Neurological disorders of the pharynx: causes, symptoms, diagnosis, treatment

At the basis of adequate functioning of the pharynx lie the most complicated mutually consistent nervous processes, the slightest violation of which leads to disorganization of food and air-flow functions at this level. Being at the "crossroads" of the respiratory and esophagus, richly endowed with blood and lymphatic vessels, innervated by V, IX, X and XI cranial nerves and sympathetic fibers, abounding in mucous glands and lymphadenoid tissue, the pharynx is one of the most sensitive organs to various pathogenic factors. Among the numerous diseases that are susceptible to the pharynx, its neurological disorders, which occur both in the inflammatory and traumatic lesions of its peripheral nerves, and in numerous diseases of the stem and overlying centers, which provide for the integral regulation of the physiological (reflex and voluntary) and trophic functions of the pharynx, are not uncommon.

Neurogenic disorders of the pharynx can not be considered isolated from similar disorders of the esophagus and larynx, since these anatomical formations represent a single functional system that receives nervous regulation from common centers and nerves.

Classification of neurogenic dysfunction of the pharynx

Syndrome of dysphagia, aphagia:

• neurogenic dysphagia;
• painful dysphagia;
• mechanical dysphagia (this form is included in the classification in order to reflect all types of impaired swallowing function).

Sensitive disorder syndrome:

• paresthesia of the pharynx;
• hyperesthesia of the pharynx;
• neuralgia of the glossopharyngeal nerve.

Syndromes of involuntary motor reactions of the pharynx:

• tonic spasm of the pharynx;
• clonic spasm of the pharynx;
• myoclonias are pharyngeal-guttural.

These concepts designate symptom complexes, which are based on violations of the pharyngeal and esophageal functions of the pharynx and esophagus. According to the concept of F.Magendi, the act of swallowing is divided into 3 phases - oral arbitrary, pharyngeal involuntary fast and esophageal involuntary slow. The swallowing and esophagus processes can not normally be interrupted arbitrarily in the second and third phases, but they can be broken in any of these phases by various pathological processes - inflammatory, traumatic (including foreign bodies of the pharynx), tumor, neurogenic, including pyramidal, extrapyramidal and bulbar structures. Difficulty swallowing (dysphagia) or complete its inability (aphagia) can occur with most diseases of the oral cavity, pharynx and esophagus, in some cases, and with larynx diseases.

Neurogenic (motor) dysphagia is observed with various processes in the brain (vasculitis, neoplasms, purulent, infectious and parasitic diseases). In this case, both the central nadchnuclear formations and the peripheral nerve structures are affected, which ensure the transfer of regulatory influences of the center to the organs of the swallowing act (the nuclei of IX and X pairs of cranial nerves and their roots - nerves). With neurogenic dysphagia, not only the motor component of the swallowing act may suffer, but also the sensory control behind it, which is disturbed by hyposthesis or anesthesia of the pharynx and the laryngopharynx. This leads to a violation of the inhibitory function of the pharynx and larynx and the ingestion of food and foreign bodies into the respiratory tract. Diphtheria neuritis of the pharyngeal nerves is most often manifested by the paresis of the soft palate, which is manifested by a violation of swallowing, especially liquid food that penetrates the act of swallowing into the nasopharynx and the nasal cavity.

The paralysis of the soft palate can be one-sided and two-sided. With unilateral paralysis, functional disturbances are insignificant, but visible disturbances are clearly visible, especially during the pronunciation of the sound "A", at which only a healthy half of the soft palate shrinks. In a quiet state, the tongue is deflected into the healthy side by the pull of the retained muscles (m. Azygos); this phenomenon is greatly amplified during phonation. In central lesions, unilateral paralysis of the soft palate is rarely isolated, in most cases it is accompanied by alternating paralysis, in particular, by the epithelial hemiplegia and rarely paralysis of other cranial nerves.

Often, the unilateral paralysis of the soft palate occurs with central lesions, manifested in the initial stage of hemorrhagic stroke or softening of the brain. However, the most common cause of hemiplegia of the soft palate is the lesion of the glossopharyngeal nerve with herpes zoster, which ranks second after herpes zoster n. Facialis and is often associated with it. In this viral disease, unilateral paralysis of the soft palate occurs after herpetic eruptions in the soft palate and lasts for about 5 days, then completely disappears.

Bilateral paralysis of the soft palate is manifested by open nasal, nasal reflux of liquid food, especially with the vertical position of the body, inability to suck, which is especially detrimental to the nutrition of infants. When the mesopharyngoscopy of the soft palate appears languidly hanging to the root of the tongue, flotation during respiratory movements, which remains immobile when the sounds "A" and "E" are pronounced. When the head is bent to the back, the soft sky passively, under the action of gravity, deviates toward the back wall of the pharynx, with the head tilted forward - toward the oral cavity. All kinds of sensitivity for paralysis of the soft palate are absent.

The cause of bilateral paralysis of the soft palate is in most cases a diphtheria toxin with a high degree of neurotrophy (diphtheria polyneuritis), less often these paralyzes occur with botulism, rabies and tetany due to a violation of calcium metabolism. Diphtheria palsy of the soft palate usually occurs when there is insufficient treatment for this disease or with unrecognized pharyngeal diphtheria. As a rule, these paralysis appear from the 8th day to 1 month after the disease. The syndrome of dysphagia sharply increases when the nerve fibers innervating the lower constrictor of the pharynx are affected. Often, after diphtheria, a combined paralysis of the soft palate and ciliary muscle of the eye is observed, which allows us to establish a retrospective diagnosis of diphtheria taken for vulgar pharyngitis or sore throat. Treatment of diphtheritic paralysis of the soft palate is carried out with antidiphtheria serum for 10-15 days, strychnine preparations, group B vitamins, etc.

