of the tongue forward, and the tip of the tongue throws the food bolus into the pharynx. This movement of the tongue root is caused by the contraction mm. geniohyoideus styloglossus and posterior internal muscles of the tongue. The described contraction of the muscles of the nasopharynx and oropharynx ensures the rapid movement of food downwards. After a sip, everything returns to its original position.

An auxiliary mechanism for swallowing - negative pressure - appears in only about 1/8 s. in stages II and III of swallowing, but this is enough for the food bolus to move from the back of the tongue to the level of the collarbones. It is created, as Barclay (1930) clarified, due to the isolation of the airways, the lowering of the pharynx and the displacement of the tongue anteriorly. Thomas (1942) also came to the conclusion about the importance of negative pressure, pointing out that peristalsis of the muscles of the pharynx and esophagus and the weight of the bolus of food are insignificant factors for swallowing, since swallowing is possible in the upside down position. Normally, negative pressure is constantly present in the front of the mouth (while the mouth is closed), and this makes it easier to keep the lower jaw in a reduced state.

On the issue of the etiology of improper swallowing, there are different opinions. Many authors consider distorted swallowing to be a direct consequence of the wrong way of artificially feeding the baby.

Often, when artificial feeding, a long nipple is used, which occupies the entire mouth of the baby, reaching the soft palate. This interferes with the proper function of the tongue, soft palate and pharyngeal muscles. In addition, a large hole is made in the nipple through which milk easily enters the mouth, so vigorous sucking leads to excessive milk flow, the child will choke and can swallow milk only when the nipple is removed from the mouth or if excess milk spills out through the corners of the mouth. This situation can also occur during breastfeeding, when too much pressure develops in the mother’s chest and the baby does not have time to swallow milk.

The forward position of the tongue of an edentulous baby can become fixed and cause improper swallowing even after teething. The muscles do not lead lower jaw until it makes contact with the top, and the tip of the tongue rests on the lips and cheeks when swallowing. Over time, increased tension may arise in the group of facial and other muscles to compensate for the weak contraction of mm. masseter and temporalis, as well as the absence of auxiliary negative pressure.

When a stream of air passes through the gap between the lips into the nasopharynx and Eustachian tubes in the oral cavity, instead of a vacuum, positive pressure is created. When swallowing incorrectly, contraction waves begin with facial muscles, the anterior position of the tongue causes an additional contraction of mm. palatoglossus, palatostyloglossus, mylohyoideus, and sometimes the muscles of the neck, which leads to anteflexion of the muscles of the neck and head (Bosma, 1963), i.e., stretching of the neck forward, making it easier to place the food bolus on the tongue and move it into the pharynx. The intense contraction of the facial muscles observed during improper swallowing (in some patients even the muscles of the eyelids contract) is reflected in the facial expression (Fig. 6). With normal swallowing, these muscles, as well as the muscles of the neck, do not contract, and the facial expression does not change.

Consequently, when swallowing incorrectly, the teeth are not closed, the lips and cheeks are in contact with the tongue, and instead of negative pressure, positive pressure occurs in the oral cavity. There is a compensatory, additional contraction of the muscles involved in swallowing, and the involvement of other muscle groups in this process. Naturally, all this is reflected in the formation of the jaws and other bones of the facial skeleton.

Improper swallowing is a neuromuscular syndrome resulting from:

· Hyperactivity of the muscles of the tongue, soft palate, lips, cheeks, muscles of the sublingual area, etc.;

· artificial feeding, improper feeding through a nipple (wide hole, etc.);

· long-term feeding of the child with liquid and semi-liquid food that does not require the effort necessary for proper muscle development;

Habits of drinking solid food to make it easier to swallow;

connection between improper swallowing and pathology of the upper respiratory tract;

· thumb sucking habits as one of the possible causes of improper swallowing;

· disorders of the nervous regulation of the muscles of the maxillofacial region of a genetic order, and according to Haskins, this is the result of cerebral insufficiency;

· short frenulum of the tongue;

large quantity mother's milk.

Rice. 6. Face Patient G., 16 years old, at the moment of swallowing: contraction of facial muscles, movement of the eyelids and eyebrows, sharp contraction of the orbicularis oris and mental muscles (“thimble appearance”); The fibers of the orbicularis muscle of the lower lip, which serves as a support for the tip of the tongue when swallowing, are especially rigid.

When swallowing in people with normal occlusion, the distribution of tongue pressure on different parts of the hard palate is as follows. With a rounded palate, pressure is distributed equally to the anterior and lateral parts of the palate and, to a lesser extent, to the area of ​​the vault (sagittal suture). With a Y-shaped palate, the pressure mainly falls on its lateral sections, then on the anterior section and, to a small extent, on the vault of the palate. With a flat sky most of pressure falls on its arch. The authors observed that during normal swallowing the pressure was half that of commanded swallowing. This should be taken into account when treating patients with impaired swallowing.

There is a difference between improper swallowing and the habit of pressing the tongue on the teeth, which clinically manifests itself in the same way, but occurs with greater intensity and carries more potential for relapse. The latter habit can be seen as a result of increased tone of the tongue muscles and weakened tone of the lips and cheeks. A clinical sign of tongue pressure on the teeth is the presence of a diastema (without other reasons) and three. Differential diagnosis between improper swallowing and the habit of pressing the tongue on the teeth is important for determining the timing of using retention devices.

The constant positioning of the tongue between the dental rows with these habits does not give them the opportunity to close. This is the reason:

· open bite (vertical), especially in the anterior part of the dentition;

· deviation of the upper teeth is vestibular, and the lower ones are oral, if the tip of the tongue rests on the upper incisors and lower lip when swallowing;

· disruption of the process of formation of alveolar processes;

· narrowing of the upper dental arch (50% of all anomalies);

· violation of tongue articulation during sound production;

· disturbances in the formation of morpho-functional balance in periodontal tissues (bone structure, ligamentous apparatus, gingivitis).

Francis (1958) established a connection between tongue pressure and improper swallowing and speech defects. Tongue pressure on teeth is 2 times more common in people with speech impairments than in people who speak normally.

If swallowing is improper, due to increased activity of the tip of the tongue, splashing of saliva is often observed during conversation, and there are also disturbances in the self-cleaning of the oral cavity, despite good care take care of your teeth, it helps periodontal disease.

In the infantile type of swallowing, as a result of incorrect position of the tongue and lips, the dentoalveolar arches are deformed and the formation of the bite is disrupted.

The position of the tongue, lips, cheeks, and hyoid bones is studied in different phases of swallowing. The main method of static assessment is lateral teleradiography of the head, which reveals hypertrophied adenoids and palatine tonsils, which contribute to the anterior position of the tongue, incorrect articulation of its tip with surrounding organs and tissues, which causes impaired swallowing function [Okushko V. P., 1965; Khoroshilkina F. Ya., 1970; Frankel R., 1961, etc.].

