Oropharyngeal and Oroesophageal motor disorders in children

Swallowing disorders can occur in all age groups, resulting from congenital abnormalities, structural damage, and/or medical conditions. Swallowing problems are a common complaint among older individuals, and the incidence of dysphagia is higher in the elderly, in patients who have had strokes, and in patients who are admitted to acute care hospitals or chronic care facilities. A formal oropharyngeal dysphagia evaluation is performed by a speech-language pathologist.

Dysphagia is classified into two major types: oropharyngeal dysphagia and esophageal dysphagia. In some patients, no organic cause for dysphagia can be found, and these patients are defined as having functional dysphagia.

Oropharyngeal dysphagia arises from abnormalities of muscles, nerves or structures of the oral cavity, pharynx, and upper esophageal sphincter.

Infants and children manifest congenital and developmental disorders of oral, pharyngeal, and esophageal motility, as well as many of the disorders seen in adults. The pediatric patient’s lack of verbal abilities may challenge elicitation of symptoms from children.

Key symptoms in young children may thus include subtle prolongation of feeds, delay in milestones of feeding abilities, impairment of normal weight gain, excessive drooling of saliva, increases of regurgitation beyond that expected physiologically, unexplained fussiness, or chronic/recurrent respiratory symptoms. “Silent” aspiration is a particularly insidious manifestation of these motor disorders in infants or neurologically abnormal older children.

Clinical Manifestation

Dysphagia, or difficulty swallowing, is the chief manifestation of oropharyngoesophageal dysmotility in children, as in adults. The presentations are complicated in young children, as they may be in adults with severe neurologic disease, by their inability to report symptoms verbally, so that second-hand reports of signs of disease must suffice to bring attention to these disorders. Thus, pediatric dysphagia manifests as signs of feeding problems or respiratory problems, the latter due to misdirected swallowing.

It has been estimated that as many as 25% of all children may manifest some type of nonspecified feeding difficulty. Although only some of these feeding difficulties are because of dysphagia per se, the clinician must maintain dysphagia in the differential diagnosis of such symptoms.

The cause of dysphagia may be organic or behavioral; if organic, it may be because of disordered anatomy or function; if it is because of disordered function, the dysfunction may have roots in neurosensory, neuromotor, or central processing functions.

Although these opposing concepts are useful for considering the primary causes of disease, often etiologies are mixed or interactions occur among primary and secondary etiologies. Because these multiple etiologies interact to promote disability, all of them should be considered for optimal management In fact, a recent study of 700 children with feeding problems found multiple etiologic contributing factors in nearly 50%. For example, an infant with cricopharyngeal achalasia may develop nasal regurgitation and subsequent obstructive nasal inflammation, making feeding more challenging to the parent and causing early fatigue in the child, so that nasal inflammation and parent and child behavioral aspects would play contributory roles in ongoing disability.

Another problem particular to young children is that a swallowing impairment owing to other causes (congenital anatomic anomalies of the swallowing organs, or general medical disease may interrupt the normal development of swallowing during critical stages, making subsequent behavioral rehabilitation of feeding aversion a critical part of the management.

A complete feeding history includes information on the duration and progression of the symptoms and many other aspects of the feeding experience for the young child. The temporal relationship of the symptoms to the act of swallowing may shed light on the location of the abnormality: pre-swallow gagging or choking may indicate oral disabilities; swallow-associated gagging points to location in the pharynx; and symptoms immediately post-swallow suggest disability in or below the upper esophageal sphincter. The associated nutritional history for a child, in contrast to the usual practice in adults, requires plotting of height and weight, and possibly weight-for-height and head circumference, in relationship to age

Oral, pharyngeal, and esophageal motor disorders in infants (0–12 months of age) and children (1–12 years of age); during adolescence (13 years of age) In contrast to the case for adults, congenital and developmental abnormalities play a prominent role in these disorders in children.

