Running title: Dysphagia in Lateral Medullary Syndrome

ACTA FACULTATIS UDC: 616.134-005.8:616.32‑008.1

MEDICAE NAISSENSIS DOI: 10.5937/afmnai39-33245

Review article

Dysphagia in Lateral Medullary Syndrome

Mile Vuković1, Mirna Zelić2

1University of Belgrade, Faculty for Special Education and Rehabilitation, Belgrade, Serbia
2Educational center “Terapika”, Belgrade, Serbia

SUMMARY

Introduction. The lateral medullary syndrome is a neurological disease caused by ischemia in the lateral
part of the medulla oblongata and is the most common form of brainstem infarction. Dysphagia is a
common and clinically significant symptom of this disease because it is closely associated with the risk of
recurrent pneumonia, malnutrition, dehydration, and an increase in mortality and prolonged hospital
treatment.
Aim. This paper aims to review and analyze data on the correlation between swallowing disorders and
lateral medullary syndrome. We intend to present the symptoms, diagnostic and therapeutic procedures of
dysphagia in patients with this syndrome in a comprehensive way.
Methodology. The following databases were used to search the literature: KoBSON-Consortium of Serbian
Libraries for Unified Procurement, PubMed, Science Direct.
Results. Based on the results of the reviewed studies, it was determined that patients with the lateral
medullary syndrome often have swallowing disorders. They are often fed through a nasogastric tube a few
months after the stroke, which significantly impairs their quality of life. To overcome swallowing
disorders and create conditions for safe swallowing function, most patients need treatment for a longer
period. In addition to the available screening tests, instrumental diagnostic methods provide insight into
the biomechanical aspects of swallowing disorders, determine the risk of aspiration, and provide a starting
point for selecting treatment strategies.
Conclusion. Treatment of dysphagia depends on the mechanisms of occurrence and the predictors of
recovery of swallowing function. When conducting treatment, among other things, it is very important to
know the pathological mechanisms of neural connections of the medulla oblongata.

Keywords: lateral medullary syndrome, dysphagia, diagnosis, treatment

Corresponding author:
Mirna Zelić
e-mail: [email protected]

