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Approach to dysphagia

Approach to Dysphagia

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Approach to dysphagia

  1. 1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Approach To DysphagiaApproach To Dysphagia Fuad Ridha MahabotFuad Ridha Mahabot 1
  2. 2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .IntroductionIntroduction • is a general term used to describe the inability to move food from the mouth to the stomach • should be differentiated from disorders that prevent transfer of food to the mouth or beyond the stomach but that are not characterized by difficulty swallowing - e.g. feeding disorder/gastric outlet obstruction • an average of 10 million Americans are evaluated for swallowing disorders annually 2
  3. 3. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .DefinitionDefinition • dysphagia - difficulty in swallowing • odynophagia - swallowing causes pain • usually patient comes with the complaint of  throat discomfort  FB sensation  feel of hold up  absolute difficulty in swallowing 3
  4. 4. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Summary of Stages of DeglutitionSummary of Stages of Deglutition • oral stage  mastication  salivation  tongue/ soft palate movements • pharyngeal stage  closure of oral/ nasopharynx/ larynx  opening of cricopharynx • esophageal stage  involuntary propulsion of bolus 4
  5. 5. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 stage Istage I stage IIstage II
  6. 6. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 stage IIIstage III
  7. 7. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .AetiologyAetiology • can de divided into:  pre-oesophageal (i.e. due to disturbance in the oral or pharyngeal phase of deglutition)  oesophageal (when disturbance is in oesophageal phase) 7
  8. 8. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Pre-oesophageal causes • oral phase - normally, food must be masticated, lubricated with saliva, converted into bolus by movement of tongue and then pushed into pharynx by elevationof tongue against hard palate • any disturbance in these events will cause dysphagia • abnormalities are due to:  cannot hold food in the mouth anteriorly due to reduced lip closure  cannot form / hold a bolus or residue on the floor of the mouth due to reduced range of tongue motion or coordination 8
  9. 9. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  unable to align teeth due to reduced mandibular movement  entry of food material into the anterior sulcus or the presence of residue in the anterior sulcus due to reduced labial tension or tone  entry of food material into the lateral sulcus or the presence of residue in the lateral sulcus due to reduced buccal tension or tone  abnormal hold position or material falls to the floor of the mouth due to tongue thrust or reduced tongue control  delayed oral onset of swallow due to apraxia of swallow or reduced oral sensation  searching motion or inability to organize tongue movements due to apraxia of swallow 9
  10. 10. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  forward tongue movement to start the swallow due to tongue thrust  residue of food on the tongue due to reduced tongue range of movement or strength  disturbed lingual contraction (peristalsis) due to lingual discoordination  incomplete tongue-to-palate contact due to reduced tongue elevation  unable to mash material due to reduced tongue elevation  adherence of food to hard palate due to reduced tongue elevation or reduced lingual strength 10
  11. 11. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Aetiology of Oral Phase congenital cleft palate, lingual thyroid inflammatory stomatitis, glossitis, ulcer, sialadenitis, TMJ arthritis, ludwig’s angina, trismus, dental trauma # maxilla/ mandible, cheek/ tongue bite, corrosive poisoning neurological palsy: palatal/ lingual/ facial; spasm: trismus/ tetanus neoplastic papilloma, salivary tumors, ranula, carcinoma, jaw tumors, etc. miscellaneous xerostomia-nutritional/ radiotherapy 11
  12. 12. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 tongue ulcertongue ulcer Ludwing’s AnginaLudwing’s Angina
  13. 13. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
  14. 14. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . • pharyngeal phase - normally, food should enter the pharynx and then be directed towards oesophageal opening • all unwanted communications into the nasopharynx, larynx, oral cavity should be closed • abnormalities are due to  delayed pharyngeal swallow  nasal penetration during swallow due to reduced velopharyngeal closure  pseudoepiglottis (after total laryngectomy) - fold of mucosa at the base of the tongue 14
  15. 15. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  cervical osteophytes  coating of pharyngeal walls after the swallow due to bilateral reduction of pharyngeal contraction  vallecular residue due to reduced posterior movement of the tongue base  coating in a depression on the pharyngeal wall due to scar tissue or pharyngeal pouch  residue at top of airway due to reduced laryngeal elevation  aspiration during swallow due to reduced laryngeal closure  stasis of residue in pyriform sinuses due to reduced anterior laryngeal pressure  delayed pharyngeal transit time 15
  16. 16. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Aetiology of Pharyngeal Phase congenital pharyngeal diverticulum (Zenker’s diverticulum) inflammatory pharyngitis, tonsillitis, quinsy, retro/ parapharyngeal abscess, TB laryngitis, acute epiglotitis, etc. trauma FB, corrosive poisoning, iatrogenic trauma, road traffic accidents neurological cricopharyngeal spasm, VC palsy (aspiration), tetanus, etc. neoplastic benign: salivary tumors, papilloma, etc., malignant: ca. tonsil/ base tongue/ hypopharynx/ larynx, salivary tumors, etc. miscellaneous Plummer-Wilson syndrome, globus hystericus 16
  17. 17. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Exudative TonsillitisExudative Tonsillitis Hypopharynx MalignancyHypopharynx Malignancy
  18. 18. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
