Pharynx

The pharynx extends from the base of the skull to the inferior border of the cricoid cartilage at part front And limit inferior vertebra C6 in part behind. Pharynx shared into three segments, namely the nasopharynx, oropharynx, and hypopharynx. The nasopharynx is located in behind cavity nose And in on palate soft. Oropharynx extending from palate soft until bone hyoid, And hypopharynx located in behind larynx. The pharynx is tubular in shape with muscular walls consisting of longitudinal muscles on the inside surrounded by an external circular muscle layer. The external muscles consist of the superior, middle, and inferior constrictor muscles which contract play a role For narrow down wall pharynx during process swallow. Contraction in a way reflex sequentially from end superior to inferior pharynx propels food through the pharynx into the esophagus. The inferior pharyngeal constrictor muscle is the thickest of the pharyngeal constrictors and consists of two parts, the thyropharyngeus and the cricopharyngeus . Posteriorly, between the lower fibers of the thyropharyngeus and the upper fibers of the cricopharyngeus, is a small triangular area called the Killian dehiscence . This space is susceptible to diverticulum formation during abnormally uncoordinated pharyngeal peristalsis in which the peristaltic wave reaches the cricopharyngeus before it relaxes. The internal longitudinal muscles of the pharynx consist of the palatopharyngeus , stylopharyngeus , and salpingopharyngeus . These muscles shorten and widen the pharynx during swallowing by elevating the pharynx and larynx. The palatopharyngeus is the largest of the longitudinal muscles. ⁵

Esophagus

The esophagus is a muscular tube that extends from the pharynx to the stomach. It is about 23-25 cm long, starting at the lower border of the cricoid cartilage (opposite the C6 vertebra) and ending at the cardiac opening of the stomach (opposite the T11 vertebra). There are three constrictions in the esophagus, which are First is at on level sphincter cricopharyngeal namely 15 cm from tooth series. Second, it is located where the esophagus is crossed by the aortic arch and the left main bronchus, namely 23 cm from the incisors. Third, the narrowing where the esophagus penetrates the diaphragm namely 40 cm from tooth series. Wall esophagus own four layer from outside to inside namely: ⁴

• Fibrous layer

• Muscular layer (outer longitudinal layer and inner circular layer continuous with the inferior constrictor of the pharynx)

• Layer submucosa (with vessels blood, nerve, mucous glands )

• Internal mucosal layer (covered with a thick layer of stratified squamous epithelium with papillae on its surface)

Physiology Swallow

1. Oral Phase

The oral phase of swallowing occurs in the mouth and consists of two stages: the preparatory stage and the propulsive stage. The preparatory stage begins when food or liquid is introduced into the mouth and results in the formation of a bolus. Bolus formation occurs through coordinated movements of the lips, cheeks, jaw, and tongue, as well as closure of the upper esophageal sphincter to keep the food or liquid in the mouth until the person is ready to begin swallowing. Liquids No need preparation For formation bolus, whereas Solid foods require processing to reduce particle size through chewing and softening by saliva. This process is under reflex control. through three nerve cranial. Nerve trigeminal to coordinate chewing and convey information sensory, nerve facial to coordinate movement lips and cheeks to aid in the placement and retention of food, and the hypoglossal nerve controls tongue movements. Once a bolus suitable for swallowing is formed, bolus the positioned in channel Which formed by tongue against the palate hard, And stage encouragement from phase oral started. Through elevation the tongue that wavy Which started from end And move to behind, bolus pushed backwards with a squeezing action through the fauces into the opening of the pharynx. ⁶

Phase Pharynx

The pharyngeal phase of swallowing begins voluntarily as the bolus crosses the anterior tonsillar pillars by sensory information conveyed via the glossopharyngeal and vagus nerves. Once initiated, the remainder of this phase is reflexive and is completed in about 1 second. As the tongue propels the bolus into the pharynx, the soft palate moves upward to close the nasopharynx from the oropharynx. The palatopharyngeal folds simultaneously move toward the midline to form funnel Which guide bolus through pharynx on. Bone hyoid and larynx Then lifted in a way anterosuperior avoid from bone behind neck, which shortens and enlarges the pharynx while creating negative pressure in the hypopharynx. Propagation bolus through pharynx achieved by four mechanism following: pressure booster tongue, contraction muscle constrictor pharynx, pressure negative hypopharyngeal, and gravity. As the bolus passes through the lower pharynx, the airway is protected by elevation of the larynx beneath the base of the tongue, closure of the vocal cords, and closure of the epiglottis over the laryngeal vestibule. The pharyngeal phase ends as the bolus passes through the lower pharynx into the esophagus via the upper esophageal sphincter. ⁶