Morphological disturbances in the structure and location of hard and soft tissues of the maxillofacial region allow us to judge functional disorders of the perioral and intraoral muscles.

During tele-X-ray cinematic study of the position of the tongue during swallowing, its back is covered with a contrast agent. When watching a film, using a freeze frame, the distance between different parts of the tongue and the hard palate is measured on the lateral TRG of the head under various physiological conditions (rest, swallowing). According to the graphical method proposed by T. Rakosi (1964), seven measurements are made. Based on the data obtained, a graph of tongue position is constructed.

Functional swallow test is based on studying the ability of the subject to swallow a lump of food or liquid in a certain time, involuntarily or on command. During normal swallowing, the lips and teeth are closed, the facial muscles are not tense, and peristalsis of the muscles of the sublingual region is noted. The time for normal swallowing is 0.2-0.5 s (liquid food 0.2 s, solid food 0.5 s). When swallowing incorrectly, the teeth are not closed and the tongue is in contact with the lips and cheeks. This can be seen if you quickly spread your lips with your fingers. When swallowing is difficult, compensatory tension occurs in the facial muscles in the corners of the mouth and chin, sometimes the eyelids tremble and close, the neck stretches and the head tilts. There is a characteristic tension of the facial muscles - pinpoint depressions on the skin in the area of ​​the corners of the mouth, chin ( thimble symptom), suction of the lips, cheeks, a push with the tip of the tongue and subsequent protrusion of the lip are often visible.

Clinical functional test according to Frenkel is intended to determine violations of the position of the back of the tongue and changes in its location during the process of orthodontic treatment and when checking the achieved and long-term results. The test is performed with specially curved wire loops. They are made from wire with a diameter of 0.8 mm calcined over a burner flame. To determine the position of the back of the tongue, a smaller loop is made in the anterior portion of the palate, and a larger one in the posterior portion.

Wire loops are bent and fitted to the model upper jaw. When making a smaller loop, its round section is placed along the midline of the palate at the level of the first premolars, bigger size- at the level of the first molars. The ends of the wire are twisted and the twisted wire is positioned, following the contour of the slope of the alveolar process.

Then it is brought into the vestibule of the oral cavity between the first premolar and the canine. The device is tried on in the oral cavity, the end is removed from the mouth in the area of ​​its corner, the handle is bent parallel to the occlusal surface of the dentition so that its front end is half as long as the back end. After inserting the finished wire loop into the oral cavity, ask the patient to sit quietly and make sure that the handle does not touch the soft tissues of the face; its location is recorded before and after swallowing saliva. By changing the position of the handle, one judges whether the back of the tongue is in contact with the hard palate or the lack of skills in lifting it. The success of orthodontic treatment and the achievement of its sustainable results are largely determined by the normalization of the position of the back of the tongue.

Research conducted by F. Falk (1975) confirmed the need to repeatedly perform such a clinical test in the process of treating pronounced dentofacial anomalies. Data indicating the position of the tongue serve as an indicator of the timing of possible cessation of treatment with the hope of sustainability of the achieved results.

Lingvodynamometry- determination of intraoral muscular pressure of the tongue on the dentition using special devices. When swallowing, the force of tongue pressure on the dentition according to Winders is variable: on the front teeth - 41-709 g/cm2, on the hard palate - 37-240 g/cm2, on the first molars - 264 g/cm2. The pressure of the tongue on the surrounding tissues when swallowing on command is 2 times greater than when swallowing spontaneously. Its shape depends on the distribution of tongue pressure on the roof of the palate.

Electromyography allows us to establish the participation of facial and masticatory muscles in the act of swallowing. Normally, the amplitude of biopotential waves during contractions of the orbicularis oris muscle is insignificant, but during contractions of the masticatory muscles themselves, it is significant. With improper swallowing, the opposite picture is observed. Attempts have been made to conduct an electromyographic study of the tongue during swallowing [Cojocaru M.P., 1973]. To study swallowing, masticationography, myography, myotonometry and other methods are also used.

Bibliography.

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2. Guide to orthodontics / edited by F.Ya. Khoroshilkina. – 2nd ed. reworked and additional – M.: Medicine, 1999. – 800 p.

3. Fleece P.S. Orthodontics / Handbook for advanced medical students. – Vinnytsia: Novaya kniga, 2007. – 312 p.

4. Khoroshilkina F. Ya. et al. Diagnosis and functional treatment of dentofacial anomalies / Khoroshilkina F. Ya., Frenkel R., Demner L. M., Falk F., Malygin Yu. M., Frenkel K. (Joint publication USSR - GDR). - M.: Medicine, 1987. - 304 p.

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6. Okushko V.P. Anomalies of the dental system associated with bad habits and their treatment: M., “Medicine”. - 1969. – 152 p.

One of the severe manifestations acute disorder cerebral circulation are swallowing disorders with impaired flow of food from the oral cavity into the esophagus (oropharyngeal, oropharyngeal, “high” dysphagia), which are traditionally considered within the framework of bulbar or pseudobulbar syndromes.

Strokes as a cause of swallowing disorders account for 25% of cases of all neurological diseases, primarily cerebral infarctions (80%). At the same time, dysphagia in acute period stroke is observed in 64-94% of cases, most often in the first 3-10 days; in the recovery period - in 23-50% of patients, and about 11% of patients at the rehabilitation stage still require tube feeding. Mortality among stroke patients with dysphagia is 27-37%.

The danger of swallowing disorders lies in the high risk of developing respiratory complications, aspiration pneumonia, tissue dehydration and activation of catabolic processes due to malnutrition.

Overall, lower respiratory tract infections develop in 12-30% of patients with strokes. In patients with swallowing disorders, aspiration pneumonia develops in 30-48% of cases. One of the main ways microorganisms enter the respiratory system is aspiration of the contents of the oral cavity and nasopharynx, which is observed in 40-50% of patients with strokes and increases the risk of developing pneumonia by 5-7 times.

The presence of dysphagia in patients with stroke and developed pneumonia increases mortality by 2.5-3 times. X-ray examination reveals manifestations of dysphagia in patients with strokes in 80% of cases and signs of aspiration of food in 45-56%.

Detection of fluoroscopic signs of a decrease or absence of the pharyngeal reflex increases the risk of developing infectious diseases of the respiratory system (IDS) 12 times, and the risk of developing persistent dysphagia is closely related to the detection of fluoroscopic manifestations of the entry of oral contents into the vestibule of the larynx or delayed evacuation of oral contents, as well as presence of any clinical signs swallowing disorders.