  19. 19. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . • other causes of oropharyngeal dysphagia - neuromyogenic  stroke  head trauma  Parkinson's disease and parkinsonism  amyotrophic lateral sclerosis  multiple sclerosis   myasthenia gravis   myopathies (inflammatory, metabolic) 19
  20. 20. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Oesopharyngeal causes - lesion may lie in the lumen, on the wall or outside the wall of oesophagus i. structural disorders  inflammatory and/or fibrotic strictures • peptic • caustic • pill-induced • radiation-induced 20
  21. 21. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  mucosal rings and webs • Schatzki's ring • multiringed esophagus (eosinophilic esophagitis) ii. carcinoma  primary (squamous, adenocarcinoma)  secondary (e.g. breast, melanoma) 21
  22. 22. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iii. disorders related to systemic diseases  pemphigus and pemphigoid conditions  Lichen planus  scleroderma (multifactorial)  intramural lesions  leiomyoma  granular cell tumor 22
  23. 23. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iv. extramural lesions  aberrant right subclavian artery (dysphagia lusoria)  mediastinal masses  bronchial carcinoma v. anatomical abnormalities  hiatal hernia  esophageal diverticulum 23
  24. 24. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vi. motility disorders  achalasia and achalasia-like disorders  idiopathic (classic) achalasia  atypical disorders of lower esophageal sphincter relaxation  Chaga’s disease  pseudoachalasia 24
  25. 25. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Ca OesophagusCa Oesophagus Gastro Oesophageal Reflux DiseaseGastro Oesophageal Reflux Disease
  26. 26. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . foreign bodyforeign body Achalasia CardiaAchalasia Cardia
  27. 27. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .History Takings and EvaluationHistory Takings and Evaluation • taking a careful history is vital for the evaluation of dysphagia. • the history will yield the likely underlying  pathophysiologic process  anatomic site of the problem in most patients - 80%  crucial for determining whether subsequently detected radiographic or endoscopic 'anomalies' are relevant or incidental 27
  28. 28. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Three fundamental aims should be met when taking a dysphagia history i. to establish whether or not dysphagia is actually present; that is, to distinguish true dysphagia from • globus sensation (in between meals) • xerostomia - loose the lubrication properties and stimulus • odynophagia - transient than dysphagia, and persists only during the 15– 30 secs that a bolus takes to traverse the esophagus 28
  29. 29. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ii. to determine whether the site of the problem is esophageal or pharyngeal iii. to distinguish a structural abnormality from a motor disorder. These avenues of enquiry are outlined below in an order that corresponds to that of a highly effective diagnostic algorithm. • history will also dictate whether the next diagnostic procedure should be endoscopy, a barium swallow or esophageal manometry • in some difficult cases, all three diagnostic techniques may need to be performed to establish an accurate diagnosis 29
  30. 30. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Where is the site of bolus hold-up? • retrosternal bolus hold-up indicates that the disorder lies within the esophagus. • however, the patient's perception of an apparent bolus hold-up in the neck has low diagnostic specificity, and cervical localization per se does not help the clinician to distinguish pharyngeal from esophageal causes of dysphagia. 30
  31. 31. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . • owing to viscerosomatic referral, in 30% of cases the perceived site of hold-up is above the suprasternal notch when the actual hold-up is within the esophageal 31
  32. 32. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Does the patient report symptoms that are predictive of oropharyn- geal dysfunction • there are four symptoms that have high specificity for oropharyngeal dysfunction:  delayed or absent oropharyngeal swallow initiation  deglutitive postnasal regurgitation or egress of fluid through the nose during swallowing  deglutitive cough indicative of aspiration  the need to swallow repetitively to achieve satisfactory clearance of swallowed material from the hypopharynx 32
  33. 33. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . • if one or more of these four symptoms are present then the cause of dysphagia is probably oropharyngeal, either structural or neuromyogenic 33
  34. 34. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Oropharyngeal vs. Oesophageal DysphagiaOropharyngeal vs. Oesophageal Dysphagia 34
  35. 35. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Oesophageal differentiation - mechanical vs. motility disorder i. is the dysphagia for the solids or liquids?  patients who have a motor disorder will describe dysphagia for liquids and solids  whereas patients who have structural disorders will describe dysphagia for solids only  once a solid bolus becomes impacted, the patient will report dysphagia for liquids and solids 35
  36. 36. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ii. motility - features  three cardinal features of dysmotility • dysphagia (for solids and liquids) • chest pain • regurgitation  regurgitation during meals, as well as spontaneous regurgitation between meals or at night, is highly suggestive of dysmotility  unlike regurgitation that is related to GERD, the regurgitated fluid in patients with esophageal dysmotility is generally not noxious to taste 36
  37. 37. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  in addition, spasm or achalasia typically cause chest pain. Although this chest pain is frequently described as 'heavy' or 'crushing', it can be indistinguishable from the typical 'heartburn' of reflux.  the pain frequently occurs during meals, but it can be quite unpredictable and sporadic or nocturnal.  sipping antacids or even water can relieve the pain related to dysmotility, which further confuses its distinction from reflux-related pain. 37
