> General Considerations

Many neuromuscular disorders can cause dysphagia (Table 13-1). Among these are various disorders causing cortical lesions; supranuclear, nuclear, and cranial nerve lesions; defects of neurotransmission at the motor end plates; and muscular diseases.

Many patients with dysphagia are elderly and hence develop this symptom secondary to other disorders (eg, stroke). History of strokes or other neurologic illnesses, nasal regurgitation and frequent coughing immediately upon swallowing, and poor oral coordination of bolus formation or dysphonia may help suggest the greater likelihood of oropharyngeal dysphagia over esophageal dysmotility, but diagnosis, assessment of severity, and therapeutic intervention are generally guided by VFSS.

Table 13-1. Neuromuscular disorders causing dysphagia.

1.  Diseases of cerebral cortex and brainstem

A.  With altered consciousness or dementia

•  Dementias, including Alzheimer disease

•  Altered consciousness, metabolic encephalopathy, encephalitis, meningitis, cerebrovascular accident, brain injury

B.  With normal cognitive functions

•  Brain injury

•  Cerebral palsy

•  Rabies, tetanus, neurosyphilis

•  Cerebrovascular disease

•  Parkinson disease and other extrapyramidal lesions

•  Multiple sclerosis (bulbar and pseudobulbar palsy)

•  Amyotrophic lateral sclerosis (motor neuron disease)

•  Poliomyelitis and post-poliomyelitis syndrome

2.  Diseases of cranial nerves (V, VII, IX, X, XII)

A.  Basilar meningitis (chronic inflammatory, neoplastic)

B.  Nerve injury

C.  Neuropathy (Guillain-Barre syndrome, familial dysautonomia, sarcoid, diabetic, and other causes)

3.  Neuromuscular

A.  Myasthenia gravis

B.  Eaton-Lambert syndrome

C.  Botulinum toxin

D.  Aminoglycosides and other drugs

4.  Muscle disorders

A.  Myositis (polymyositis, dermatomyositis, sarcoidosis)

B.  Metabolic myopathy (mitochondrial myopathy, thyroid myopathy)

C.  Primary myopathies (myotonic dystrophy, oculopharyngeal myopathy)

Adapted, with permission, from Goyal RK. Dysphagia. In: Fauci AS, et al (editors). Harrison's Principles of Internal Medlclne,17th ed. McGraw-Hill, 2008:237-240.

Transport and may aggravate the symptoms of pharyngeal stasis. On the other hand, a hypotonic UES may lead to esophagopharyngeal reflux and aspiration not related to swallowing.

Because many neuromuscular structures involved in swallowing are also involved in speech, dysarthria and dys-phonia are common in these patients. Moreover, patients usually have evidence of neuromuscular defects in other parts of the body. Many patients with oropharyngeal dysphagia have impaired consciousness and cognitive functions that may make evaluation difficult.

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