The newborn human infant requires the normal structure, function, and maturation of the oropharyngoesophageal organs in order to take in the nutrients needed for growth to adulthood. In addition, the pharyngeal intersection of the pathways for nutrient acquisition and respiration mandate that the airway protective structures and reflexes develop appropriately as the nutrient acquisition functions mature. Concurrent with the child’s general neurologic development, the primitive reflexive infant suck and swallow are transformed into the mature, voluntary-reflexive, complex, integrated deglutitive functions of biting, chewing, bolus formation, and propulsion into the pharynx. Simultaneously, the airway protective reflexes also mature. The exquisite timing involved in the pharyngeal separation of these two functions by reflexive airway protections is further challenged in infants by the rapidity of their respiratory rates. This physiologic tachypnea increases even further during the frequent respiratory infections children undergo in their first years of life4 or during lung disease associated with prematurity.

The intricacies of these interactions in the proximal striated muscle and deglutitive organs are also impacted by behavior state, attention, and social learning by cognitive input from the developing cerebrum7; and by issues of timing and coordination modulated by sensory feedback.8 Congenital suprabulbar palsies, owing to anoxia or ischemia from congenital vascular anomalies or to abnormalities of neuronal migration, can cause dysphagia in association with dysarthria and drooling, and these disabilities may coexist with other suprabulbar abnormalities: epilepsy, learning disabilities, and delayed motor, cognitive, and language development.

The reflexive nature of many of these deglutitive functions can be disturbed by impairments appearing anywhere in the controlling neural reflex arcs of a neonate. The anatomic source for some of these impairments may be beneath the resolution of available imaging methods but can only be surmised by clinical examination, as has been described for watershed infarcts in fetal and neonatal brainstem, clinically expressed as cranial neuropathies of nerves III to XII, producing abnormalities including dysphagia and aspiration.

Infancy is the time during which congenital abnormalities of these organs or effects of in utero or neonatal exposures usually become evident. In addition, failure of appropriate maturation of functions and reflexes, owing to various etiologies, manifests in childhood. Finally, many disorders of these organs that occur in adulthood also occur in childhood, but may have different epidemiology, manifestations, or optimal management in these younger patients.

Disorders of the smooth muscle esophagus in children vary from those in adults to a lesser degree than the deglutitive disorders; these pediatric lower esophageal disorders are also discussed here.

Some signs and symptoms of swallowing difficulties include difficulty controlling food in the mouth, inability to control food or saliva in the mouth, difficulty initiating a swallow, coughing, choking, frequent pneumonia, unexplained weight loss, gurgly or wet voice after swallowing, nasal regurgitation, and dysphagia (patient complaint of swallowing difficulty). When asked where the food is getting stuck patients will often point to the cervical (neck) region as the site of the obstruction. The actual site of obstruction is always at or below the level at which the level of obstruction is perceived

Symptoms

1. Silent Aspiration
2. Pneumonias, Bronchiectasis, Asthma, Wheezing, Stridor, Apnea
3. Abnormalities in Speech Development
4. Drooling
5. Tongue Thrust
6. Dysphagia
7. Vomiting/Regurgitation
8. Chest Pain, Odynophagia
9. Impactions (Bolus Impactions)
10.Symptoms of Misdirection of Swallows into Airway.
11. Prolonged Feeds/Anorexia/Food Refusal
12. Poor Weight Gain/Malnutrition/Failure to Thrive
13. Nasopharyngeal Regurgitation
14. Laryngeal Penetration and Aspiration
15. Coughing/Choking/Gagging; Hoarseness/”Wet Voice”p

Diagnostic

Diagnostic evaluation of the child often benefits from an actual observation of a feeding by a clinician trained in such observations. Diagnostic procedures used in children suspected of oral, pharyngeal, or esophageal motor disorders may include radiography (particularly esophagram or videofluoroscopic swallowing study), manometry, endoscopy of the esophagus or airway (including fiberoptic endoscopic evaluation of swallowing with sensory testing), scintigraphy, esophageal pH-metry or impedance, or central nervous system imaging.

Treatment

Therapeutic interventions, often optimally choreographed by a multidisciplinary team, include a multitude of “conservative” measures, focused pharmacotherapies, and surgical interventions.

Source : GI Motility online

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