Neurogenic dysphagia is difficulty swallowing that develops in approximately 400,000 to 800,000 people per year due to neurological disorders or injuries. Dysphagia can be serious as it increases the risks of pneumonia, malnutrition, dehydration, and airway obstruction. The physiology of swallowing involves voluntary and reflex oral, pharyngeal, and esophageal phases. Central control of swallowing occurs in brainstem structures while cortical regions help with preparation and modulation. Common neurogenic causes of dysphagia include strokes and other brain injuries, motor neuron diseases like ALS, and inflammatory myopathies. Evaluation involves medical history, physical exam of swallowing functions, and sometimes imaging tests. Treatment depends on

1. Neurogenic Dysphagia
DR BHAVIN J PATEL
SR NEUROLOGY
GMC KOTA

2. Introduction
The word dysphagia is derived from the Greek phagia (to eat) and dys (with
difficulty)
It has been estimated that neurogenic dysphagia develops in approximately
400,000 to 800,000 people per year
Dysphagia can be a serious health threat because of the risk of aspiration
pneumonia,malnutrition, dehydration, weight loss, and airway obstruction.
It exerts a large influence on the outcome of rehabilitation (eg, length of
hospital stay, mortality/morbidity)

3. Physiology of swallowing
It comprises a mixture of voluntary and reflex act.
Swallowing can be divided in to phases:-
1. Oral phase:- preparatory and transport
2. Pharyngeal phase
3. Esophageal phase

4. Neurophysiology of swallowing
Central control of swallowing has traditionally been ascribed to brainstem
structures, with cortical supervision and modulation emanating from the inferior
precentral gyrus
Supplementary motor area may play a role in preparation for volitional
swallowing, and the anterior cingulate cortex may be involved with monitoring
autonomic and vegetative functions.
 PET studies also consistently demonstrate distinctly asymmetrical left-sided
activationof the cerebellum during swallowing

5. Neurophysiology of swallowing
The dorsomedial pattern generator resides in the medial reticular formation is
involved with the initiation and organization of the swallowing sequence.
The ventrolateral pattern generator, lies near the nucleus ambiguus directly
control motor output to the pharyngeal musculature and proximal esophagus.
It has become evident that a large network of structures participates in the act of
swallowing, especially volitional swallowing.

6. Neuromuscular Causes of dysphagia

7. Neurogenic causes of dysphagia

8. Evaluation of dysphagia

9. History:- oropharyngeal phase
Coughing or choking with swallowing
Excessive tongue movement or spitting food out of the mouth,
 Poor tongue control,
Pocketing of food in the mouth,
Wet or “gurgly” voice after eating, hoarse or breathy voice,
Prolonged time to eat or reluctance to eat
 Nasal regurgitation
Difficulty initiating swallowing
 Food sticking in the throat
 Sialorrhea

10. History :- esophageal phase
Sensation of food sticking in the chest or throat
 Symptoms of gastroesophageal reflux disease(GERD), including heartburn,
belching, sour regurgitation, and water brash
Prolonged time to eat or reluctance to eat
Other associated factors/symptoms of dysphagia include the following:
Change in dietary habits
Recurrent pneumonia
General weakness
Mental status changes

12. Examination
Complete Head and neck examination
 Inspection of oral cavity and Dentition
 Oropharynx
 IDL and Nasolaryngoscopy
 Cranial nerve examination ( tongue, gag and cough reflex, hoarseness, vocal
cord mobility)
Neck for lymph nodes, neck masses, thyroid enlargement, loss of laryngeal
crepitus and integrity of laryngeal cartilages

13. Examination
General factors such as body habitus, drooling, and mental status should be
noted.
Voice quality (e.g. a wet sounding voice suggesting pooling of secretions),
Wheezing or labored breathing, and any cranial nerve weakness should be noted.
 Gurgling noise in the neck or crepitus in the neck may indicate the presence
of Zenker’s diverticulum.
 Inspection or palpation of the tongue and tongue strength may unmask
fasciculation of one or both sides
Laryngeal examination is important but can be made difficult by the presence of
pooled secretions

14. Investigation

15. Approach to dysphagia

16. Treatment
Lifestyle modification
Dietary modification
Enteral feeding
Pharmacological:- botulinum toxin
Cricopharyngeal myotomy
Surgery for chronic aspiration
Surgery for esophageal motility disorder

17. MCQ
Which of the following area not involved in swallowing process?
A. anterior cingulate and insula
B. cerebellum
C. precentral gyrus
D. mid-brain

18. MCQ
Neurogenic dysphagia will affect which phase of swallowing?
A. oral preparatory
B. pharyngeal
C. esophageal.
D. Oral transport

19. MCQ
Dysphagia is more common in which of the following
inflammatory myopathy?
A. dermatomyositis
B. polymyositis
C. Inclusion body myositis

20. MCQ
Which of the following phase is most commonly affected in MG?
A. oral preparatory
B. pharyngeal
C. esophageal.
D. Oral transport

21. MCQ
Which of the following is false?
A. right hemispheric lesion affect pharyngeal phase while left
hemispheric lesion have oral phase impairment.
B. unilateral medullary infarction can produce disruption of bilateral
swallowing centre
C. tongue deviation can be present in 30% hemispheric stroke
D. incidence of dysphagia and aspiration is more in cortical then
subcortical stroke.

22. MCQ
Which is the true sequence for appearance of dysphagia in Parkinson
plus syndrome from earliest to late?
A. MSA> PSP> CBD> DLB
B. PSP>CBD>DLB>MSA
C. PSP>DLB>CBD>MSA
D. DLB>PSP>CBD>MSA

23. Thank you