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Review article

INTRODUCTION tions in preparation for swallowing, including

awareness of an impending feeding situation and
Lateral medullary syndrome (LMS), also cal- visual recognition of food. It also includes an in-
led Wallenberg syndrome and posterior inferior crease in the amount of saliva as a physiological
cerebellar artery syndrome (PICA), is a neurological response to food (5). Depending on the place of oc-
disease caused by ischemia in the lateral part of the currence of the disorder, there are two basic types of
medulla oblongata. It occurs due to occlusion in the dysphagia: 1. oropharyngeal and 2. esophageal dys-
vertebral artery or the posterior inferior cerebellar phagia (6).
artery. The syndrome was first described in 1895 by To understand the nature of dysphagia and
Adolf Wallenberg, a German neurologist, to whom implement adequate therapy, a good knowledge of
this syndrome is often referred. Clinical studies the physiology of swallowing is important. Eating
show that it most often occurs in men with an aver- and swallowing are complex motor actions that
age age of 55.6 years (1). include voluntary and reflex activities of as many as
As LMS usually occurs due to occlusion of the 30 muscles and five cranial nerves. These motor
arteria vertebralis (VA), which is the first lateral actions have two biological roles: 1) food transfer
branch of the subclavian artery, the following is an from the oral cavity to the stomach and 2) respi-
overview of the provision of this artery to ratory protection (7). Different authors point to dif-
understand its connection with swallowing. After ferent divisions of swallowing phases. According to
separation from the subclavian artery (art. subclavia Logeman (8), swallowing has four phases: a) prepa-
(AS), the vertebral artery extends vertically upwards, ratory oral, b) oral, c) pharyngeal and e) esophageal.
and then crosses the anterior side of the transverse Matsuo and Palmer (9) further break down the oral
extension of the seventh cervical vertebra and enters phase into three more levels: food transfer through
the opening of the transverse extension (foramen the oral cavity, food processing by chewing and
transversarium) of the sixth cervical vertebra, then saliva, and food transfer to the oropharynx. In the
extends upwards). Passing through the openings of literature, a division into only three phases can be
the transverse extensions of the atlas, it then enters found: oral, pharyngeal, and esophageal (7).
its bony groove (sulcus arteriae vertebralis) on the The patterns of movement in the preparatory
posterior arch of the atlas, and then penetrates the oral phase vary depending on the viscosity of the
posterior atlantooccipital membrane, the dura mater, food, its quantity as well as the degree of pleas-
passes through the large occipital foramen and antness (the subjective sense of taste). The moment
enters the cranial cavity, through the large occipital the fluid is placed in the mouth, the lips close, which
opening. Finally, this artery ascends along the clivus requires nasal breathing, and the soft palate and
to meet the eponymous artery of the opposite side tongue prevent premature leakage of fluid into the
with which it merges into one arterial tree-arteria pharynx. In case of solid food, the tongue rotates,
basilaris (AB) (2). AV damage in any part of its placing food on the teeth laterally due to chewing.
pathway can lead to ischemia in the medulla At this stage, the food bolus is softened by saliva.
oblongata and thus cause swallowing disorers. During the oral phase, the tip of the tongue is raised,
According to empirical data, lesions in the medulla touches the alveolar ridge, the posterior part is
oblongata can manifest as median, dorsolateral, lowered and opens the passage to the pharynx. The
inferodorsolateral, and paramedical (3). dorsal surface of the tongue moves upwards, ex-
The clinical picture of the lateral medullary panding the area of contact with the palate and
syndrome depends on the location of the lesion. The pressing the fluid against the palate. When taking
patient manifests dysphagia, the sensory deficit on solid food, in the oral phase the food is completely
the ipsilateral side of the face, contralateral trunk, prepared and thus facilitates the pharyngeal phase
and extremities. Ataxia, dizziness, Horner's syn- of swallowing. The pharyngeal phase begins with
drome (unilateral ptosis, miosis, and facial anhydro- the trigger of the pharyngeal swallowing reflex. The
sis) also occur (4). velopharyngeal sphincter rises and closes the path to
Dysphagia includes difficulty swallowing and the epipharynx, the suprahyoid muscles push the
controlling saliva, as well as difficulty feeding. In the larynx up and forward, and the epiglottis closes.
broadest sense, dysphagia encompasses a disorder of Pushing the larynx forward and under the base of
all behavioral, sensory, and preliminary motor ac- the tongue also causes the adduction of the vocal