A combination of clinical outcomes such as persistent dysphagia, development of IDDS, or fluoroscopic signs of aspiration is more often detected in individuals with oral contents entering the larynx, with delayed evacuation, in patients over 70 years of age, and in male patients.

Along with aspiration, the risk of developing pneumonia is increased by depression of consciousness and being on mechanical ventilation (ALV), feeding through a nasogastric tube, elderly age, multiple localization of stroke foci, myocardial infarction, arterial hypertension, atrial fibrillation, previous diseases of the pulmonary system, diabetes mellitus, gastroprotection with gastrointestinal pump inhibitors.

Management of patients with pneumonia in block conditions intensive care for stroke patients, it reduces 30-day mortality by 1.5 times.

Factors that increase the risk of developing pneumonia in patients with stroke:

• Aspiration.
• Depression of consciousness.
• Being on a ventilator.
• Feeding through a nasogastric tube.
• Elderly age.
• Multiple localization of stroke foci.
• Myocardial infarction.
• Arterial hypertension.
• Atrial fibrillation.
• Pre-existing diseases of the pulmonary system.
• Diabetes.
• Taking proton pump inhibitors.

In this case, the development of early (before 72 hours) pneumonia is determined by the presence of previous strokes, the severity of the patient’s condition, the localization of lesions in the brain stem or cerebellum, and late (after 72 hours) by the presence of cardiodilatation, previous pulmonary pathology and coma.

All stroke patients, regardless of stroke severity, should undergo standardized screening for dysphagia, which statistically significantly reduces the risk of developing nosocomial pneumonia and requires institutions to have standardized dysphagia screening protocols.

The pathogenesis of swallowing disorders is associated with the development bulbar syndrome in 13.5% of cases of observation, pseudobulbar syndrome- in 31.2% and syndrome of impaired formation of food bolus - in 55.3%. Signs of several syndromes can be combined in the same patient.

In hemispheric strokes, more severe dysphagia and more frequent respiratory complications are observed with bilateral localization of lesions (in 55.5 and 66.6% of patients, respectively), less often with right hemisphere (37.5 and 25%) and left hemisphere (23 and 15. 3%) localization of foci.

Bilateral damage to the corticonuclear tracts causes the development of pseudobulbar syndrome; the right-sided localization of the process, with the involvement of cortical and subcortical structures, causes a disorder of the gnostic component of the swallowing function, and the left-sided localization causes the development of bucco-lingual, oral apraxia, which also causes a swallowing disorder. Damage to the cerebellum can also cause the development of dysphagia due to discoordination of the muscles of the tongue and pharynx.

In this case, the right hemispheric localization of the stroke focus is combined with a predominant violation of the initiation of the act of swallowing, disorders of the pharyngeal phase of the swallowing process, a high risk of aspiration and a slow recovery of swallowing function (more than 2-3 weeks) against the background of minor disturbances in the oral transit of the food bolus.

Left hemisphere strokes are accompanied by disturbances in the oral phase of the act of swallowing with poor processing of the food bolus, impaired transit of food in the oral cavity, a disorder in the control of salivation and a feeling of difficulty in moving the muscles of the lips and tongue with a faster recovery, most often within 1-3 weeks.

In strokes with bilateral hemispheric lesions, disturbances in both the oral and pharyngeal phases of swallowing are observed, with a predominance of oral dysfunction and a longer recovery.

With brainstem strokes, there is an isolated or combined impairment of the oral and pharyngeal phases of swallowing with a significant increase in the risk of aspiration and respiratory complications and slow recovery.

With hemispheric (supratentorial) localization of ischemic foci, the most associated with the development of dysphagia were the affected areas located in the internal capsule, primary somatosensory, motor and supplementary motor cortex, orbital-frontal cortex, subcortical nuclei - putamen, caudate nucleus and others basal ganglia, in contrast to foci located in the insula and in the temporoparietal cortex.

Moreover, after data correction taking into account the severity of stroke on the NIHSS scale and the volume of the lesion statistical significance This connection was preserved only for lesions with damage to the internal capsule.

The presence of dysphagia in patients with stroke increases the costs of treatment and rehabilitation of surviving patients by more than 6 times, taking into account the duration of restoration of impaired function: videofluoroscopy 6 months after the onset of stroke reveals subclinical signs of swallowing disorders in more than 50% of surviving patients.

Anatomy and physiology of the act of swallowing

Afferent structures that ensure the act of swallowing are receptors located on the mucous membrane of the tongue, palate, pharynx, centripetal fibers and sensory nuclei of the V, IX and X pairs of cranial nerves, and efferent structures - motor nuclei V, VII, IX, X and XII pairs of cranial nerves and their centrifugal fibers to the striated muscles of the tongue, cheeks, soft palate, pharynx and upper third(cervical part) of the esophagus.

The central link consists of the stem centers for the regulation of swallowing, which are the nuclei of the reticular formation of the brain stem and are located in the dorsolateral parts of the medulla oblongata on both sides below the nuclei of the solitary tract, the cortical centers of swallowing, located in the posterior parts of the frontal lobes, the cortical centers of these sensory and motor analyzers in pre- and postcentral gyri, centers of praxis and gnosis in the parietal lobes (precuneus), mechanisms of memory and volitional initiation (insula, cingulate gyrus, prefrontal cortex), as well as connections between all these formations.

Physiologically, the act of swallowing is a reflex and consists of 3 phases (damage to the nervous system causes disruption of the first two phases):

• oral (oral) - arbitrary,
• (oro)pharyngeal (pharyngeal, oropharyngeal) - fast, short involuntary;
• esophageal (esophageal) - slow, long-term involuntary.

The stem centers for the regulation of swallowing are connected with the respiratory and vasomotor centers of the reticular formation, which ensures breath holding and increased cardiac activity during swallowing. Cortical swallowing centers implement voluntary regulation of the act of swallowing.

Clinical manifestations of swallowing disorders

The clinical picture of dysphagia syndrome is caused by central or peripheral paresis of the muscles of the tongue, soft palate and constrictor muscles of the pharynx and is manifested by the following symptoms:

• difficulty chewing, deposition of food behind the tertiary cheek;
• food falling out of the mouth while eating;
• drooling or inability to swallow saliva;
• disturbances in swallowing food;
• regurgitation;
• choking when swallowing saliva, liquid or liquid food;
• coughing or coughing before, during or after swallowing;
• changes in voice quality during or after swallowing;
• difficulty breathing, intermittent breathing after swallowing.

The holistic clinical picture of swallowing disorders is determined by the topic of the pathological process and may be different depending on the hemispheric or brainstem localization of the lesion, and may also be accompanied by other accompanying symptoms “in the neighborhood.”