Esophageal Phase

The esophageal phase is the reflex phase that begins when the bolus moving forward passes the upper esophageal sphincter and enters the esophagus. The upper esophageal sphincter relaxation moment phase pharynx triggered And still open until bolus pass cricopharyngeal part Which relax from constrictor pharynx inferior. By Because That, Relaxation of the cricopharyngeal muscle is essential for normal swallowing and failure to do so at the proper rate or timing can result in discoordination of the other swallowing mechanisms leading to dysphagia. Once the bolus has passed the upper esophageal sphincter, it is pushed through the esophagus into the stomach through wave peristaltic Which produce pressure positive. Secondary peristaltic waves occur in response to local distension, allowing clearance of any bolus left behind after the primary peristaltic wave. Peristaltic waves in the upper two-thirds of the esophagus move more fast than one third part lower. Matter This due to by the fact that part on esophagus contain muscle striped, whereas one third part lower non-striated. In part lower esophagus, there is segment throughout 3 cm and extends above and below the diaphragm with an average pressure that is 8 mmHg greater than the intragastric pressure. This segment forms the esophageal sphincter lower in lower contraction tonic Because strength intrinsic And extrinsic. Intrinsic forces are created by the internal circular muscle fibers of the esophagus, and extrinsic forces are created by the pressure of the diaphragm. After the bolus passes through the esophagus, powers This relax, And sphincter esophagus lower open just before the peristaltic wave carrying the bolus reaches it. ⁶

Dysphagia

1. Oropharyngeal Pathology

Dysphagia is difficulty or inability to swallow. Oropharyngeal dysphagia is most often associated with chronic neurological conditions, especially Parkinson's disease, stroke, and dementia that are not part of physiological aging. It may also be the first symptom of neuromuscular disorders such as amyotrophic lateral sclerosis or myasthenia gravis. ⁵

A number of condition chronic, like health tooth Which bad, tooth false, dry mouth (xerostomia), or medication side effects may also indicate progressive oropharyngeal dysfunction. Tardive dyskinesia with choreiform tongue movements is associated with use antipsychotic term long can cause decompensation in older adults. Chronic cough associated with ACE inhibitor use may also interfere with swallowing or aspiration.

Structural abnormalities (eg, Zenker's diverticulum, cricopharyngeal bar or tumor, chronic infection with Candida or herpes virus) and extrinsic compression from cervical osteophytes or goiter can also interfere with normal swallowing. ⁵

Table 2.1 Reason dysphagia oropharynx ⁵

Chronic progressive disease (geriatric syndrome).

• Stroke

• Parkinson's Disease

• Alzheimer And dementia other

• Sarcopenia

Neuromuscular                          disease •        Sclerosis lateral amyotrophic

• Myasthenia gravity

  • Sclerosis multiple

  • Dermatomyositis/polymyositis (myopathy)

  • Drugs antipsychotic*.

Reason structural                       •     Cancer head And neck

• Surgery or radiation recently This for the head And cancer neck (change anatomy)

  • Mucositis Which induced by chemoradiation and edema (short term)

  • Zenker diverticulum

  • Osteophyte cervical

  • Lymphadenopathy

  • Goiter

  • Cricopharynx trunk

Reason oral                                •  Teeth or teeth bad fake

• Dry mouth (eg, xerostomia); Medications that cause dry mouth (eg, alpha and beta blockers , angiotensin converters,                             enzyme inhibitors ,               anticholinergics, antihistamines, anxiolytics, calcium channel blockers , diuretics, muscle relaxants, tricyclic antidepressants)

  • drugs *.

Pathology of the Esophageal

Gastroesophageal reflux disease, functional esophageal disorders, and eosinophilic esophagitis are the most common causes of esophageal dysphagia. Less common causes include medications, obstructive lesions, and esophageal motility disorders. ⁵

