OSTEOPATHIC CONSIDERATIONS ON SWALLOWING DYSFUNCTIONS

The tongue appears in the development of the embryo between the fourth and fifth weeks, in the form of two lateral and one median rigonphaments. Most of the muscles of the tongue are derived from myoblasts from the occipital somites innervated by the hypoglossal nerve, the first pharyngeal arch.

The development of tongue function in the foetal period has this sequence: the first of all is the reflection which is already presented at the 10th week of uterine life; at the 13th week, the foetus begins to swallow; At the 5th month, start suckingthefinger. The brainstem has neurophysiological control of tongue mobility as early as the 60th day of intrauterine life. In the first years of life, swallowing has an atypical physiology around 6/7 years of age, with the appearance of definitive molars it turns into typical swallowing.

Which movement is physiological of swallowing, which swallowing movement can be considered osteopathic dysfunction and which is pathological, therefore an atypical swallowing.

The physiological movement of swallowing, the tip of the tongue has contact with the palatine folds, the middle portion of the tongue has contact with the hard palate; The posterior portion assumes an angle of 45° against the pharyngeal wall to allow saliva and the food bolus to proceed towards the digestive system, in this swallowing condition there is no compensation of the cervical curve. During this process the levator muscles of the jaw are contracted, they determine the contact of the molars, the muscles of facial expression are not used during the act of swallowing.

When there is a state of osteopathic swallowing dysfunction, the second part of the movement does not take place, i.e. the thrust of the tongue on the hard palate, so compensations are created during swallowing and the cervical vertebrae are used abundantly, creating an extension movement of the head. There are many causes that disrupt physiology

swallowing: neurological factors, fascial system dysfunction and emotional factors. If this dysfunction is already present in the first years of life, i.e. absence of thrust of the tongue on the hard palate, we will not allow the upper jaw to develop and we will have a narrow, crowded upper dental arch, with a very ogival palate. In addition to perturbing the development of the upper arch, balance will be disturbed, such as the visceral system, which will tend to go into ptosis over time, and the physiology of the cervicals.

Atypical swallowing is a pathological picture, the tongue is even lower during swallowing and pushes on the arches of the teeth, these move and an open byte is created, also for this case the causes are the same as previously described, in some cases the expressive muscles may also be dysfunctional, for example the lower lip is held by the child between the two arches and this will move the upper central incisors forward.

The thrust of the tongue on the upper jaw will condition its development in the first years of life, the bones of the face develop after those of the skull base and the cranial vault. This thrust is essential for the development of the upper arch and for breathing, it must be remembered that the bones of the face are often victims of intrauterine trauma and childbirth, the antero-posterior axis of the newborn undergoes strong compression during childbirth and osteopathic dysfunctions of the upper jaw and occiput are created, which then condition the relative functions and their development.

Most authors consider that language dysfunctions are determined by motor innervation, but I do not agree.

Swallowing is an unconscious action caused by the need to release saliva and food to the esophagus, it occurs approximately every 30 seconds in wakefulness and

once a minute in sleep, more or less 1600-2000 times over a 24-hour period.

When swallowing, the tongue imparts a force on the palate that varies from a minimum of 700 gr. to a maximum of 3000 gr. forced swallowing. If we consider an average of 1800 gr. and multiply by 2000, the result is that 3,600,000 gr. of intermittent pressure is discharged on the palate and teeth within 24 hours.

With this thrust applied to the palate correctly we will help the development of the bones of the face and their functions, such as breathing and development of the upper jaw and therefore of the upper arch. Especially in the first years of a child’s life, if all this does not happen, his development will be conditioned forever and the pressures of orthodontic therapy will not be enough to change the ogival palate into a flat palate. The tongue is the best orthodontic appliance that exists if it works the tongue works properly. Many authors consider lingual dysfunction to be caused only by a neurological disturbance, later we will discuss what other reasons perturb the physiology of swallowing.

The lingual functions are: sucking reflex, swallowing, breathing, chewing, phonation and balance.

We analyze the possible osteopathic dysfunctions that create neurological problems of swallowing.

First of all, let’s try to understand what happens if soft tissues compress a nerve continuously, an edema of the intrinsic vascular system of the nerve itself is created and this will disturb the functionality of the sensory or motor fbre, in the case of the motor fbre of the nerve you will begin to give incorrect stimulation to innervated muscles, This will work the muscles concentrically, also creating trigger poins activations in the long run. Let’s start by describing the nerves that work in swallowing, describing their function and their weak points of possible compression determined by soft or bone tissues.