For repeated (including lacunar and “silent”) cortical and subcortical (hemispheric) strokes (in case of bilateral damage to the corticobulbar tracts) - clinic pseudobulbar syndrome:

• dysfunction of chewing and sagging of the lower jaw (central paresis of the masticatory muscles);
• disorder of swallowing function in the oral phase (impaired formation of a food bolus and its movement to the root of the tongue) due to impaired movements of the tongue or cheek (central paresis of the muscles of the tongue or cheek);

associated symptoms:

• aphasia (with cortical strokes in the dominant hemisphere);
• dysarthria (with subcortical strokes or cortical strokes in the non-dominant hemisphere), caused by central paresis of articulatory muscles - the tongue, soft palate, larynx, cheeks and lips;
• reflexes of oral automatism;
• violent laughter and crying;
• buccolingual (buccal-lingual, oral) apraxia;

For stem strokes - clinic bulbar syndrome:

• choking when swallowing saliva, liquid or liquid food, caused by particles getting into the larynx and trachea;
• identification of solid food residues in the cheek pockets due to paresis of the muscles of the tongue or cheek;
• entry of liquid or liquid food into the nose due to paresis of the muscles of the soft palate;
• difficulty swallowing solid food due to paresis of the pharyngeal constrictor muscles;
• nasolalia-nasal, a “nasal” tone of voice caused by incomplete covering of the entrance to the nasopharynx cavity by the velum palatine;
• feeling of a lump in the throat;
• dysphonia - a change in the sonority and timbre of the voice caused by paresis of the true vocal cords; the voice becomes hoarse, hoarse, the strength of phonation decreases down to aphonia, with only whispered speech retained;
• dysarthria caused by peripheral paresis of the muscles of the tongue, soft palate, and larynx;
• heart rhythm disturbances in the form of tachycardia, respiratory rhythm;

Developmental symptoms aspiration:

• choking or coughing after swallowing;
• intermittent or difficult breathing, choking after swallowing;
• change in voice quality after swallowing - “wet”, “gurgling” voice, hoarseness, temporary loss of voice;
• altered voluntary cough.

More than 2/3 of cases of aspiration are clinically unnoticed and are detected already at the stage of aspiration pneumonia (“silent”, “silent” aspiration).

There are 3 types of aspiration:

1) pre-swallowing - aspiration occurs during chewing of food in preparation for swallowing;

2) intraswallowing - aspiration occurs when food passes through the pharynx;

3) post-swallowing - aspiration occurs due to the fact that part of the food remains on the back wall of the pharynx and enters the airways when they open with the first breath after swallowing.

Before feeding a stroke patient, swallowing function must be assessed. As a result of assessing the predictors of aspiration before and after the water swallow test, the risk of aspiration is determined: high - if two or more predictors are identified and low - if one predictor is present; There is no risk of aspiration if the following predictors are not detected:

• before the test: dysarthria; dysphonia;
• altered, abnormal cough;
• reduced or absent pharyngeal reflex;
• immediately after swallowing water - cough;
• within 1 minute after swallowing water - a change in voice (they are asked to pronounce the sound “a” in a drawn-out manner).

Methods for studying swallowing function

• clinical and anamnestic;
• clinical neurological;
• clinical and instrumental.

Anamnestic method

Information about swallowing disorders can be obtained by interviewing the patient himself, his relatives or caregivers, as well as from reports from medical personnel.

It is necessary to pay attention to uncontrolled drooling, leakage of fluid from the mouth, apraxia or poor coordination of the oropharyngeal muscles, weakness of the facial muscles, choking, coughing, shortness of breath or choking during swallowing, difficulty in starting to swallow, the nature of the food that causes dysphagia, nasal regurgitation, changes in voice quality after swallowing - the appearance of a nasal or “wet” tone of voice, the state of respiratory function at rest.

At the same time, the patient may not complain of a swallowing disorder due to impaired awareness of the fact of dysphagia or decreased sensitivity in the oral cavity or pharynx, which requires determining the risk of aspiration using objective tests.

Clinical study of swallowing function

A clinical study consists of conducting a neurological examination in order to establish a topical and clinical diagnosis in general and to determine the state of swallowing function in particular.

Bedside clinical trial the act of swallowing is the basis for the examination of swallowing function. At the same time, the preservation of the pharyngeal reflex is not always an indicator of safe swallowing. In almost half of patients, aspiration is not accompanied by clinically significant manifestations - the so-called “silent” aspiration.

Clinical examination of swallowing function includes:

• examination of the soft palate at rest;
• examination of the soft palate during phonation;
• determination of palatal and pharyngeal reflexes;
• performing a swallowing test.

When examining the soft palate at rest, it is necessary to pay attention to the deviation of the uvula from the midline to the healthy side and the sagging of the palatine palate on the side of the paresis of the muscles of the soft palate.

During phonation, the mobility of the velum and the uvula of the soft palate is determined during the prolonged pronunciation of the sounds “a” and “e”. In this case, there is an increased deviation of the uvula from the midline to the healthy side and a lag or absence of tightening of the velum on the side of the paresis of the muscles of the soft palate.

Research methodology palatal reflex: with a spatula, touch the mucous membrane of the soft palate in turn on both sides symmetrically. Irritation of the mucous membrane of the soft palate causes the velum to pull upward, equally pronounced on both sides. The absence or lag of tightening of the palatal curtain on one side compared to the opposite indicates paresis or paralysis of the muscles of the soft palate (the “scenes” phenomenon).

Technique for studying the pharyngeal reflex: with a spatula, touch the mucous membrane of the posterior wall of the pharynx in turn, symmetrically on both sides of the midline. Irritation of the mucous membrane of the back wall of the pharynx causes swallowing, and sometimes even gagging or coughing movements. A decrease in the severity or absence of this response on one side compared to the opposite indicates paresis or paralysis of the pharyngeal constrictor muscles.

Bilateral absence or symmetrical decrease in the palatal and pharyngeal reflexes may not be associated with organic brain damage.

Quite a lot of variations of tests for assessing swallowing function have been described and used. If aspiration is suspected, a test swallow test (“empty” swallow test) is performed in the form of the patient swallowing his own saliva. There are other similar tests, when the patient is given a small amount of water in a teaspoon, or a test with 3 teaspoons of water, which are offered to drink in turn and after each of them, the appearance of signs of aspiration (cough, change in the sonority of the voice) is observed.

If these tests are successful, the swallowing test itself is performed, which exists in 2 variants: an aqueous swallowing test and a provocative swallowing test.

Method of conducting a water swallow test(The Water Swallowing Test): the patient is asked to swallow 90 ml (variations in various clinics- from 30 to 150 ml) of water from a cup without stopping. The appearance of a cough or a rough, “wet” voice within one minute after this indicates the presence of dysphagia.