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 Mile Vuković, Mirna Zelić

cords, which closes the glottis and thus prevents the mechanism within the brainstem bring to the fore a
penetration of food into the larynx and airways. central pattern generator (CCE) that can be consid-
These actions achieve separation of the digestive and ered a functionally connected set of neurons capable
respiratory tract, filling of the pharynx, its passive of producing a rhythmic, predictable output in the
emptying and active peristalsis of the pharyngeal absence of afferent sensory input (13). The central
muscles. Thus, the sequences of swallowing in the pattern generator can also be found in other systems
pharyngeal phase are lifting of the larynx, anterior such as chewing (14), movement (15), breathing (16).
movement of the chiode bone, movement of the epi- Many components of the neural network for swal-
glottis, closing of the larynx, movement of the pha- lowing are not intended only for swallowing, but the
ryngeal wall, contraction of the pharynx, and open- swallowing pattern is closely related to chewing and
ing of the pharyngoesophageal segment. A lesion in breathing through the common bases of neurons
the lateral part of the medulla oblongata disrupts the (17).
order of swallowing. Patients cannot begin to con- Sensory information from the pharynx is
tract the suprachiodine muscles, which disrupts the transmitted to the afferent fibers V, VII, IX, and X of
movements of the pharynx and the base of the the cranial nerve and ends in the nucleus tractus
tongue. Without sufficient pressure on the base of solitarius in the medulla oblongata, in the brainstem.
the tongue, the epiglottis loses its ability to close Through afferent fibers, information reaches the
completely (10). The esophageal phase begins in the cerebral cortex where the cortical response to swal-
esophagus, which consists of striated and smooth lowing begins (18).
muscles. This phase allows the transfer of food to the The posterior cerebellar artery is the largest
stomach. With peristaltic movements, the food goes branch of the vertebral artery and begins on the
down. The esophageal phase is an involuntary phase anterolateral side of the medulla oblongata near the
of swallowing and is slower than the pharyngeal lower cranial nerves. Swallowing is affected by the
phase (9). complex relationship of this artery with the n.
Eating and swallowing are closely related to facialis, n. vagus, n. glossopharyngeal, n. hypoglos-
breathing. In healthy adults, breathing is interrupted sus (19).
during swallowing, both due to the physical closure
of the airways by raising the soft palate and closing PATHOPHYSIOLOGICAL MECHANISMS
the epiglottis and due to the neural control of res- OF DYSPHAGIA IN LMS
piration in the brainstem. Understanding the phys-
iology and pathophysiology of eating and swal- Risk factors for LMS include hypertension,
lowing are key to the evaluation and treatment of smoking, and diabetes. A significant cause of LMS is
swallowing disorders (8). the dissection of the vertebral artery, which can be
caused by: neck injury, Marfan's syndrome, Eichler
NEURAL SWALLOWING CONTROL Danlos syndrome, and fibromuscular dysplasia. In
young people, vertebral artery dissection is the most
Supratentorial regions are crucial for modu- common cause of LMS (20).
lation and initiation of swallowing itself, and brain- Swallowing disorder, to some degree, is pres-
stem structures are recognized as the basic motor ent in between 50 and 100% of patients with lateral
plan for the pharyngeal response. The first evidence medullary infarction (21). Dysphagia after medullary
of a swallowing center was presented by Miller and infarction is more common in patients with lesions
Sherrington in 1915. Additionally, Miller (11) spoke in the upper and middle level, as well as in the dor-
of electrostimulation of specific nuclei of the brain- solateral level of the medulla oblongata. Video-
stem that do not elicit the pharyngeal phase of fluoroscopy in these patients shows a disorder of the
swallowing, although muscles are innervated from opening of the esophageal sphincter, food debris in
these motor nuclei. Such an observation suggested the piriform sinuses due to weakness of the muscles
that there is a complex interdependent cycle of the that make up the pharyngeal wall, as well as mul-
swallowing process. Some studies have highlighted tiple attempts to swallow to move the bolus from the
the importance of the medulla oblongata in the pharynx to the esophagus. It has been shown that
coordination between swallowing and respiration more precise localization and level of the lesion can
(12). Ongoing considerations of the swallowing