  38. 38. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . How long has dysphagia been present? Is it intermittent? Is it progressive? • slowly progressive, long-standing dysphagia, particularly against a background of reflux, is suggestive of a peptic stricture. • severity of heartburn correlates poorly with esophageal mucosal damage. For example, patients who have severe mucosal changes, including strictures and Barrett's mucosa, could have had minimal or no heartburn in the immediate past. 38
  39. 39. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . • a short history of dysphagia — particularly with rapid progression (weeks or months) and associated weight loss — is highly suggestive of esophageal cancer • long-standing, intermittent, nonprogressive dysphagia purely for solids is indicative of a fixed structural lesion such as distal esophageal ring or proximal esophageal mucosal web 39
  40. 40. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
  41. 41. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Physical ExaminationPhysical Examination Physical examination for dysphagia:  patient's level of alertness and cognitive status, including vital signs  examination of cranial nerves V and VII-XII  complete examination of neck and chest including assessment of cervical lymph nodes (if present)  assessement of voice  direct observation of lip closure, jaw closure, chewing and mastication, tongue mobility and strength, palatal and laryngeal elevation, salivation, and oral sensitivity  inspection the oral cavity and pharynx 41
  42. 42. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  examination of soft palate for position and symmetry during phonation and at rest  evaluation of pharyngeal elevation by placing 2 fingers on the larynx and assessing movement during a volitional swallow  examination of gag reflex by stroking the pharyngeal mucosa with a tongue depressor  direct observation of the act of swallowing. At a minimum, watch the patient while he/she drinks a few ounces of water. If possible, assess the patient's eating of various food textures. After the swallow, observe the patient for 1 minute or more to see if a delayed cough response is present 42
  43. 43. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  skin should be examined for features of connective tissue disorders, particularly scleroderma and CREST (calcinosis, Raynaud's phenomenon, esophageal dysmotility, sclerodactyly and telangiectasia) syndrome.  muscle weakness or wasting might be evident if myositis is present, and myositis can overlap with other connective tissue disorders that affect the esophagus  signs of malnutrition, weight loss and pulmonary complications from aspiration should be looked for 43
  44. 44. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .InvestigationsInvestigations Blood Investigations – to screen for  infectious or inflammatory conditions  nutritional status  fluid-electrolyte imbalance  thyroid function - in detecting dysphagia associated with hypothyroidism or hyperthyroidism Radiography i. chest x-ray - mediastinum, cardiac and pulmonary status, aspiration pneumonia, also to rule out secondaries 44
  45. 45. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ii. lateral x-ray soft tissue neck - to detect any soft tissue lesions of post cricoid or retropharyngeal space, prevertebral widening, osteophytes, foreign bodies, etc. iii. barium swallow iv. CT scan - to evaluate mass lesions in the neck v. MRI • useful when neurologic disorders are suspected • delineate mass lesions in the brain • evaluate degenerative processes in the brain and spinal cord 45
  46. 46. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Barium SwallowBarium Swallow in Achalasiain Achalasia CardiaCardia
  47. 47. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Endoscopies i. direct laryngoscopy ii. flexible nasopharyngoscopy iii. bronchosocpy iv. oesophagoscopy  give direct examination of pharyngeal as well as oesophageal mucosa  permits biopsy 47
  48. 48. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Special Tests i. Videofluoroscopic Swallowing Study (VFSS) • a.k.a Modified Barium Swallow (MBS) • definitive study for evaluation of the swallowing mechanism • uses different barium consistencies and simulated foods • assess pharyngeal anatomy and motility and may evaluates all phases of swallowing • superior to FEES for evaluating the oral phase and aspiration 48
  49. 49. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ii. Fiberoptic endoscopic evaluation of swallowing (FEES) • using transnasal laryngoscope • food colored with blue liquid dye viewed directly via scope • advantages - for detection premature bolus loss, laryngeal penetration, tracheal aspiration, and pharyngeal residue • disadvantages - not demonstrate the motion of essential food pathway structures • FEES may be helpful when VFSS is not feasible (e.g. in critically ill patient, patients in ICU who cannot be transferred to the fluoroscopy room) 49
  50. 50. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iii. Oesophageal Manometry • to assess motor function of the esophagus • a catheter with several electronic pressure probes is passed into the stomach to measure esophageal contractions and to define upper and lower esophageal responses to swallowing • advantages: – senses the activity of the muscles – identifies subtle failures of pressure generation or hyperfunctioning of the sphincters – helps accurately diagnose the site of dysfunction 50
  51. 51. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iv. Oesophageal pH Monitoring • standard criteria for diagnosing reflux disease • a nasogastric probe is inserted into the patient's esophagus to record pH levels • these levels are compared with the patient's record of symptoms over 24 hours to determine whether acid reflux contributes to his/her symptoms v. Swallowing and Laryngeal Electromyography vi. Scintigraphy 51
  52. 52. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Swallow Carefully!!!Swallow Carefully!!! Thank YouThank You 52

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