dysphagia final

7/30/2019 Dysphagia Final

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DYSPHAGIA


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Dysphagia : defined as having difficulty in

swallowingwhich may affect any part of theswallowing pathway from the mouth to the stomach

Odynophagia : term used to describe pain during

swallowing

Patient will often try to localize the level of dysphagiaand the clinician must try to distinguish oropharyngeal

from esophageal dysphagia.


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In oropharyngeal dysphagia there is difficulty inpreparing and transporting the food bolusthrough the oral cavity as well as initiating theswallow.

It may be associated with aspiration ornasopharyngeal regurgitation.


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In esophageal dysphagia patient complain offood sticking in lower throat,neck,retrosternalregion or epigastrium.


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CAUSES OFDYSPHAGIA

PRE-OESOPHAGEAL OESOPHAGEAL

PHARYNGEALPHASE

ORAL PHASEOUTSIDE THE

WALL

WALLLUMEN


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Pre-oesophageal Causes

Oral causes

a. Disturbance in mastication: Trismus , fracture ofthe mandible,tumours of upper and lower jaw,

temporomandibular joint disordersb. Disturbance in lubrication: xerostomia, Mikuliczdisease

c. Tongue disorders: paralysis of tongue,painfululcers, tumours of tongue, lingual abscess,totalglossectomy

d. Palatal defects: cleft palate, oronasal fistula

e. Stomatitis, ulcerative lesions, Ludwigs angina


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Pharyngeal causes

a. obstructive lesions: grossly enlarged tonsil,tonsillartumours, tumours of soft palate,pharynx,base oftongue, supraglottic larynx

b. Inflammatory conditions: acute tonsillitis,peritonsillar abscess, retro or parapharyngeal abscess,acute epiglottitis, laryngeal oedema

c. Spasmodic conditions: tetanus, rabies

d. Paralytic conditions: palatal paralysis due toDiphtheria, bulbar palsy, cerebrovascular accidents.These cause food to regurgitate into the nose


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Oesophageal causes

a. Within the Lumen: stricture , foreign body, atresia,benign or malignant tumour

b. Within the wall:

i. Acute or chronic esophagitis

ii. Hypomotility disorders:e.g, achalasia cardia,scleroderma, amyotropic lateral sclerosis

iii. Hypermotility disorders: e.g, cricopharyngeal spasm,diffuse esophageal spasm


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c. Outside the lumen:i. Hypopharyngeal or Zenkers diverticulum

ii. Hiatus hernia

iii. Cervical osteophytes

iv. Thyroid lesionsv. Mediastinal lesions: tumours,lymph node enlargement,

aortic aneurysm,


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Miscellaneous

Presbydysphagia

Caustic stricture.

Foreign bodies in the pharynx and esophagus.

Pharyngeal pouch.

Globus pharyngeus.

Patient with tracheostomy. Thyroid disease.


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Management

History and examination -

Sudden onset.

- pricking sensation on swallowing.

- recent ingestion of food or foreign body.

- drooling of saliva.


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History and examination -

Woman, lump in the throat, more markedbetween the meals. Progressive with weight loss. Intermittent. More to liquids. More to solids and progressing to liquids also.


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History and examination-

Lump in the throat.

- regurgitation of undigested food .

Examination

- oral cavity, oropharynx, larynx and

hypopharynx.- neck, chest and nervous system.


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Investigation

Blood tests

- exclude anaemia as a cause or effect of thedysphagia.

- ESR or C reactive protein - may be raised inmalignancy or chronic inflammatory processes.

- liver and renal function tests, serum calciumlevels metastases are suspected.

- thyroid function tests goitre, malignancy.


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Chest radiograph

- signs of aspiration and chest infection.

- achalasia.

- pulmonary neoplasm or metastases.


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Barium swallow Patient is given a cup of barium and asked to swallow

repeatedly.

The patient is lies in supine position and viewed in theanteroposterior plane.

The bolus is followed fluoroscopically to the stomach.

It is designed to examine anatomy and motility in theesophagus.


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It is contraindicated in esophageal perforation asit may cause mediastinitis.

It is also contraindicated if aspiration issuspected as it is slow to clear from the lungs.

In above conditions a low molecular weightnonionic, water soluble contrast medium is usedas this is less irritant and should cause minimalcomplications.


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Barium videofluoroscopy swallowingstudy (VFSS) Gold standard for evaluating the swallowing

mechanism.

It is a comprehensive test for all phases ofswallowing, but particularly useful for the oral

and pharyngeal phases.

Liquid,pureed,solid foods are used.