The swallowing provocative test is a two-stage test, is used less often, and helps to identify a latent form of dysphagia.

Methodology for conducting a swallowing provocation test(The Water Provocation Test, Swallowing Provocation Test): a bolus of 0.4 ml of distilled water is poured into the upper part of the pharynx through a small nasal catheter (internal diameter 0.5 mm), followed by another 2 ml, which causes involuntary swallowing. Latency time is measured with a stopwatch from the moment of water administration until the onset of the swallowing movement, which is manifested by a visually observable characteristic laryngeal movement.

In order to objectively confirm dysphagia, a swallowing test is also performed with timing of water swallowing. If there is no pharyngeal reflex in to the fullest It is not possible to perform this test, nor to diagnose aspiration.

Method of conducting a swallowing test “for a while”: The patient is asked to drink 150 ml of water from a glass as quickly as he can. In this case, the time of emptying the glass and the number of sips are recorded, and then the swallowing speed and the average swallow volume are calculated. Swallowing rates below 10 ml/s indicate the presence of dysphagia.

It is possible to supplement the swallowing test with a food test, when the patient is asked to swallow a small piece of pudding placed on the back of the tongue.

Instrumental methods for assessing dysphagia

Instrumental methods for assessing dysphagia and aspiration in patients with strokes are also quite numerous:

• video fluoroscopy;
• transnasal fibroendoscopy;
• pulse oximetry;
• electromyography of the submental muscle group.

Videofluoroscopy(videofluoroscopy, video fluoroscopic study of swallowing with barium) is the gold standard for assessing swallowing, usually performed in a lateral projection, allows you to visualize all phases of swallowing, show the mechanism of dysphagia and identify “silent” aspiration.

Most often, aspiration develops as a result of impaired swallowing function in the pharyngeal phase, when there is a disorder in the closure of the larynx or paresis of the pharyngeal muscles. The purpose of the study is to determine the consistency of food that does not cause dysphagia and the posture or maneuver that ensures swallowing is safe for the patient.

Video fluoroscopy technique for swallowing: the patient sits at an angle of 45-90° and absorbs liquid or food of varying consistency, saturated with barium. The total research time is 10-15 minutes. The recording can be saved and played back in slow motion to assess swallowing and aspiration into the airway.

However, the density of barium differs significantly from the density of normal food, and therefore the passage of barium still cannot fully assess the risk of aspiration from normal foods. However, there is no standard protocol for the volume and consistency of barium used, the videofluoroscopy procedure is relatively complex and time-consuming, and it is impossible to examine patients who have difficulty maintaining an upright position.

The non-radiological gold standard for the functional diagnosis of swallowing disorders and assessment of the morphological causes of dysphagia has been transnasal fibroendoscopy(naso-endoscopy, fiber-optic endoscopic assessment of swallowing), allowing video monitoring of the act of swallowing in real time and recording a video image for subsequent analysis.

Transnasal fibroendoscopy technique: a naso-endoscope is passed through the nose and placed to the level of the uvula or soft palate in such a way as to provide an overview of the pharynx and larynx. The test is safe and can be repeated as often as necessary. As a result, the anatomical features of the pharynx and larynx, the physiology of the act of swallowing, the passage of food from the oral cavity to the pharynx, the presence of aspiration and the response to compensatory maneuvers are assessed.

The transnasal fibroendoscopy procedure also makes it possible to determine the consistency of food that does not cause dysphagia, and the posture or maneuver that ensures swallowing is safe for the patient.

Monitoring blood oxygen saturation during bedside swallow tests increases the positive predictive value of screening to 95% and can detect up to 86% of aspirations while minimizing oral fluid intake - 10 ml of water is sufficient.

Principles of management of patients with stroke and swallowing disorders

The generally accepted standard of care for stroke patients is rapid assessment of swallowing function. Screening for dysphagia should be performed as soon as possible after the patient's hospitalization (as soon as their condition allows), before starting oral medications, fluids, or food, but no later than 24 hours after admission to the hospital.

Monitoring of swallowing disorders should be performed daily throughout the hospitalization. Most often, during strokes, swallowing safety is restored within a few days to several weeks (in most cases, within up to 3 months), which is largely due to the functional reorganization of the motor cortex of the intact hemisphere. In the future, if dysphagia persists, swallowing impairment is assessed every 2-3 months during the first year, then every 6 months.

The strategy to prevent complications and restore normal swallowing includes direct and indirect methods.

Direct methods:

• optimizing the position of a stroke patient during meals;
• modification of the consistency of food and drinks;
• safe swallowing rules;
• compensatory techniques during swallowing.

Indirect methods:

• rehabilitation oropharyngeal exercises;
• stimulation of the structures of the oral cavity and pharynx:
• transcutaneous and intrapharyngeal electrical stimulation;
• thermal tactile stimulation;
• transcranial magnetic stimulation of motor projection zones of the oral cavity and pharynx;
• acupuncture;
• behavioral therapy.

Screening tests

Screening tests are aimed at early bedside assessment of dysphagia and can be performed by nursing staff on the stroke team. The purpose of the survey is to:

• assessing the patient's level of consciousness and ability to participate in the examination, as well as assessing the degree of postural control (ability to sit upright independently or with support), which generally determines the possibility of oral feeding;
• monitoring oral hygiene and the degree of control of oral secretion;
• monitoring manifestations of disorders of the oropharyngeal phase of swallowing (shortness of breath, cough, “wet” voice);
• assessing the patient's voice quality, muscle function and oral sensitivity and primary departments pharynx, ability to cough;
• if necessary, conduct tests with swallowing water (to assess the risk of aspiration).

Examples of screening tests used in world practice:

• Massey Bedside Swallow Screen (2002);
• Timed Test of Swallowing and Questionnaire (1998);
• Screening Tool for Acute Neurological Dysphagia (STAND) (2007);
• Standardized Swallowing Assessment (SSA) (1993, 1996,1997,2001);
• Gugging Swallowing Screen (GSS) (2007);
• Toronto Bedside Swallowing Screening Test (TOR-BSST) (2009);
• Bames-Jewish Hospital Stroke Dysphagia Screen (BJH-SDS) (2014).

A single test generally accepted for all clinics has not been defined, but the GSS and TOR-BSST tests have shown the highest sensitivity and specificity. Moreover, using 8 or 10 teaspoons of water in the test increases the sensitivity of the TOR-BSST test from 79% when using 5 spoons to 92% and 96% when using 8 or 10 spoons, respectively.