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Review article

represent a significant predictor of dysphagia and connected in the nucleus ambiguous and the ad-
aspiration in lesions in the medulla oblongata (3, 21). jacent reticular formation. That is why the dorsal
Lesions in the medulla oblongata usually neurons of this region are considered to be program-
cause disorders of the oropharyngeal phase of swal- matic interneurons that set up sequential patterns of
lowing because they are located in important centers neuronal activation that are transmitted to the
for swallowing: nucleus tractus solitarius and nucle- ventral parts for motor activation (24).
us ambiguous. Patients with a unilateral medullary At the neurological level, bilateral swallowing
lesion have mostly intact oral bolus control but sig- centers in the medulla oblongata function as one
nificant trigger damage and neuromotor control of integrated center, and the lesion of part of the center
the pharyngeal phase of swallowing. If a trigger for is sufficient to cause a complete loss of swallowing
the pharyngeal swallowing reflex exists, a delay of function. Dysphagia within the LMS is more severe
10 to 15 seconds is observed. When pharyngeal swal- and has a longer duration compared to dysphagia
lowing is triggered, the following is observed in with hemispherical stroke (3). In most patients with
these patients: 1) reduced lifting of the larynx, which lateral medullary infarction in the acute phase, dys-
leads to reduced opening of the cricopharyngeal phagia is a severe symptom, which is why the pa-
region and collection of food debris in the piriform tient requires non-oral feeding. However, swal-
sinuses; 2) unilateral weakness of the pharynx, lowing disorders in these patients often spontane-
which again leads to the collection of food debris in ously restitute within two months after the stroke.
the piriform sinuses. Unilateral paresis or vocal cord In hemispherical stroke, the frequency of symptoms
paralysis occurs in many patients. Symptoms of la- in the oral swallowing phase is higher, while the
ryngeal weakness and occasional hiccups, as well as symptoms in LMS are related to the pharyngeal
velopharyngeal incompetence in LMS, indicate dam- swallowing phase. In other words, swallowing dis-
age to the nucleus ambiguous (22). Lesions involving order in LMS occurs as a result of contraction of the
the nucleus tractus solitarius cause decreased senso- proximal pharynx with the absence of motor activity
ry function of the pharynx, base of the tongue, and of the upper esophageal sphincter and proximal
epiglottis. Decreased sensory function leads to a esophagus during swallowing (23).
higher risk of aspiration, as well as food residues in Empirical studies indicate variability in the
the pharynx. Some studies focus on the ability to duration and severity of dysphagia in patients with
open the upper esophageal sphincter. Lesions in the lesions in the dorsolateral part of the medulla oblon-
medulla oblongata affect the ability of the cricopha- gata. Although the lesion is unilateral, its effect on
ryngeal muscle to relax. In patients with lateral med- swallowing is mutual. It is assumed that this occurs
ullary infarction, the upper esop hageal sphincter is because the premotor neurons in the ambiguous
damaged ipsilaterally (3, 8). nucleus and their connections are damaged. Conse-
Two bilateral centers in the brainstem are quently, damage or disruption of the connection of
thought to represent the anatomical structure for the cranial motor neurons that participate in swallowing
central pattern generator (CCE). The dorsal part of with the contralateral ambiguous nucleus leads to
the medulla oblongata is anatomically located 1.5 to swallowing disorders. Preserved ipsilateral premo-
4 mm rostrally from the obex and consists of the area tor neurons and contralateral centers in the medulla
that surrounds and includes the nucleus tractus oblongata may affect the degree and duration of
solitarius and the adjacent reticular formation. The dysphagia (25).
nucleus tractus solitarius is the primary sensory
nucleus for the n.facialis, n.glossopharyngeus, and DIAGNOSTIC PROCEDURES FOR
n.vagus. Afferent pathways from the pharynx and ASSESSMENT OF DYSPHAGIA IN LMS
larynx travel through these cranial nerves to the
nucleus tractus solitarius and it also receives im- Early detection of risk through a post-stroke
pulses from the trigeminal sensory nucleus of the aspiration screening test is crucial because it allows
pons. Mucosal receptors in the pharynx respond to for rapid intervention, reduces mortality, length of
touch, water, pressure and facilitate movement and hospital treatment, and overall treatment costs (26).
reactivation of swallowing (23). The dorsal neurons Accordingly, the screening test is the first step in
of the medulla oblongata lack a connection with the evaluating swallowing in the acute phase of a stroke.
n. hypoglossus and n.trigeminus and are directly Screening involves performing a minimally invasive