Central paralysis of the soft palate, caused by the lesion of the brainstem, is combined with alternating paralysis (bulbar paralysis). The causes of these lesions can be syphilis, cerebral apoplexy, syringobulbia, brainstem tumors, etc. Palatal paralysis is also observed in pseudobulbar paralysis caused by damage to the nidonuclear conductive pathways.

Paralysis of the soft palate can occur during a hysterical fit, manifested, as a rule, and other symptoms of hysteroid neurosis. Usually, with such paralysis, the voice becomes nasal, but there is no nasal reflux of the swallowed fluid. Manifestations of hysterical neurosis are extremely diverse and externally can simulate various diseases, but more often they imitate neurological and mental diseases. Neurological symptoms include different in severity and prevalence of paralysis, rifling, violations of pain sensitivity and coordination of movements, hyperkinesia, limb tremor and contraction of facial muscles, various speech disorders, spasms of the pharynx and esophagus. The peculiarity of neurological disorders in hysterical neurosis is that they are not accompanied by other disorders common to neurological disorders of organic origin. Thus, with hysterical paralysis or spasms of the pharynx or larynx, there are no changes in reflexes, trophic disorders, dysfunction of the pelvic organs, spontaneous motor vestibular reactions (spontaneous nystagmus, symptom of miss, etc.). Sensitivity disorders in hysteria do not correspond to zones of anatomical innervation, but are limited to zones of "stocking", "gloves", "socks".

Paresis and paralysis in hysteria encompass groups of muscles involved in performing any arbitrary purposeful motor act, for example chewing, swallowing, sucking, squeezing, movements of the internal muscles of the larynx. Thus, hysterical glossoplegia, which occurs under the influence of negative emotions in persons suffering from neurasthenia, leads to disruption of active movements of the tongue, its participation in acts of chewing and swallowing. At the same time, an arbitrary slow movement of the tongue is possible, but the patient can not stick his tongue out of the mouth. The resulting decrease in the sensitivity of the mucous membrane of the tongue, pharynx, and entrance to the larynx aggravates dysphagia, often leading to aphagia.

Diagnosis of functional dysphagia of hysteroid genesis does not cause difficulties due to remitting (repeated) nature and rapid disappearance after taking sedatives and tranquilizers. With true dysphagia of organic genesis, the diagnosis is based on the signs of a causative (underlying) disease. To such diseases can be attributed banal inflammatory processes with bright symptoms, specific processes, neoplasms, lesions, developmental anomalies.

Paralysis of the pharynx is characterized by impaired swallowing, especially dense food. They do not arise in isolation, but are combined with paralysis of the soft palate and esophagus, and in some cases also with paralysis of the laryngeal muscles that expand the vocal cavity. In these cases, the gastric tube for feeding is always adjacent to the tracheotomy tube. The causes of such paralysis are most often diphtheria neuritis of the glossopharyngeal and other nerves taking part in the innervation of the pharynx, larynx and esophagus, as well as severe forms of typhus, encephalitis of various etiologies, bulbar poliomyelitis, tetany, poisoning with barbiturates and narcotic drugs. Functional disorders are explained by paralysis of the constrictors of the pharynx and muscles lifting it and the larynx during the swallowing act, which is determined by palpation of the larynx and during mesopharyngoscopy (examination of the pharynx during the pharynx can be performed provided that the subject before clamping clamps between the molars a stopper or other object, which allows for endoscopy). This technique is necessary due to the fact that a person can not take a sip if his jaw is not compressed.

Paralysis of the pharynx can be one-sided in the case of unilateral damage to the glossopharyngeal nerve and the motor fibers of the vagus nerve. This kind of hemiplegia of the pharynx is usually associated with a one-sided paralysis of the soft palate, but does not touch the larynx. Such a picture can be observed either with insufficient cerebral circulation, or after a viral infection. In herpes zoster one-sided paralysis of the pharynx is usually associated with the same-named paralysis of the soft palate and mimic muscles of the same etiology. Hyposesthesia of the pharyngeal mucosa on the side of the lesion is also noted. Paralysis of the glossopharyngeal nerve is manifested by the accumulation of saliva in pear-shaped sinuses.

X-ray examination with contrast reveals the asynchronous movements of the epiglottis and the pharyngeal compressors during swallowing and the accumulation of a contrasting substance in the region of the epiglottis fossa and especially in the pear-shaped sinus on the side of the lesion.

The occurrence of bulbar laryngeal paralysis is due to the generality of their innervation apparatus, the proximity of the glandopharyngeal nerve and vagus nerve and the efferent fibers of these nuclei. These disorders will be described in more detail in the section of neurogenic functional disorders of the larynx.

Painful dysphagia occurs with inflammatory processes in the oral cavity, pharynx, esophagus, larynx and surrounding tissues, with foreign bodies of the pharynx and esophagus, injuries of these organs, inflammatory complications, decaying infectious granulomas (except syphilis), tumors, etc. The most painful tuberculosis ulcers, less painful decaying malignant tumors and the least painful are syphilitic affection of the walls of the esophagus. Painful dysphagia with inflammatory processes in the oral cavity, paramindalic space is often accompanied by contracture of the temporomandibular joint or reflex trism. More rarely, painful dysphagia is neurogenic in nature, for example, in the trigeminal, lumbosopharyngeal and upper laryngeal neuralgia, as well as in various hysterical neuroses, manifested by prozopalgia, paralysis, paresis and hyperkinesis in the chewing and swallowing-esophagus complex.

[1], [2], [3], [4], [5], [6], [7], [8]