Guide Principles of Deglutition: A Multidisciplinary Text for Swallowing and its Disorders

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Swallowing Mechanism: Three phases

Pediatrics; doi: Dev Med Child Neurol. Crowe L, Chang A, Wallace K Instruments for assessing readiness to commence suck feeds in preterm infants: effects on time to establish full oral feeding and duration of hospitalization. Cochrane Database of Systematic Reviews , Issue 4. J Perinatol; Considering the Role of Top-Down Mechanisms. Adv Child Dev Behav; J Adv Nurs; J Hum Lact; doi: Semin Speech Lang; Lubbe W Clinicians guide for cue-based transition to oral feeding in preterm infants: An easy-to-use clinical guide.

ISBN 13: 9781461437932

J Eval Clin Pract March 2 doi: J Pediatr; Mobbs EJ, Bobbs GA, Mobbs AE Imprinting, latchment and displacement: a mini review of early instinctual behavior in newborn infants influencing breastfeeding success. Acta Paediatr; doi Virtual Mentor; Deglutition syncope DS is a form of neurally-mediated syncope in which loss of consciousness occurs during or immediately after swallowing. An year-old man was brought to the emergency department after a witnessed syncopal episode that occurred while he was eating at a restaurant.

He remained unconscious for several seconds, but was easily revived. His medical history included longstanding reflux controlled with a proton pump inhibitor, coronary artery disease, bioprosthetic aortic valve replacement for aortic stenosis, and a right carotid artery stenosis. The patient had recently started an evaluation for for left-sided otalgia and dysphagia to solids and liquids associated with lightheadedness and near-syncope. The symptoms were triggered by ingestion of large boluses of food and carbonated beverages.

Prior cardiology evaluation included hour ambulatory electrocardiography, which revealed first-degree atrioventricular block and transient, asymptomatic Mobitz type II second-degree atrioventricular block. A transthoracic echocardiogram was unrevealing. An esophagram revealed mild intermittent esophageal dysmotility, but no structural abnormalities. Maxillofacial CT showed chronic left-sided sinusitis and bilateral mastoiditis treated with a short course of steroids and clarithromycin.

Upper endoscopy and esophageal manometry had been recommended, but had not yet been performed. On current presentation, initial laboratory studies demonstrated a mild normocytic anemia and thrombocytopenia.


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Troponin T was negative. Electrocardiogram revealed normal sinus rhythm, first-degree atrioventricular block, and left anterior fascicular block, but was unchanged from prior. A noncontrast maxillofacial CT showed persistence of sinus disease. The patient was admitted and placed on continuous telemetry monitoring. The following morning, he was swallowing medications and experienced recurrent symptoms accompanied by a period of atrioventricular block resulting in a 3-second pause Figure 1.

A dual chamber permanent pacemaker was placed after electrophysiology evaluation. Upper endoscopy revealed a normal esophagus without stricture, stenosis, or inflammation. There was mild chronic gastritis without Helicobacter pylori Figure 2. The patient's dysphagia resolved and has not recurred at 3-month follow-up. His otalgia initially persisted, but was corrected by subsequent sinus surgery. Surveillance pacemaker interrogation has not revealed any recurrent pauses or arrhythmias requiring pacemaker correction.

Electrocardiogram while patient swallowed pills. Pre-syncopal symptoms lightheadedness, dizziness were elicited during the presented interval. Note the presence of type II, second-degree atrioventricular block and 2 non-conducted P-waves, with a total pause of approximately 3 seconds. Examination of the A esophagus and B duodenum demonstrated normal landmarks and endoscopic appearance. C Antral erythema in a patchy distribution was noted. D Retroflexion and examination of the fundus and cardia was also normal. DS is a situational form of the reflex, or neurally-mediated, syncope syndromes.

Patients may present with overt syncope or more subtle pre-syncopal symptoms, such as dizziness, lightheadedness, or weakness.

Principles of Deglutition: A Multidisciplinary Text for Swallowing and its Disorders

It occurs most commonly in adult males. Of the 80 cases reported between and , 31 The precise mechanism of syncope in DS remains speculative, and several pathways may be involved. Current theories suggest the irritation or aberrant activation of a vagal reflex, resulting in cerebral hypoperfusion. This vagal mechanism is supported by numerous reports documenting the prevention of syncope with pre-administration of atropine. Diagnosis is established by a clinical history suggesting the temporal association of swallowing with syncopal or presyncopal symptoms.

A careful history of episodes and associated triggers should be taken. As in our case, documentation of an associated arrhythmia via continuous cardiac monitoring is critical for determining the appropriate treatment.

Deglutition Syncope: A Case Report and Review of the Literature

If unsuccessful, electrophysiology studies should be strongly considered. Once the diagnosis is established, attempts at identification of an underlying cause should be undertaken. Given the association with gastroesophageal disease, esophageal radiography and upper endoscopy are important initial studies. If negative, esophageal manometry, pH, and impedance studies should be considered.

A Multidisciplinary Text for Swallowing and its Disorders

In our patient, the existence of numerous plausible etiologic conditions precluded the precise identification of an underlying cause. Despite a history of coronary artery disease and cardiothoracic surgery, no cardiac conduction disease was detected. Despite dysphagia, no gastroesophageal pathology was identified. The chronic sinusitis and mastoiditis bears mention, as a case of DS associated with periodontitis and mastoiditis has been reported.

Fortunately, DS is highly treatable. Although no randomized trials have been conducted, there are several accepted tenets to its management. Identification and avoidance of trigger substances is vital. Carbonated beverages have been frequently implicated as the inciting agent for DS, as the dissolved carbon dioxide distends the gastric lumen and elicits the vagal reflex. Cases of DS due to achalasia and hiatal hernia have also been reported and resolved with pneumatic balloon dilation and Nissen fundoplication, respectively.

Withdrawal of medications that slow cardiac conduction e.


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Author contributions: A. Kahn drafted the manuscript.

Principles of deglutition: A multidisciplinary text for swallowing and its disorders

LM Koepke assisted with drafting and critically revising the manuscript. Umar conceptualized and designed the manuscript, assisted with critical revision, and is the article guarantor. National Center for Biotechnology Information , U. Published online Oct 9. Umar , MD 2.