Disturbance reflux gastroesophageal (GERD) And exposure sour Which recurring causes change start from inflammation submucosa And dysmotility to erosive esophagitis and strictures. Patients with GERD may experience dysphagia even in the absence of obvious mucosal damage. Eosinophilic esophagitis is an increasingly common inflammatory condition triggered by food allergens. Chronic eosinophilic infiltration leads to progressive fibrosis of the esophageal ring and dysmotility. Like irritable bowel syndrome or dyspepsia functional, Functional esophageal disorders are thought to be caused by abnormalities in gut-brain interactions and central nervous system processing. Patients with these conditions are particularly sensitive to the amount of sour physiological. Patient Possible report dysphagia, although painful chest pain and heartburn are more common. These disorders may be the cause of many patients who report intermittent difficulty swallowing but never seek care and find no explanation even after extensive workup. Medications may cause dysphagia due to direct mucosal injury (pill esophagitis), esophageal motility disorders, or lower esophageal sphincter relaxation and reflux. Esophageal cancer, strictures, Schatzki rings , And fibrosis must under consideration on patient Which come with dysphagia. However, the prevalence of this condition is relatively low, especially in patients under 50 years of age. Esophageal motility disorders such as achalasia, distal esophageal spasm, and systemic sclerosis (scleroderma) are rare. Like opioid-induced bowel dysfunction and constipation, opioid-induced esophageal dysfunction may also occur. ⁵

Table 2.2 Etiology esophageal dysphagia . ⁶

Disease reflux gastroesophageal And esophagitis (30% until 40%)

• Esophagitis eosinophilic

• Functional dysphagia

Disturbance esophagus functional (20% until 30%)

• Gastritis functional

• Disease reflux gastroesophageal (nonerosive)

• Globe pharyngeus

• Reflux Hypersensitivity Treatment (5%)

• Pill esophagitis (irritation direct Which relate with ascorbate sour,

  bisphosphonates, iron sulfate, drug anti-inflammatory nonsteroidal, potassium chloride, quinidine, and tetracycline)

• Reflux is caused by decreased tone of the lower esophageal sphincter (associated with alcohol, anticholinergics, benzodiazepines, caffeine, calcium channel blockers, nitrates, and tricyclic antidepressants)

Condition structural or mechanical (5%)

• Narrowing esophagus or peptic (caused by by erosive esophagitis )

• Impaction object foreign or food (dysphagia beginning I)

• Malignancy (cancer esophagus or stomach, mass mediastinum with extrinsic compression)

• RingSchatzki

Disturbance motility esophagus (< 5%)

• Contractility No There is

• Achalasia

• Spasm distal esophagus

• Obstruction flow go out intersection esophagogastric

• Hypercontractile (jackhammer).

• Disturbance motility hypercontractile

• Dysfunction esophagus consequence opioid

Channel diagnose dysphagia, There is a number of step important Which need followed, namely, identifying the presence of dysphagia, ensuring whether the patient is really experience dysphagia or only feel sensation Which similar, like globus, xerostomia (dry mouth), or odynophagia (painful swallowing). True dysphagia is difficulty swallowing that interferes with food transport, while globus is a sensation of a lump or pressure in the throat that is often unrelated to the act of swallowing and does not interfere with food transport. Then determine the Location of the Problem: Once dysphagia is confirmed, the next step is to identify whether the problem is in the esophagus or pharynx. Understanding this location is important because the type and cause of dysphagia can vary depending on which part is affected. Step furthermore differentiate abnormality structural from abnormality motor. Dysphagia can due to by problem structural, like obstruction, or motor problems involving damage to the muscles or nerves that control swallowing. Further testing, such as imaging or motor function tests, can help differentiate between the two types. ¹¹

Results from dysphagia screening can help identify individuals who are at high risk for dysphagia and require further evaluation using method diagnostic Which more detailed, like FEES ( Fiber optic Endoscopic Evaluation of Swallowing ) or VFS ( Videofluoroscopic Swallowing Study ). Dysphagia screening can also be helpful in planning early interventions, such as dietary modification or swallowing rehabilitation therapy, to reduce the risk of complications associated with dysphagia. ⁶

The EAT-10, is the most frequently mentioned screening instrument in the literature, and according to a number of study tool This Also capable predict aspiration risk is a questionnaire consisting of 10 questions related to dysphagia. Score Respondent For each question is 0 up to 4, Where score 0 show No There is problem And score 4 show the problem that very heavy. If score reach 3 or more show that there were swallowing problems or dysphagia in the respondents. Some of the most clinical parameters important Which displayed by EAT-10 between other heavy body, go out to eat, food solid-liquid, drugs, painful moment swallow, enjoyment, food in the throat, coughing, and stress when swallowing. ⁶

1. History Medical And Physical examination

History medical And inspection physique Which comprehensive very important in evaluating patients with dysphagia. Both can often indicate the diagnosis. ⁷

