E.N.T.Dysphagia.(dr.hewa)

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E.N.T.Dysphagia.(dr.hewa)

  1. 1. 1
  2. 2.  Dysphagia :is difficulty in swallowing which may affect any part of swallowing pathway Odynophagia :Is sensation of pain during swallowing 2
  3. 3.  Congenital : * Choanal atresia * Cleft lip & palate * Laryngomalacia * Unilateral vocal cord paralysis * Laryngeal cleft * Trachiooesophageal fistula * Vascular rings. 3
  4. 4.  Acquired : 1- Traumatic : - Accidental & iatrogenic - Blunt trauma , penetrating injuries & compression effect . - Direct injury & cranial nerve damage . - Head injury . 4
  5. 5. 2- Infectious : - Acute pharyngitis , tonsillitis , quinsy . - Glandular fever - Acute supraglottitis. - Herpetic , fungal , cytomegalovirus mucosal lesion . - Candidiasis. - Tuberculosis. - Submandibular , parapharyngeal & retropharyngeal abscess 5
  6. 6. 3- Inflammatory : 0- Gastroesophageal reflux disease + stricture formation . 0- Patterson Brown– Kelly or Plummer ‫ ــ‬Vincent syndrome . 0- Systemic autoimmune disorders : scleroderma , S.L.E. , dermatomyositis , mixed connective tissue disease , benign pemphigoid , Crohn’s disease . 6
  7. 7. 4- Oesophageal motility disorders : * Achalasia. * Diffuse oesophageal spasm . * “ Nutcracker “ oesophagus .5- Neoplastic : * Benign & malignant tumours of the oral cavity , pharynx , oesophagus . * Nasopharyngeal CA. * Skull base tumours . * Leukaemias & lymphomas . * Enlarged mediastinal lymph nodes . 7
  8. 8. 6- Neurological * C.V.A. * Isolated recurrent laryngeal nerve palsy * Parkinson’s disease * Multiple sclerosis . * Myasthenia gravis . * Motor neuron disease . 8
  9. 9. 7- Drug induced : * drugs causing oesophagtis . * Inhibitory drug side effects . * Excitatory drug side effects . * Drug complications . 9
  10. 10. 10
  11. 11. 8- Aging : * Presbydysphagia .9- Miscellaneous : * Foreign body in the pharynx & oesophagus . * Caustic stricture * Pharyngeal pouch . * Globus pharyngeus . * Patiant with tracheostomy . * Thyroid disease . 11
  12. 12. HistoryPhysical ExamReview of systemsImaging Studies 12
  13. 13.  Onset , duration , severity Perceived level of Dysphagia Type of food F.B. sensation in throat / Globus pharyngeus Regurgitation (oral or nasal , timing ) Aspiration weight loss Pain Hoarseness / airway obstruction Neck swelling Ear ache 13
  14. 14. ◙ Onset /duration / course◙ Perceived level of obstruction◙ Type of food : more to solid or fluid - Progressive dysphagia for the solid suggested structural lesion - Dysphagia for liquid suggested neurological lesion - Odynophagia ( painful swallowing ) suggested spasm , mucosal inflammation, or distention 14
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  16. 16. Complete E.N.T. Examination :- Oropharyngeal- Laryngeal- Neck examination Neurological Examination Associated physical examination 16
  17. 17. 17
  18. 18. A- Laboratory test : Hb. , S.iron binding capacity , blood film , ESR , C-reactive protein , liver fun. test , B. urea &elect.B- Radiological :♪ - Plain X-ray . Widening of prevertebral space , F.B. , vert. osteophyte , radiolucent area (thyroid CA ) , CX-ray♪ - Barium swallow .♪ - Fluoroscopy : with video .♪ - Endoscopy ( flexible / rigid ) : - Visualizes interior of pharynx , larynx , esophagus . - Diagnoses ulcer , tumours - can take biopsy .♪ - CT/MRI - For tumours , extrinsic compression .C- Manometry : Diagnoses motility disorders . 18
  19. 19. a b Oral contrast study of the esophagus shows pooling of contrast medium in the diverticular pouch (*) in the anteroposterior (a) and lateral (b) projections 19
  20. 20. Carcinoma Sternocleidomastoid muscleThe axial CTscan demonstrates a mass that is completely fillingthe right hypopharynx. The arrows point to an ipsilaterallymph-node metastasis below the sternocleidomastoid muscle. 20
  21. 21. 21
  22. 22. EsophagoscopyEsophageal Squamous Cell Carcinoma. 22
  23. 23. Medical Treatment• if possible address underlying cause (e.g., iron supplementation for Plummer-Vinson, pyridostigmine for myasthenia gravis, benztropine for Parkinson’s disease, antibiotics for acute bacterial pharyngitis)• utilize an alternative temporary route of nutrition (nasogastric tube feeds, parenteral nutrition) 23
  24. 24. Medical Treatment• begin a reflux regimen (see GERD, below)• aggressively address aspiration pneumonia (hold oral feeds, antibiotic regimen, and aggressive pulmonary toilet)• Botulinum Toxin Injections: may be considered for cricopharyngeal spasms, inject toxin into cricopharyngeus muscle 24
  25. 25. • change food consistencies (pureed diet easier to tolerate initially, liquids are more difficult to manage)• posture techniques (chin tuck, head turn to the poorer functioning side), palatal prostheses, muscle strengthening exercises 25
  26. 26. • Supraglottic Swallow : patient voluntarily closes airway at vocal folds by holding breath before swallow, voluntary cough after swallow, follow with an additional swallow for residual bolus in pharynx or pyriform• Mendelsohn Maneuver : voluntarily elevates and anteriorly displaces larynx to prolong upper esophageal sphincter opening 26
  27. 27. • Esophageal Dilation :may be considered for achalasia (distal Lower Eso spasm), and pharyngealor esophageal strictures, webs, postoperative scarring, and postRadiation strictures• Cricopharyngeal Myotomy :may be considered for cricopharyngeal spasms (incomplete Upper Eso.relaxation) or abnormal muscular contraction during relaxation 27(controversial), theoretically relaxes pharyngoesophageal segment
  28. 28. • Gastric or Jejunal Feeding Tube : temporary or permanent enteric feeding• Vocal Fold Medialization:for unilateral vocal fold paralysis 28
  29. 29. 29

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