When conducting comparative research with videofluoroscopy, the BJH-SDS screening test showed a sensitivity and specificity for detecting dysphagia of 94 and 66%, respectively, and for detecting aspiration of 90 and 50%.

If signs of dysphagia are identified as a result of screening, a full assessment of swallowing is subsequently performed using the ASHA test to clarify the causes, nature (which phase of swallowing is impaired) and severity of the disorders. In this case, the assessment includes detailed control of the swallowing phases, motor and sensory status of the oral cavity, and analysis of anamnesis data. If necessary, an instrumental study of swallowing function is prescribed.

Nutrition control and feeding rules for a patient with dysphagia

It is necessary to control the consistency and volume of food in order to improve the transit of the food bolus. Standard practice is to change the consistency of food and liquids (a switch to soft foods and thick liquids is necessary), as well as prohibiting oral intake for the most severely ill patients. However, if possible, oral feeding is preferable.

To prevent aspiration in patients with swallowing disorders, proper organization of the feeding process and selection of food consistency are necessary. However, there is no single diet for dysphagia. Standards for modifying solids and liquids in patients with stroke and swallowing disorders vary from country to country.

Rules for feeding patients with strokes and swallowing disorders:

• Patients with existing aspiration should begin eating only after receiving instructions to prevent aspiration;
• a thorough inspection of the oral cavity is necessary before eating (to remove accumulated bacteria from the oral mucosa) and after finishing feeding (the remaining food can be aspirated);
• need control over the need to use dentures; teeth and dentures must be brushed at least 2 times a day to ensure the cleanliness of the oral cavity;
• feeding must be carried out only in a sitting position (torso at an angle of 90°), with support under the back; if necessary, the patient can be supported with pillows; You cannot feed a lying patient;
• Meals should be carried out in a calm environment. The patient should eat slowly and without being distracted by conversations, TV, radio;
• It is necessary to observe symptoms of dysphagia during meals and for 30 minutes after meals; at the same time, the patient’s body position must be maintained vertical or close to it for 30-60 minutes to ensure esophageal clearance and gastric secretion and reduce reflux;
• the person conducting the feeding should be at eye level with the patient;
• Only a small amount of food can be given at a time, the frequency of intake must be increased;
• when feeding, food is placed on the unaffected side in small portions;
• during feeding, it is necessary to ensure that the head is tilted forward; the patient’s head must not be tilted backward;
• feeding is carried out from a metal teaspoon and at a low speed (patients with right hemisphere strokes are characterized by impulsiveness and a tendency to swallow at too fast a pace);
• It is not recommended to use plastic spoons and spoons in patients with an increased bite reflex;
• it is necessary to teach the patient to take food and bring it to the mouth with one hand or both hands at once. If he can use a spoon to eat, you need to make the handle of the spoon thicker - this will make it easier to hold it (you can use a piece of rubber hose or make the handle out of wood);
• at the moment of swallowing food, it is necessary to turn your head in the direction of the lesion - towards the paretic muscles of the pharynx or tongue;
• it is necessary to ensure that swallowing is completed before offering the next portion;
• if the patient cannot absorb liquid, you need to teach him to drink from a spoon; Safe swallowing from a wide cup or glass is encouraged;
• To stimulate swallowing, you can use a drinking straw or a sippy cup with a long spout, which prevents the head from moving backward and thus reduces the risk of aspiration;
• it is necessary to teach the patient to bring food or liquid to the middle of the mouth, and not to the side, and to take food into the mouth using the lips, not the teeth;
• it is necessary to teach the patient to keep his lips closed and his mouth closed when he chews or swallows food. If underlip sags downward, you need to teach the patient to support it with his fingers;
• After eating, you need to make sure that no pieces of food remain in your mouth - you need to rinse your mouth or clean the oral cavity with a napkin. If the patient chokes, he should be given the opportunity to cough, but should not be given anything to drink, since the liquid easily penetrates the respiratory tract.

Food requirements when feeding patients with strokes who have swallowing disorders:

• food should look appetizing;
• addition citric acid in food improves the swallowing reflex by improving taste and stimulating acid;
• food should be warm enough, as patients with dysphagia need long time to receive it. If the patient does not feel warm food in his mouth, he should be fed food at room temperature;
• Solid and liquid foods should be offered at different times, drinks should be given before or after meals;
• Semi-hard foods are best tolerated: casserole, thick yogurt, pureed vegetables and fruits, watery cereals, jelly, soufflé, cutlets;
• It is necessary to select the consistency of food (soft food, thick puree, liquid puree) and liquid (consistency of mousse, yogurt, thick jelly, syrup, water). It is recommended to add thickeners to all liquids, such as starch or food gelatin. It should be remembered that with thinner food or drink it is more difficult to take a safe (without aspiration) sip. Soups or solid foods can be smoothed using a blender or mixer;
• Dried fruits and fermented milk products (kefir, yogurt) are recommended, especially for bedridden patients with a tendency to constipation;
• it is recommended to provide the patient with a sufficient amount of potassium salts (dried apricots, raisins, cabbage, potatoes, figs) and magnesium (buckwheat and oatmeal porridge);
• it is necessary to exclude from the diet foods that often cause aspiration - liquids of normal consistency (water, juices, tea), or easily crumbles - bread, cookies, nuts;
• Meat in pieces and citrus fruits, the fibers of which are difficult to chew, are not recommended;
• It is not recommended to mix food and drinks at one time - it is advisable to drink before or after meals.

IN general view the special diet includes 4 different consistencies: dense liquid, pureed, crushed and soft chopped food. A soft diet eliminates all hard, small and fibrous food particles. In this case, the meat can have 3 consistencies: chopped, chopped and ground.

Chopped food is actually semi-hard and is preferable to purees because it has more fibrous structures that encourage swallowing.

Puréed food has the consistency of a pudding and is generally easier to swallow than the more common diet because it is thick enough to form a bolus, stimulating oral sensitivity and improving swallowing ability. At the same time, feeding pureed food also poses a risk of aspiration.

Patients receiving thick liquids have a lower risk of developing aspiration compared to those receiving liquid food.

There are 4 types of liquid consistency:

• mousse consistency (liquid sticks to the fork);
• consistency of yogurt (liquid drips off the fork in large drops);
• consistency of syrup (liquid envelops the fork, but quickly drains from it);
• consistency of water (liquid immediately flows off the fork).

In the acute period of a stroke, the consistency of liquids is selected depending on the patient’s capabilities. In this case, at first it is preferable to use a thick liquid for feeding (mousse, yogurt, jelly, kefir), which is much easier to swallow than water, since it passes more slowly through the oropharynx and thereby leaves more time to prepare for the start of swallowing.