The medical history should include the nature of the dysphagia, the progression of the problem, and whether the problem occurs with solids, liquids, or both. Difficulty swallowing solids generally suggests an obstruction or mechanical problem such as an intermittent esophageal membrane or ring. In contrast, progressive dysphagia is more likely to be caused by a progressive stricture or malignancy. Dysphagia with liquids suggests a motility disorder such as achalasia. or sclerosis systemic. If nature intermittent, so Possible caused by spasm esophagus. A number of matter Which need asked on history including: ⁷

• Chronology beginning

• Duration And development of symptoms

• Problem with initiation swallow or after a number of swallowing seconds

• Symptom especially in neck or chest

• Happen with food congested, fluid, or both of them

• Change diet Which done Alone related with consistency food; preference for liquids or semisolids

• Eat slowly​

• Cleaning throat during or after Eat

• Cough, choked, or regurgitation postnasal Which related

• History infection chest recurrence

• Decreased function

• Neurological deficit

• Decrease heavy body

• Feeling Embarrassed

• Isolation social, frustration, or depression

Signs physique can includes: ⁷

• Lost tooth or disease gingiva

• Closing lips Which abnormal

• Change mucosa local

• Change neurological

Difficulty initiating a swallow is more typical of oropharyngeal dysphagia and esophageal dysphagia usually occurs within seconds of swallowing. Clinicians need to differentiate between both of them Because often time is process pathological different . ⁷

Symptom dysphagia oropharygeal: ⁷

• Delay initiation swallow oropharyngeal

• Cough deglutition

• Aspiration nasal during swallowing

• Need swallow repetitive For clean nasal secretion

• Sensation globe

Symptom dysphagia esophagus: ⁷

• Symptom appear a number of second after initiation swallow

• Regurgitation food Which No digested

• Dysphagia feel more in in chest

Although dysphagia oropharyngeal often seen on population geriatrics, smoking history or use alcohol, with or without decline heavy body Unwanted findings suggest the possibility of underlying malignancy. Regurgitation of undigested food, hoarseness, halitosis, a feeling of fullness in the throat, and a history of aspiration may indicate Zenker's diverticulum which is believed to result from weakness of the cricopharyngeal muscle. ⁷

2. Inspection Support

   1. Oropharyngeal Dysphagia

In patients with clinical evidence of oropharyngeal dysphagia, the initial test is a clinical swallowing evaluation performed by a speech pathologist or nurse. However, test This own limitations And Possible No detect more from 50% of patients with aspiration. Early detection of oropharyngeal dysphagia using screening tools can reduce complications, especially in the older population. Several screening evaluation tools are available, but they have poor predictive value for aspiration.

After evaluation swallow clinical, two test instrumental often used to assess oropharyngeal dysphagia. Videofluoroscopic swallow study (VFSS) allows direct visualization of bolus passage by evaluating swallowing physiology, swallowing efficiency, and aspiration risk through a two-dimensional view. Although this study has significant diagnostic value, scientific tools need to be developed to improve reliability and reduce inter-reader variability, which is a limitation of this study. Fiberoptic endoscopic evaluation of swallowing (FEES) is performed by inserting an endoscope through nose For observe nasopharynx, oropharynx, And larynx to allow direct visualization and detailed analysis of the swallowing structures and their function during the consumption of foods of varying consistencies. ⁷

The choice of test is determined by the characteristics of the patient. To perform VFSS, the patient must be able to sit upright and mobilize to the radiology department. In contrast, FEES can be performed in bed. The results of a recent systematic study showed that FEES is more sensitive in detecting penetration, residue, and aspiration than VFSS. However, both are the gold standard for assessing dysphagia related to Parkinson's disease. In addition, high-resolution manometry can complement other diagnostic strategies to assess upper esophageal sphincter pathology, especially in patients with globus sensation. ⁷

Patients with signs of malignancy, such as weight loss or bleeding should undergo a head and neck evaluation and laryngoscopy. from pharynx And larynx. Attention special must given on oropharynx and possible Zenker's diverticulum. Esophagography usually diagnoses Zenker's diverticulum. In addition, computed tomography of the head and neck may be considered to rule out malignancy. ⁷

1. Dysphagia Esophageal

Patient without symptom supra-esophageal, results test barium swallow or FEES who does not striking, And proof clinical dysphagia esophagus must referred to to gastroenterologist for barium video-esophagogram. Evaluation This must covers anatomy And esophageal motor function. Barium esophagography is relatively simple and inexpensive and can be considered as line First compared to endoscopy on dysphagia esophagus.