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 Mile Vuković, Mirna Zelić

procedure that is not a diagnostic procedure. The performed, which implies the existence of hyper-
purpose of swallowing screening is to detect the risk salivation. Patients with lateral medullary syndrome
of aspiration and dysphagia. If screening indicates generally cannot swallow saliva. Non-control of sa-
the presence of risk, diagnostic procedures are per- liva can be a symptom of the weakness of the facial
formed. The validity of the screening, through the nerve. Therefore, the assessment of cranial nerves is
sensitivity and specificity of the test, implies the performed by placing orders on the patient to per-
degree to which the test measures the risk of as- form certain motor actions or to send sensory man-
piration. Sensitivity is the probability that some of ifestations. A more comprehensive assessment in-
the clinical signs of aspiration (cough, choking) will volves assessing the cough reflex (31, 32).
be present. There are different variations of the Videofluoroscopy (VFSS) or modified barium
screening test, but they all refer to the use of water, ingestion occupies a special place in the diagnostic
the volume of which ranges from 3 ml (27) to 90 ml procedure of dysphagia. Videofluoroscopy is treat-
(28). When performing the screening method, there ment-oriented and allows real-time insight and visu-
are signs of aspiration, cough during or after swal- alization of the bolus through the oral cavity, oro-
lowing, choking, change of voice. pharynx, hypopharynx, and esophagus using mod-
ified barium. This method is otherwise considered
Instrumental diagnostic procedures the gold standard in diagnosing dysphagia (7). VFSS
provides insight into the manipulation of the bolus
Before any instrumental diagnostic methods in the oral cavity (chewing, bolus formation, di-
are performed, the medical documentation is eval- recting the bolus to the posterior part), evidence of
uated and, if possible, heteroanamnestic data are aspiration/penetration into the airways (before, dur-
taken from the caregiver. The history of the disease, ing, and after swallowing), the amount and local-
possible diseases that may be associated with dys- ization of food residues in the oral cavity and phar-
phagia, previous strokes, the presence of other neu- ynx (29). VFSS results determine treatment strate-
rological diseases, data on the possible presence of gies. A significant part of this diagnostic finding is
head or neck cancer, as well as data on possible sur- the lateral section of the swallowing process, which
gical interventions are considered; application of enables the observation of tongue base movement,
pharmacological agents as well as the functional velopharyngeal sphincter, chiolaryngeal elevation,
status of the patient concerning independence before laryngeal closure, contraction of the pharyngeal con-
admission to the hospital, cognitive status, ability to strictor, and opening of the upper esophageal
communicate are analyzed, too (29). A team of ex- sphincter (7).
perts, including a speech therapist, gastroenterol- The next diagnostic method is video endo-
ogist, otorhinolaryngologist, radiologist, nurse, and scopy. This method allows the specialist to formulate
physiotherapist, participates in the diagnostic pro- an effective plan for swallowing therapy and is a
cedure. The speech therapist detects swallowing safe instrumental method of diagnosis for the pa-
disorders and monitors the patient through all di- tient. It is a minimally invasive technique that is well
agnostic procedures and later through treatment. tolerated and in which the patient is not exposed to
The gastroenterologist performs diagnostic proce- radiation. It is performed using a flexible laryngo-
dures related to the esophageal segment. The oto- scope that is placed through the nose and extends
rhinolaryngologist diagnoses oral, pharyngeal, la- through the pharynx to see the pharyngeal and la-
ryngeal and pathology at the level of the trachea ryngeal structures during swallowing (32). Video
and, together with the speech therapist, cooperates endoscopy allows static and dynamic assessment of
with videofluoroscopy. The radiologist applies ra- structures in the upper respiratory tract and upper
diological procedures by which, together with the digestive tract. This method provides information on
speech and language pathologist, they assess the pathophysiological deficits of the soft palate, phar-
swallowing disorder. A nurse trained in swallowing ynx, and larynx, and provides direct insight into
disorders as well as a physiotherapist who assists in superficial anatomy, mucosal abnormalities, effects
posture adequate for performing indicative proce- of altered structures on bolus flow, and airway pro-
dures also participate in the diagnostic procedure tection, glottis occlusion, bolus pathway, and bolus
(30). Before instrumental diagnostics, an evaluation location in the hypopharynx. This method assesses
of anatomical structures and structural integrity is