Then gradually, as swallowing function is restored, they move on to more fluid liquids. Until the patient's swallowing function is restored, it is necessary to avoid liquids of normal consistency (water, juices, tea, milk). If the patient has very difficulty swallowing liquids, liquid can be added to solid foods and the food can be pureed to the consistency of a liquid puree. It is not recommended to use dry food - bread, cookies, crackers, nuts.

Due to the fact that, in general, patients with strokes consume insufficient amounts of fluid and are characterized by dehydration, especially patients with aspiration detected by videofluoroscopy, receiving thick liquids and taking diuretics, it is necessary to take sufficient amounts of fluid throughout the day.

Compensatory techniques

• changing the position of the head (turning towards the lesion - towards the paretic muscles of the pharynx or tongue) to reduce the likelihood of aspiration;
• bending the chin to the sternum before swallowing food, which promotes the juxtaposition of the epiglottis and the arytenoid-subglottic fold and leads to the closure of the airways during swallowing;
• in addition to this technique, simultaneous tilting of the torso anteriorly is possible;
• double swallowing - the implementation of a repeated swallowing movement in order to minimize reflux after swallowing and prevent new aspiration;
• cough after swallowing - coughing movements after swallowing food to prevent aspiration.

Rehabilitation exercises

• Shaker reception- while lying on your back, raise your head for a few seconds, repeating this 20 times. Helps improve the opening of the upper esophageal sphincter by strengthening the suprahyoid muscle and thereby reducing food debris in the pharynx after swallowing;

• Mendelssohn's maneuver- prolonged contraction of the suprahyoid muscles to ensure elevation of the larynx, opening of the upper esophageal sphincter and closing of the airways;

• touch the tip of your tongue to the soft palate with your mouth open, and then with your mouth closed (6-8 times);
• holding the tip of your tongue firmly with your teeth, make a swallowing movement (you should feel tension in the throat and difficulty at the beginning of swallowing);
• swallowing a drop of water from a pipette;
• if possible: swallowing saliva, drops of water, juice, or simply simulating swallowing movements (perform the exercise only after consulting a doctor);

• imitation of familiar movements (6-8 times): chewing; coughing; gagging movements; yawning with the mouth wide open, noisily sucking in air; yawning with the mouth closed; image of whistling without sound, straining the oral cavity; gargling; snoring while inhaling and exhaling (imitation of a sleeping person); chewing and swallowing semolina porridge; swallowing a large piece; strongly inflate your cheeks and hold them in this state for 5-6 seconds;

• pronunciation of sounds (6-8 times): firmly pronounce the vowel sounds “a”, “e”, “i”, “o”, “u”; repeat the sounds “i/u” one by one. The pharyngeal muscles should tense; firmly pronounce the sounds “a” and “e” (as if pushing); sticking out your tongue, imitate the sound “g”; silently pronounce the sound “y”, pushing the lower jaw forward; How long does it take to exhale to pull out the sound “m”, closing your lips; tapping your fingers on the larynx with one exhalation, stretch out the sound “and” either low or high; pronounce several times, holding the tip of the protruding tongue with your fingers, the sounds “i/a” (separated by a pause); stick out your tongue and, without removing it, pronounce the sound “g” five times.

New therapeutic techniques are neuromuscular electrical stimulation of the pharyngeal muscles (transcutaneous and intrapharyngeal), transcranial magnetic stimulation and biofeedback.

The use of electrical stimulation of the pharyngeal muscles makes it possible to increase the likelihood of a pronounced clinical improvement in swallowing function by more than 5 times and the likelihood of restoration of swallowing function by more than 3 times, while reducing the manifestations of aspiration by 30% and the risk of developing aspiration complications by 5 times. Acupuncture and behavioral therapy also contribute statistically significantly to reducing the manifestations of dysphagia.

Transcranial magnetic stimulation for 20 minutes per day for 5 days improved swallowing reaction time and reduced the number of aspirations of fluid and food debris, but had no effect on oropharyngeal transit time and laryngeal closure.

Enteral nutrition

Enteral methods include feeding by nasogastric tube or percutaneous endoscopic gastrostomy. Parenteral nutrition is used if it is impossible to use enteral nutrition - if the latter is contraindicated or intolerant, and should be limited in time.

Early feeding through a nasogastric tube improves patient survival, so insertion of a tube within the first 48 hours after the onset of stroke is recommended. However, tube feeding only partially reduces the risk of developing pneumonia, which is associated with the rich content of microorganisms in the oral cavity; any disturbances in normal nutrition contribute to the development of lower respiratory tract infections.

The nasogastric tube is easy to install, but also easily clogged, and can easily be intentionally removed by the patient himself or unintentionally removed if it is poorly secured, when washing, dressing the patient or during any other movements, or when vomiting. Overall, nasogastric tube displacement occurs in 58-100% of patients.

Removal of a nasogastric tube may be earlier in patients with hemispheric stroke compared with patients with brainstem lesions, in younger patients, in those with mild onset, and in those with better recovery functional state.

If it is impossible to restore safe swallowing in the short term (within 3-4 weeks), it is necessary to organize enteral nutrition through percutaneous endoscopic gastrostomy (preferred to surgical one), which can be delayed for several weeks.

There is evidence of a 5-fold reduction in mortality over 6 weeks with percutaneous endoscopic gastrostomy feeding compared with nasogastric tube feeding, which is associated with the use of small portions of food. If long-term nutritional support is required (more than one month), percutaneous endoscopic gastrostomy is also preferable to a nasogastric tube because it is more convenient.

In patients with a reduced pharyngeal reflex, it is possible to use periodic oropharyngeal feeding, in which, before each meal, a probe is inserted into the pharynx through the mouth, portions of food and nutritional supplements are introduced at a rate of no more than 50 ml/min, after which the probe is removed and washed with water.

For enteral nutrition, special enteral hypercaloric polysubstrate balanced mixtures are used at the rate of 2200-3000 kcal/day. Nutrizon, Nutrizon Energy, Nutricomp ADN standard mixtures are used in patients diabetes mellitus- Nutricomp ADN fiber and others - 500-2000 ml/day (25-150 ml/hour).

Enteral formulas can be prescribed as a single method of tube feeding, as well as mixed enteral-oral or enteral-oral. parenteral nutrition. You can drink the mixture through a straw or pour it into a glass, like drinking yogurt.

Total parenteral nutrition is an intravenous injection of 500-1000 ml of a 10-15% solution of amino acids (infezol 40 and infezol 100), 1000 ml of a 20% glucose solution and 500 ml of a 20% fat emulsion solution of the 2-3rd generation (lipofundin, Medialipid, Stmctolipid and LipoPlus, SMOF Lipid respectively). In this case, glucose and glucose-containing solutions can be administered no earlier than 7-10 days after the patient’s admission, provided that blood serum glucose levels are stable (no more than 10 mmol/l).

