Rachel Campbell

Grand Rounds
Clinical Neuroscience Fall 2014

I attended pediatric Grand Rounds of The University of Texas Medical Schools

Neurology Department. The Grand Rounds covered two case studies: one regarding a
child with immune encephalitis, and the other regarding a child who presented with
dysphagia. The latter case study will be the focus of this paper.
DN, an eleven-year-old male who lost forty pounds unintentionally over the
course of four months, began presenting symptoms of fatigue, weakness and dysphagia
following his parents divorce. According to the patient, the difficulty swallowing began
after he choked on a piece of chicken. DN was treated for streptococcal pharyngitis at an
urgent care clinic, but continued to complain of midline pain inside his neck that
worsened as he swallowed; he began to eat and drink only mashed potatoes, soup and
chocolate milk. DNs past medical history included a tonsillectomy, adenoidectomy and
multiple tooth extractions. He had been admitted to the hospital multiple times for his
symptoms, but there were no significant findings except for chronic inflammation from
gastroesophageal reflux disease.
Upon DNs most recent hospital admission, the review of systems was positive
for weight loss, fatigue, sore throat, dysphagia, odynophagia, sialorrhea, and weakness.
DN carried a towel with him so he could wipe the saliva he was not swallowing from his
face. Physical and neurological exams showed DN had slight atrophy of his tongue and
some drooping of his upper eyelid. Neurological exams demonstrated that his cranial
nerves were intact except for decreased soft palate elevation bilaterally. Differential
diagnoses included diencephalic syndrome, acute disseminated encephalomyelitis,
syringobulbia, a variety of neuromuscular disorders including myasthenia gravis, and
anorexia nervosa

Rachel Campbell
Grand Rounds
Clinical Neuroscience Fall 2014
DNs diagnostic work-up included a videofluoroscopy of his swallowing, which
confirmed the diagnosis of dysphagia, along with MRIs of his brain and spine, and
multiple lab tests. These tests ruled out all differential diagnoses except for anorexia
nervosa. A swallow study was performed and was normal. Due to the diagnoses of
anorexia nervosa and dysphagia, a psychologist became involved in treating DN.
Dysphagia is a condition that presents as difficulty swallowing, which hinders
the patients ability to eat, drink or take medication. Deglutition, the act of swallowing,
is a process involving three stages of both voluntary and involuntary neuromuscular
contractions and relaxations. The cranial nerves involved in swallowing are the
trigeminal nerve (CN V), facial nerve (CN VII), glossopharyngeal nerve (CN IX), vagus
nerve (CN X), and hypoglossal nerve (CN XII).
The first phase of swallowing, the oral phase, includes processing food into a
bolus to allow it to be swallowed. It also consists of propelling the food from the oral
cavity into the oropharynx. Taste, temperature sensation and proprioception are all
necessary to form food into a bolus. The cranial nerves involved in this process are CN
V, which controls most muscles of mastication to help move the mandible to chew, CN
VII to assist the lips and face in making the proper motions, and CN XII, which
innervates the tongue and allows for tongue shape, position and movement. The
trigeminal and vagus nerves also assist in moving the floor of the oral cavity to help
propel the bolus.
The second phase of swallowing, the pharyngeal stage, encompasses many
overlapping events including the epiglottis folding backward to protect the airway from
the bolus to prevent aspiration, and the tongue moving into the pharynx to push the
bolus downward. The swallowing reflex is triggered in this phase. Cranial nerves V, IX

Rachel Campbell
Grand Rounds
Clinical Neuroscience Fall 2014
and X allow for velar, pharyngeal and laryngeal movement, and CN IX sends sensory
input to the medulla and allows for the motor output by CN X. One of cranial nerve IXs
major role in swallowing is that it innervates the stylopharyngeus muscle, which
elevates the larynx and pulls it forward during the pharyngeal stage of the swallow
(Paulette & Sanders, 2010).
In the last phase, the esophageal phase, CN X helps with swallowing by allowing
involuntary smooth muscle contractions to propel the bolus into the stomach. CN IX and
X create the signals for the gag reflex, a protective mechanism to prevent aspiration.
If there is dysfunction with any of these cranial nerves during any phase of
swallowing, dysphagia may be the result. One common neurological cause of dysphagia
is stroke, but it can also be due to other upper motor neuron lesions such as tumors or
multiple sclerosis. Dysphagia may present in individuals of any age. Just as we saw in
DN, dysphagia is linked with drooling, weight loss, change in diet habits, and general
weakness due to poor nutrition. Dysphagia can result in aspiration pneumonia,
malnutrition, dehydration, and airway obstruction.
Upon completion of the Grand Rounds presentation, the audience was able to
ask questions regarding this case study. While dysphagia was evident and not disputed,
a psychologist listening to the presentation disagreed with the anorexia nervosa
diagnosis and offered an alternate diagnosis of avoidant restrictive food disorder, which
is an eating disorder that prevents the intake of certain foods. It was very interesting to
attend Grand Rounds, hear different opinions and gain knowledge of how neuroscience
impacts patient diagnoses.

Rachel Campbell
Grand Rounds
Clinical Neuroscience Fall 2014

References
Lundy-Ekman, L. (2012) Neuroscience; Fundamentals for rehabilitation, 4th ed. St. Louis
MO. Saunders, Elsevier, Inc. ISBN 0978-1-4557-0643-3.

M.G. Paulette, M. G., & Sanders, R. G. (2010). Cranial nerves IX, X, XI and XII.
Psychiatry MMC, 7 (5), 37-41. http://www.ncbi. nlm.nih.gov/pmc /
articles/PMC2882282.

Normal Swallow Function. (n.d.). Retrieved November 11, 2014 from

usc.louisiana.edu/~ncr3025/roussel/codi531/normalswallow.html