Altman Kenneth W
Mount Sinai School of Medicine, New York, NY, USA.
Nestle Nutr Inst Workshop Ser. 2012;72:119-26. doi: 10.1159/000340000. Epub 2012 Sep 24.
The etiology of oropharyngeal dysphagia can be broad, and includes aging with atrophy, debilitation, stroke, neurodegenerative and muscular diseases, tumor and postsurgical deformity, as well as effects due to medications and drying of the mucosal membranes. Pathophysiology depends on the multiple causative factors, including the cortex and neural connections to generate the swallow, as well as the oropharyngeal musculature. While chronic debilitation and age may result in nutritional deficiency and poor hydration, the other causes generally present with aspiration risk more acutely. Bacteriologically, aspiration pneumonia is usually polymicrobial with a predominance of Gram-negative enteric bacilli. However, there is emerging evidence to suggest that odontogenic sources may complicate the severity of bacterial load. The principles behind science-based interventions are primarily aspiration assessment with bedside evaluation, and ultimately modified barium swallow (videofluoroscopy) or functional endoscopic evaluation of swallowing (with or without sensory testing). Each has its advantages and logistical concerns. Intervention and rehabilitation is unique to the patient's needs, but may include reconditioning and therapy with a speech and language pathologist, and surgical options. The emerging roles of neuroplasticity and external neuromuscular stimulation are also discussed.
口咽吞咽困难的病因广泛，包括衰老伴萎缩、身体虚弱、中风、神经退行性疾病和肌肉疾病、肿瘤及术后畸形，以及药物影响和黏膜干燥。病理生理学取决于多种致病因素，包括产生吞咽动作的皮质及神经连接，以及口咽肌肉组织。虽然慢性身体虚弱和年龄增长可能导致营养缺乏和水分摄入不足，但其他病因通常更易引发急性误吸风险。从细菌学角度来看，吸入性肺炎通常是多微生物感染，以革兰氏阴性肠道杆菌为主。然而，越来越多的证据表明牙源性感染可能会加重细菌负荷的严重程度。基于科学的干预措施背后的原则主要是通过床边评估进行误吸评估，最终进行改良钡餐吞咽造影（视频荧光透视）或吞咽功能内镜评估（有无感觉测试）。每种方法都有其优点和实际问题。干预和康复需根据患者需求定制，但可能包括与言语治疗师一起进行的康复训练和治疗，以及手术选择。文中还讨论了神经可塑性和外部神经肌肉刺激的新作用。