More technologically advanced are all-in-one parenteral nutrition systems (kabiven, oliclinomel, nutricomp lipid). In this case, one container, which is a three-section bag, contains solutions of amino acids, glucose and fat emulsions in various combinations and may include electrolytes. This technology ensures the use of one infusion system and one infusion pump and a stable rate of content administration.

Antibiotic therapy

Prophylactic appointment antibacterial drugs in patients with strokes is unacceptable, since it suppresses the growth of endogenous microorganisms that are sensitive to them and the proliferation of resistant microorganisms, which will subsequently require the use of more expensive antibiotics.

• increased body temperature more than 37 °C;
• weakened breathing upon auscultation of the lungs and the appearance of shortness of breath;
• cough disturbance;
• bladder catheterization;
• formation of bedsores.

Taking into account the largest proportion of gram-negative microflora, staphylococcus and anaerobic bacteria in the etiology of hospital-acquired pneumonia in patients with severe forms of stroke, at the first signs of pneumonia, antibiotics should be prescribed before obtaining the results of determining sensitivity to antibiotics wide range actions - cephalosporins of the I-IV generation (in combination with aminoglycosides) or fluoroquinolones of the II-IV generation (ciprofloxacin, levofloxacin, gatifloxacin, moxifloxacin), often in combination with metronidazole or with modern macrolides.

Due to the high oto- and nephrotoxicity of first-generation aminoglycosides, second-generation drugs are used. Gentamicin and tobramycin are prescribed at 3-5 mg/kg/day in 1-2 administrations parenterally. The reserve drug can be the third generation aminoglycoside amikacin, which is administered at 15-20 mg/kg/day in 1-2 doses. At the same time, aminoglycosides are not effective against pneumococcus and are inferior to other effective antistaphylococcal antibiotics as more toxic.

Monotherapy with carbapenems is possible: imipenem - 0.25-1 g every 6 hours (up to 4 g/day), meropenem - 0.5-2 g every 8-12 hours.

The combined use of combined protected antipseudomonal ureidopenicillins (ticarcillin/clavulanic acid, piperacillin/tazobactam) with amikacin is possible.

In most cases, with an adequate choice of antibiotics, the duration of antibiotic therapy is 7-10 days. For atypical pneumonia or staphylococcal etiology, the duration of treatment increases. For pneumonia caused by gram-negative enterobacteria or Pseudomonas aeruginosa, treatment should continue for at least 21-42 days.

The swallowing process is repeated periodically, not only while awake, but also during sleep. Like breathing, this process often occurs involuntarily. The average frequency of swallowing is 5-6 times per minute, however, with concentration or strong emotional arousal, the frequency of swallowing decreases. The swallowing process follows a clear sequence muscle contractions. This sequence is provided by a region of the medulla oblongata called the swallowing center.

Swallowing difficulties can develop without a person noticing. Impaired oral feeding, weight loss, a significant increase in the time it takes to swallow food - all this can be a manifestation of a violation of swallowing function. Signs of difficulty swallowing may include:

• throwing back the head or moving the head from side to side, helping to move the food bolus;
• the need to wash down food with water;

Despite pronounced difficulties in swallowing, the tongue and the muscles that lift the velum palatine can function normally.

A swallowing disorder is medically called dysphagia.

What diseases cause difficulty swallowing:

Swallowing disorders can lead to serious consequences:

• exhaustion of the body, weight loss;
• cough during and after swallowing, constant choking;
• feeling of lack of air while swallowing;
• pain and shortness of breath;
• development of pneumonia;

Depending on the causes of swallowing disorders, there are:

• Mechanical (organic). A similar violation can occur when the size of a piece of food and the lumen of the esophagus do not match.
• Functional. This type of swallowing difficulty occurs when peristalsis and relaxation are impaired.

Both mechanical and non-mechanical problems can occur for a variety of reasons. Organic (or mechanical) swallowing disorder is associated with direct external or internal pressure on the esophagus. In such a situation, the patient says that it is difficult for him to swallow food. There may be several reasons for mechanical impact:

1. Blockage of the esophagus by any foreign body or food;
2. Narrowing of the lumen of the esophagus, which can occur due to:

• swelling resulting from inflammatory process(stomatitis, sore throat, etc.);
• damage or scars (burns from taking pills, scars from operations or after inflammation);
• malignant and benign formations;
• stenosis;

3. External pressure may be a consequence of swelling of the thyroid gland, compression by blood vessels, etc.

Functional swallowing disorders include disorders associated with impaired muscle function. Violations can also be divided into 3 groups:

1. Disorders associated with tongue paralysis, brain stem damage, sensory disturbances, etc.
2. Disorders associated with damage to the smooth muscles of the esophagus. Such violations lead to weakness of contractions and impaired relaxation.
3. Disorders associated with diseases of the muscles of the pharynx and esophagus;

Other causes of difficulty swallowing include: Parkinson's disease, parkinsonism syndrome, inflammation of the esophageal mucosa and connective tissue diseases.

“Lump in the throat” syndrome The feeling of a lump in the throat (globus pharyngeus syndrome) is one of the most common complaints when visiting an otolaryngologist. During their lifetime, approximately 45% of people experience this sensation. This syndrome began to be studied as one of the manifestations of hysteria, but during the study it became clear that only a part of the cases were due to psychiatric reasons.

There are several reasons for the sensation of a lump in the throat:

1. There really is something in the goal and this object interferes with swallowing. The sensation of a lump in the throat in this case can be caused by swelling of the uvula of the soft palate, a tumor or cyst, or an enlarged palatine or uvular mendala. The cases described above are quite rare and can easily be excluded during examination at a doctor's appointment.
2. There is a feeling of a “lump in the throat”, but there are no objects directly in the throat that could interfere with swallowing. These are the most common cases. Most often, this sensation is caused by reflux disease. Reflux is the backflow of stomach contents into the esophagus and further into the throat. Muscle spasm in the throat, which causes the feeling of a “coma,” is provoked by gastric contents (the acidic contents of the stomach burn the mucous membrane of the esophagus and throat). Also, the symptom of “coma in the throat” can be accompanied by chronic pharyngitis.
3. Psychological factors. Often the appearance of the “coma in the throat” syndrome is facilitated by stressful situations, a state of strong excitement or fear.

The “globus pharyngeus” syndrome has not been fully studied to date, but in most cases it does not pose a threat to human life, and the causes that caused it are quite easy to eliminate. However, to determine the exact causes and prescribe timely treatment, an in-person examination by a doctor is necessary.

If you have difficulty swallowing or feel a lump in your throat, get a consultation or make an appointment on the Clinical Brain Institute website.