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Review article

the patient's ability to swallow a bolus of different focuses on exercise without the inclusion of food or
textures and consistency (7). fluids, while direct treatment refers to the intake of
Although video endoscopy and video- food and fluids. This classification was performed
fluoroscopy provide insight into the pathophys- from the aspect of aspiration risk (29). Exercises in
iology of swallowing, their application limits visuali- the treatment of dysphagia refer to the integration of
zation in three dimensions, and therefore today interdependent elements in the act of swallowing. As
dysphagias are approached from the angle of a new the deficit of the pharyngeal phase of swallowing is
perspective. For that purpose, computerized tomog- most often noticed in the lateral medullary syn-
raphy is used, which enables 3D imaging, as well as drome, therapeutic exercises should be based on ini-
quantitative measurements. Using computed tomog- tiating and strengthening the movements of the base
raphy, the dynamics of the movement of structures, of the tongue, hyoid, pharynx, larynx, and upper
which participate in the act of swallowing, is simul- esophageal sphincter. In this way, it acts on hyola-
taneously assessed (29). ryngeal elevation, closure of the larynx, constriction
The methods of quantitative analysis of mo- of the pharynx, and dilatation of the upper esoph-
tion are mainly used to collect kinematic and kinetic ageal sphincter (25).
data. This group of methods includes high-reso- Shaker exercise involves a combination of iso-
lution manometry, which provides insight into metric and isokinetic exercises to strengthen the
kinetic parameters such as the pressure of the base of suprahyoid muscles (m. geniohyoid, m. mylohyoid,
the tongue and the narrowing of the pharynx. As the and m. digastric) and allow shortening of m. thy-
pharyngeal phase of swallowing is very complex rohyoid. This exercise results in a reduction of
and requires high coordination of muscle contrac- residues in the piriform sinuses and a reduction in
tions and the creation of pressure to efficiently trans- hypopharyngeal intrabolic pressure. It is performed
fer the bolus to the esophagus, the high-resolution three times a day for six weeks (35, 36).
method provides information on the pressure in the Tongue base retraction exercises allow pres-
pharynx and upper esophageal sphincter during sure to be created to trigger the pharyngeal bolus.
swallowing (33). The base of the tongue passes the bolus through the
pharynx, retracting and making full contact with the
TREATMENT OF DYSPHAGIA IN LMS pharyngeal wall and thus applying pharyngeal
pressure to the bolus. The exercise is designed to
Many patients with LMS who have swal- improve the maximum range of motion of the base
lowing disorders require appropriate treatment. of the tongue, establishing the power to push the
Given the complexity of the problem, a team of bolus and ensure the passage of the entire bolus
experts usually participates in the treatment. The through the pharynx (37).
professional team for the treatment of dysphagia The Masako maneuver or contraction of the
includes doctors, dentists, speech therapists, nurses, posterior part of the pharynx together with the
physiotherapists, and nutritionists. In Japan, studies gradual movement of the base of the tongue during
were conducted on the participation of various team swallowing provides the driving force necessary to
members in the rehabilitation of dysphagia and the move the bolus through the upper part of the
results indicated that the participation of speech pharynx. The "swallowing tongue" swallowing ex-
therapists was 34%, dentists 20%, nurses 14%, doc- ercise is aimed at contracting the pharynx, physio-
tors 8%, nutritionists 8%, while the rest of the par- logically increasing the anterior movement of the
ticipation was related to occupational therapists. and pharyngeal muscles (m. superior constrictor), and
physiotherapists (7). As a rule, the team leader in the thus improving the contact between the base of the
treatment of dysphagia in LMS is a speech therapist. tongue and the posterior wall of the pharynx. The
The traditional approach to the treatment of swal- goal of the exercise is to strengthen the contractions
lowing in patients with lateral medullary syndrome of the pharynx (38, 39).
includes exercises for the pharyngeal muscles, which Thermotactile stimulation also plays an im-
include: Shaker exercises, tongue base exercises, and portant role in the treatment of dysphagia. It is a
Masako maneuver, as well as expiratory muscle sensory stimulation technique used to improve the
exercises (34). Treatment of swallowing disorders is trigger of the pharyngeal reflex in patients in whom
classified as direct and indirect. Indirect treatment the swallowing reflex is delayed and who have a