If esophageal dysphagia is suspected, the next step is to determine whether the dysphagia is caused by a structural or motor disorder. Dysphagia that is worse with solid foods usually indicates a structural disorder, such as a stricture or tumor, that is blocking the passage of food. If dysphagia happen with food liquid And congested, This often leading to problem motor, like achalasia or spasm esophagus, in where muscles or the nerves that control swallowing may not function properly. Then based on progression, if dysphagia is progressive, where symptoms get worse over time, it is more often associated with structural abnormalities, like enlargement tumor. Dysphagia Which appear And is lost more often occurs in motor disorders, where the esophageal muscles may function well on some occasions but not consistently. Odynophagia or pain when swallowing may occur which is due to inflammation or infection of the esophagus. And Can happen Good on abnormality structural and motor, although it occurs more frequently in certain conditions such as esophagitis. ¹¹

Veins Jugular Phlebectasis

1. Definition Veins Jugular Phlebectasis

Jugular vein phlebectomy means dilatation of the jugular vein. This condition is commonly observed in children or young adults. Jugular vein phlebectomy internal usually appear as swelling Which can happen neck, consistency soft, usually grow bigger with maneuver Which increase pressure intrathoracic like maneuver Valsalva, sneeze, or cough, And usually unilateral. ⁸

Epidemiology Veins Jugular Internal Phlebectasis

Internal jugular phlebectasis is a rare disorder that can occur unilaterally. or bilateral, And often diagnosed during time children. Thus, the occurrence of internal jugular phlebectasis in adults is compared with the emergence on time children very much seldom occurred. ¹² Several cases have been reported to have experienced internal jugular phlebectasia appearing in age mature; However, swelling neck seen clear since born on both cases said. ¹² The incidence of this condition is rare and only about 100 cases of phlebectasis have been previously reported. The jugular veins involved include the internal jugular vein as the most common, followed by the external jugular vein and the anterior jugular vein. ⁸

Etiology Veins Jugular Internal Phlebectasis

Scarcity condition This so that Not yet There is possibility etiology Which can be found. However, hypothesized that lack of elasticity main wall veins may be the reason that explains most of the congenital cases. In addition, increased pressure in the internal jugular vein is another hypothesis that can cause phlebectasis. ⁸

A number of writer has to hypothesize that injury direct previously on the neck or procedure medical like catheterization vein central, ventilation pressure positive, neck surgery, or tumor. Histopathological changes in cases treated with resection surgery covering depletion layer muscle And elastic. However, most of the case No show change significant compared to with normal venous wall. Several authors have found this abnormality in patients with neurofibromatosis type 1 and Ehlers-Danlos syndrome. ⁸

Pathophysiology Veins Jugular Internal Phlebectasis Causes Dysphagia

The term phlebectasis differs from aneurysm. Phlebectasis indicates a homogeneous fusiform dilatation along the vein, whereas an aneurysm is characterized by localized ectasia. Phlebectasis also differs from varicose veins in that it lacks tortuosity. Throughout vein jugular internal there is structures important in swallowing such as nerves and anatomical structures. Voice changes, paralysis of the vocal cords voice, and/or dysphagia is a number of symptom Which can observed. The proximity of the jugular vein to the vagus nerve and other lower cranial nerves is a cause from symptoms This. Besides That, dysphagia can due to by obstruction of the canal. Mass big can influence channel Which make patient experiencing dysphagia. ⁹

This condition has also been reported in a case involving a boy. aged 7 month with phlebectasis vein jugular internal right Which large mass causing dysphagia. The mass was removed via a cervico-thoracic approach. with repair symptom post operation. Opposite with Which Hopefully, the ectasia is not fragile and is covered with a pseudocapsule of fibrofatty tissue which makes removal easier. ³

Phlebectasis vein jugular internal usually appear in side right with right and left ratio 5.2:1.0. ¹² Internal jugular vein phlebectomy is more frequently seen on the lateral side. right Because valve vein almost No Once seen on vein right brachiocephalic vein. ¹³ LaMonte et al hypothesized that phlebectasis is mostly right-sided because the right innominate vein is in contact with the pleura. apical right. ¹³ By Because That, every improvement pressure intrathoracic can be directly channeled into the right internal jugular vein. ¹²

Inspection Transnasal Esophagoscopy (TNE)

Transnasal Esophagoscopy (TNE) is a widely used tool in diagnosis And treatment patient Which own complaint in in head And neck. This is because this additional investigative examination provides the advantage of visualize in on level muscle cricopharynx If compared to with esophagogastroduodenoscopy (EGD). ¹⁹