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Lateral and anteroposterior views are observed.

- transit time

- pooling

- aspiration

-motor function

-symmetry of the swallowing pathway .


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It identify the cause for aspiration andmanoeuvres can be designed and tested to

reduce the aspiration.

This manoeuvres are particularly useful in

- neurological disease.- after surgery or radiotherapy.


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Fibreoptic endoscopic evaluation ofswallowing (FEES) Observe the larynx and pharynx at rest and

during the pharyngeal phase of swallowing.

Pooling of saliva in the hypopharynx.

Reduced or absent endolaryngeal sensation.

Aspiration before and after swallowing .

It is useful in neurological and post surgicalpatients and can be performed bedside.


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Flexible upper gastrointestinalesophagoscopy It is performed to visualize, assess, stage and

biopsy the esophagus in patients with

esophagitis, barrettes esophagus and tumors.

It is poor at detecting disease of the

hypopharynx.


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Manometry

It is used to examine esophageal peristalsis andthe adequacy of functioning of the upper and

lower sphincters.

It is particularly helpful in patients with atypicalchest pain and unexplained causes of dysphagia.

Conditions pathognomonic manometric findingsinclude achalasia, diffuse esophageal spasm,nutcracker esophagus and scleroderma.


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Twenty-four hour ambulatory esophagealpH monitoring

pH sensor placed 5cm above the manometricallydefined LES.

Normal esophageal pH varies between 5-7 andGERD is present when the pH is less than 4.

Expressed as percentage of time the pH is lessthan 4 over 24 hour period DeMeester score.


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It is most accurate method of diagnosing GERD.

It is useful when standard investigations arenormal in a patient with typical or atypicalsymptoms.


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Computed tomography

- useful in malignant dysphagia to stage their

disease.

MRI of the head and neck

- it is indicated when neurological cause ofdysphagia is suspected such as multiple sclerosis

- cerebral tumors

- nasopharyngeal carcinoma.


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MRI of the head and neck

- it is particularly useful for lesions around theforamen magnum and the brainstem.

- it is also used to diagnose vascular anomalies.


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Treatment

Compensatory strategies

( no change in swallowing physiology)- postural changes.

- changes in volume/speed of food delivery.

- techniques to improve oral sensory

awareness.- dietary changes.

- prosthetics.


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Postural techniques

Head back improve inefficient oral transit ofthe bolus.

Head rotation towards the damaged side (directs the bolus down the stronger side)

- unilateral vocal cord palsy orhemilaryngectomy.


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Head tilt towards the stronger side-

- unilateral oral and pharyngeal palsy on the

same side.

Lying down on one side-

( eliminates the effect of gravity on the

pharyngeal residue )- Reduced pharyngeal contraction.


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Changes in volume/speed of presentation

Patients with weak pharyngeal musculature inwhich the bolus takes time to clear.


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Techniques to improve oral sensory

awareness Patient who present with a delayed onset of

swallowing.

( either at oral or the pharyngeal stage)

- increasing downward pressure of the spoon

- presenting a sore bolus.- presenting a cold bolus.


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Prosthetics Patients with head and neck cancer.

- palatal lift velar incompetence due toparalysis.

- palatal obturator- to close the defect.

-palate lowering, reshaping tongue resection( > 50 %)


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Rehabilitative therapy The supraglottic swallow

-To teach voluntary closure of the vocal folds

before, during and after the swallow.

- To improve reduced or late vocal fold closure.


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The super- supraglottic swallow-

- close the laryngeal vestibule.

- improve closure of laryngeal vestibule.


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Effortful swallow

- Raise the posterior motion of the tongue base

during the pharyngeal phase of contraction.

- improve posterior movement of tongue base.


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Mendelsohn manoeuvre

- increase the duration of laryngeal elevation

during swallowing.

- Increasing the duration and extent of the

cricopharyngeal opening.

-


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Shaker manoeuvre

- head raising exercise to strengthen laryngeal

movements during swallowing.

- increase hyoid motion and increase time of

opening of the UES.


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Presbydysphagia Affect all stages of swallowing

Oral phase

- loss of teeth and tongue connective tissue.

- reduced strength of mastication.

- weakness of velopharyngeal reflexes.


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Pharyngeal phase

- decreased elevation of the larynx.

- prolongation of the pharyngeal transit time.

Esophageal stage

- prolongation of UES relaxation time andesophageal transit time.


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Diagnosis - barium video fluoroscopic swallowing study.

- flexible endoscopy.

Treatment - compensatory strategies.- rehabilitative therapy.

- medical or surgical.


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Thank you

dysphagia final

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