280 Acta facultatis medicae Naissensis 2022; 39(3): 275-284

 Mile Vuković, Mirna Zelić

high risk of aspiration. Cold stimulation is a sensory is occupied by instrumental diagnostics, which en-
stimulus that goes to the brain stem and induces an ables insight into which phase the act of swallowing
improvement in swallowing physiology that re- is most damaged. In addition to detecting a swal-
quires the ability to swallow voluntarily without lowing damage, instrumental diagnostics directs us
stimulation. Alveolar arches are especially recom- to choose the appropriate treatment. Since speech
mended for mechanical thermal stimulation because therapy occupies a central place in the treatment of
they are sensitive to activate the swallowing reflex dysphagia, and the treatment of swallowing dis-
(8, 40). orders is based on good diagnostics, it is extremely
The method of neuromuscular electrostim- important to educate speech therapists about the
ulation (NMES) is also used. This therapeutic tech- existing diagnostic procedures, their scope, and lim-
nique stimulates the neck muscles to activate the itations. Since dysphagia in lateral medullary syn-
sensory swallowing pathways. NMES implies drome is a significant and often the only persistent
strengthening the musculature that participates in symptom, the treatment of swallowing disorders in
the act of swallowing. It originated from many years patients with this syndrome is a real challenge for
of use in physical therapy. Since 2002, the VitalStim speech therapists and other professionals. As the
device has been used in the United States in the deficiency of the pharyngeal phase of swallowing is
treatment of dysphagia resulting from stroke and most often noticed within the lateral medullary
neuromuscular diseases (41, 42). syndrome, the program of therapeutic exercises
should be based on initiating and strengthening the
CONCLUSION movements of the base of the tongue, hyoid, phar-
ynx, larynx, and upper esophageal sphincter. In that
Having insight into the scientific literature on way, it acts on hyolaryngeal elevation, closing of the
dysphagia and research of neural connections of the larynx, constriction of the pharynx, and dilatation of
medulla oblongata, we have concluded that in pa- the upper esophageal sphincter. The ability to estab-
tients with LMS, the velopharyngeal sphincter, re- lish neural control of swallowing and the location of
traction of the base of the tongue, as well as the pha- the lesion is considered an important predictor of
ryngeal phase of swallowing is most often damaged. swallowing disorders in patients with LMS.
In the diagnosis of dysphagia in LMS, a special place

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Curative

Disfagija kod lateralnog medularnog sindroma

Mile Vuković1, Mirna Zelić2

1Univerziteta u Beogradu, Fakultet za specijalnu edukaciju i rehabilitaciju Beograd, Srbija

2Edukativni centar „Terapika“, Beograd, Srbija

SAŽETAK

Uvod. Lateralni medularni sindrom je neurološko oboljenje izazvano ishemijom u bočnom delu produžene
moždine i predstavlja najčešći oblik infarkta moždanog stabla. Disfagija je čest i klinički značajan simptom
ovog oboljenja jer je usko povezana sa rizikom od ponovljene pneumonije, malnutricije, dehidracije, te sa
povećanjem procenta mortaliteta i produženim bolničkim lečenjem.
Cilj. Cilj ovog rada bio je pregled i analiza podataka o korelaciji poremećaja gutanja i lateralnog medularnog
sindroma. Namera nam je da na sveobuhvatan način prikažemo simptome, dijagnostičke i terapijske
procedure disfagije kod bolesnika sa ovim sindromom.
Metodologija. Za pretraživanje literature korišćene su sledeće baze podataka: KoBSON – Konzorcijum
biblioteka Srbije za objedinjenu nabavku, PubMed, Science Direct.
Rezultati. Na osnovu rezultata pregledanih studija utvrđeno je da bolesnici sa lateralnim medularnim
sindromom često imaju poremećaje gutanja. Oni se neretko hrane putem nazogastrične sonde i po nekoliko
meseci nakon moždanog udara, što značajno narušava njihov kvalitet života. U cilju prevazilaženja smetnji u
gutanju i stvaranja uslova za bezbednu funkciju gutanja, većina bolesnika ima potrebu za tretmanom u
dužem vremenskom intervalu. Pored dostupnih skrining testova, instrumentalne dijagnostičke metode
omogućavaju uvid u biomehaničke aspekte poremećaja gutanja, determinišu rizik od aspiracije i
predstavljaju polaznu osnovu za odabir strategija tretmana.
Zaključak. Tretman disfagije zavisi od mehanizama nastanka i faktora predikcije oporavka funkcije gutanja.
Pri sprovođenju tretmana, pored ostalog, veoma je važno poznavanje patoloških mehanizama neuralnih veza
produžene moždine.

Ključne reči: lateralni medularni sindrom, disfagija, dijagnostika, tretman

284 Acta facultatis medicae Naissensis 2022; 39(3): 275-284