Transnasal esophagoscopy is performed using topical anesthesia without sedation. Anesthesia topical given on cavity nose with use cotton lidocaine 2% to get the effect of vasoconstriction and reduce pain, then two sprays of xylocaine 10% sprayed on the oropharynx and hypopharynx to reduce reflex gag reflex and reduce pain. Flexible esophagoscope with a 5.8 mm diameter scope using the Olympus Evis Excera II camera system. This tool has a water flushing system and air suction, as well as suction through the available working channel. ²⁰

Table 2.5 Indication relatively Transnasal Esophagoscopy ²¹ Dysphagia

Odynophagia

Swallow food Which contains caustic

Symptom reflux gastroesophageal Which Already in progress long (GERD/regurgitation) Symptoms esophagus Which settle down although Already get treatment proper reflux

Evaluation foreign object

Evaluation esophagus consequence varicose veins esophagus Anorexia

Therapy

Injection Installation toxin botulinum stricture dilation Ensoscopic ablation

Therapy Placement capsule telemetry pH Wireless Tracheoesophageal puncture

1. Veins Jugular Internal Phlebectasis

Lesion tend For handled in a way conservative For avoid air embolism, venous thrombosis, and injury to important structures in the neck during dissection. Several veins and plexuses that drain into the internal jugular vein are not only close with its formation in base skull but Also during his journey in neck. Communication Which Already There is This help in flow flow veins to the opposite internal jugular veins as many of these are likely to have been opened preoperatively due to turbulence in ^{phlebectasis.3}

Ligation unilateral vein can cause edema cerebral And increased intracranial pressure, especially if the vein is the dominant vein and the vein is contralateral No capable to balance flow go out. Although seldom, problem This may occur during surgery or transiently in the immediate postoperative period. Transient elevation of blood pressure in patients may trigger the Cushing reflex . No long-term complications have been observed in the literature. Removal has been the most common mode of management. ³

Dysphagia Management

1. Modification diet

Diet modification can be done by eliminating foods with certain consistencies or sizes that can cause dysphagia. Modification of bolus consistency should be done given as a last resort due to changes diet often No comfortable for patient. If therapy other No To prevent aspiration or improve swallowing effectiveness, certain consistencies must be eliminated from the patient's diet. In addition, patients are also recommended to eat food in smaller sizes and with a smaller consistency. gentle (especially on patient with dysphagia oropharyngeal). Patient Which not possible to swallow or the swallowing process has a high risk of aspiration, a nasogastric tube can be installed to maintain enteral nutrition (for example in patients with stroke). To help patients with dysphagia, food is usually modified into certain textures, including ^23,24 :

• Pureed food : Food processed until it has a soft texture like porridge or mashed potatoes, suitable for patients who have difficulty swallowing solid foods.

  • Soft food : The texture is denser than puree but still easy to chew and swallow, such as pudding or steamed fish .

  • Fluid thick ( thickened liquids ) : Fluid Which modified consistency so that it does not easily enter the respiratory tract, for example by using a special thickener for water, juice or milk.

Exercise Postural And Maneuver Swallow

Swallowing rehabilitation is generally performed on stable dysphagia patients and on patient dysphagia with disease chronic progressive (for example disease Parkinson's). Rehabilitation swallow This aiming For strengthen muscles jaw, lips, and tongue. In addition, patients are also asked to always eat in an upright position. Some postural exercises that can be done include chin tuck, head rotation to the affected side, a combination of head rotation and chin tuck, side-lying posture, and head tilt ² . The chin-tuck maneuver helps push the food bolus towards the pharynx and esophagus, compensates for the delay in glottis closure, and reduces the risk of aspiration during the swallowing process. ^23,24

There are 4 swallowing maneuvers that can be performed by patients with dysphagia, namely supraglottic swallow, super-supraglottic swallow, effortful swallow , and Mendelsohn maneuver. The purpose of the Mendelsohn maneuver is to increase the duration and elevation of the larynx, thereby increasing the opening of the cricopharyngeal. ²⁵

1. Diagnosis Appeal

Diagnosis appeal covers laryngocele, hygroma cystic, cyst branchial, and superior mediastinal mass. Chest radiography can exclude the diagnosis of laryngocele or mediastinal tumor due to the absence of air or a wide mediastinum on the film. The diagnosis is confirmed by ultrasonography combined with Doppler imaging or contrast-enhanced spiral computed tomography (CT). Color Doppler as an inexpensive technique is the diagnostic modality of choice, especially in developing countries. ⁸

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