The function of the third mandibular branch trigeminal nerve is to stabilize swallowing by contraction of the closing muscles of the

mandible at the time of swallowing, does not disturb the physiology of swallowing.

The facial nerve innervates the suprahyoid and subhyoid muscles, the hyoid muscles are active in swallowing and in the maximal opening of the mouth, one of the most usual dysfunctions of this nerve is determined by otitis, which creates a positivity of the facial nerve present in the ear canal. When this happens, the tone of the hyoid muscles and those of the mimicry will begin to work concentrically. The function of swallowing will be disturbed, but also the jaw which can deviate in the movement of maximum opening, on the side of the facial nerve that has begun to work incorrectly.

The hypoglossal nerve, which innervates the muscles of the tongue, passes from the hypoglossal canal to the level of the lateral masses of the occiput, this occipital area is subject to somatic dysfunction already in uterine life, the most critical moments are the last month and in childbirth. During childbirth the lateral masses of the occiput are used as a fulcrum for the rotation of the baby, the most common exit of the newborn is clockwise and the left lateral masses create a compaction of the hypoglossal nerve canal, this dysfunction creates compression of the hypoglossal canal and its perturbation of its physiology. For this reason, the tongue most often pushes up the left incisors.

The visceral part of the neck is innervated by the glossopharyngeal and vagus, which innervate the involuntary musculature of the pharynx and esophagus, which directly disturb the movement of the cricoid cartilage, where the subhyoid muscles are inserted. Pathologies of the larynx will disturb the physiology of swallowing, as well as esophageal reflux, in these cases the physiological movement of the cricoid cartilage will be disturbed, therefore also that of swallowing, the vocal cords will also have to compensate, as well as the cervical ones. Another actor that restricts the movement of the cricoid cartilage is the right bronchus.

Fascial correlations in relation to swallowing.

Fascial ascending dysfunctions disrupt the physiology of swallowing, fascial fssations of the supporting tissues of the viscera of the rib cage easily tend to disturb the mobility of the hyoid bone and cartilage

Cricoidea.

The peripheral and mixed internal fascial chain, which surrounds the internal tissues of the rib cage, endothoracic fascia, pleura and pleural dome, have a correlation with the middle cervical fascia that inserts on the hyoid, so a pulmonary pathology or bronchi will create a fssation of the tissues and will tend to create a deviation of the hyoid bone and also of the tongue in an ipsilateral direction to the visceral dysfunction.

In the event that there are dysfunctions of the mediastinal area the correlation with the tongue will be to lower its tongue body and the thrust of the tongue on the hard palate will be missing, the most common points of dysfunction are the fascial sheets between the pleura and the mediastinal, but also an esophagus in is subject to refustion.

Emotional aspects.

Behavioural regressions of an older sibling in relation to the appearance of a younger sibling, with a difference between them of 2/4 years. It often happens that the older brother takes the younger brother’s attitudes by bringing his tongue down and partially out. The older brother imitates him in order to get the same attention that his mother gives to the younger.

The upper jaw, the dental arch and the adaptations of the tongue.

The tongue with its intrinsic muscles adapts to the upper dental arch and the space it is given to fill the cavity. The structures of the bones of the face during childbirth go into dysfunction, especially in very long labors, in these cases the bones of the fascia go into dysfunction, their development will be disrupted by their dysfunctions. Often nasal breathing will be impaired, and the child will lower his tongue to breathe with his mouth open. Losing the thrust of the tongue on the palate will certainly lead to orthodontic problems. The area of the pre-maxillary and post-maxilla, if dysfunctional and not rushed with osteopathy, obviously treated in the first years of life or with orthodontics, the tongue will adapt to the conformation of the incisors and sometimes the tongue has a a bit boxy.

Postural compensations of the hyoid bone and mandible in relation to balance.

It is very common to meet subjects who have a head anteposition with stiffness of the cervical and also of the front neck. In these cases the patient has a posterior support on the calcaneus, why does this happen? The main actor is the cerebellum, which brings the patient’s body backwards and in order to maintain the upright position, the curves of the cervical and lumbar will try to compensate and create dysfunctions. By analyzing the cervicals, fixations of the hyoid and cricoid cartilage are created, these structures will be more posterior and in relation to swallowing they will lower the body of the tongue and the tip will have contact only with the palatine folds. All this will lead to poor balance.