Dysphagia refers to difficulty swallowing and can affect any part of the swallowing pathway. There are two main types - oropharyngeal dysphagia where food gets stuck in the mouth or throat, and esophageal dysphagia where food gets stuck in the lower throat or chest. Dysphagia has many potential causes including neurological issues, infections, inflammation, tumors, and motility disorders of the esophagus. Evaluation involves a thorough history and physical exam as well as tests like barium swallow, endoscopy, and manometry. Zenker's diverticulum is a common esophageal diverticulum that can cause dysphagia, and treatment options include an external surgical approach
2. STAGES OF SWALLOWING
A. VOLUNTARY
I. ORAL PREPARATORY: Prepares food for swallowing and includes
mastication
a. Lip closure, tensions from labial and buccal musculature (CN VII)
b. Rotary jaw motion (CN VII)
c. Lateral tongue rolling (CN XII)
d. Anterior bulging of soft palate seals oral cavity and widens nasal airway
(CN IX and X)
II. ORAL: Food moves from oral cavity to pharynx
• a. Posterior propulsion of food by tongue along hard palate (CN XII)
• b. Triggers pharyngeal swallow by glossopharyngeal nerve (CN IX)Delayed
trigger by SLN at laryngeal inlet
• c. Prolonged with age and increased velocity
3. B. INVOLUNTARY
I. PHARYNGEAL
• a. Soft-palate elevation allowing velopharyngeal closure, preventing
nasopharyngeal regurgitation (CN XI and XII)
• b. Base of tongue retraction allowing for subsequent bolus propulsion
• c. Hyolaryngeal elevation allowing for airway protection and closure (CN XI
and XII)
• d. Pharyngeal constrictor muscle contraction (CN IX)
• e. Cricopharyngeal relaxation/pharyngoesophageal segment opening (CN
X) Cricopharyngeus muscle is under tonic contracted to prevent air
ingestion with inhalation and reflux from esophagus
II. ESOPHAGEAL
a. Peristalsis
• Upper one-third of mixed voluntary muscles
• Lower two-thirds involuntary
STAGES OF SWALLOWING CONT.,
4. DEFINITION
• Dysphagia is defined as having
difficulty in swallowing which may
affect any part of the swallowing
pathway from the mouth to the
stomach.
• Approximately half of the dysphagia
patients are seen in ENT clinics.
5. HISTORY AND EXAMINATION
• Patients complain that foods or liquids
are no longer being swallowed easily
and there is a sensation of food
sticking.
• Clinician must try to distinguish
oropharyngeal from oesophageal
dysphagia
6. OROPHARYNGEAL VS.OESOPHAGEAL
DYSPHAGIA
• In Oropharyngeal dysphagia, there is difficulty in
preparing and transporting the food bolus through the
oral cavity as well as initiating the swallow. This may be
associated with aspiration or nasopharyngeal
regurgitation.
• In Oesophageal dysphagia, patients complain of
food sticking in their lower throat, neck, retro-sternal
discomfort or epigastrium.
10. ACQUIRED: TRAUMATIC
• Accidental and iatrogenic
• Blunt trauma, penetrating injuries and
compression effects
• Direct damage and injury to cranial nerves
• Head injury
16. ACQUIRED: DRUG INDUCED
• Drugs causing oesophagitis
• Swallowing tablets with insufficient water
or just before going to bed can cause
oesophagitis
• Oesophagus at the level of aortic arch
most vulnerable to contact by acid
producing drugs (with pH less than 3)
such as tetracyclines, doxycycline, vitamin
C and ferrous sulphate
17. Acquired: Drug Induced (2)
• Broad-spectrum antibiotics and
chemotherapeutic agents may cause
secondary viral ulceration or fungal infections
• Stevens-Johnson syndrome is a more
serious complications of antibiotic therapy
with an acute erosive pharyngitis/
oesophagitis as well as delayed
oesophageal strictures
• Inhibitory drug side effects by
anticholinergics, tricyclic antidepressants and
calcium channel blockers
18. ACQUIRED: DRUG INDUCED (3)
• Excitatory side effects of drugs like
cisapride and metaclopramide.
• Dysphagia can be a complication of drugs
like antihypertensives, ACE Inhibitors,
anticholinergics, antiemetics,
antihistamines, diuretics, and opiates by
causing xerostomia
24. CLINICAL EXAMINATION
• Complete Head and neck examination
– Inspection of oral cavity
– Dentition
– Oropharynx
– IDL
– Nasolaryngoscopy
– Cranial nerve examination ( tongue, gag and
cough reflex, hoarseness, vocal cord mobility)
– Neck for lymph nodes, neck masses, thyroid
enlargement, loss of laryngeal crepitus and
integrity of laryngeal cartilages.
25. SPECIAL INVESTIGATIONS
• Blood tests to exclude anaemia (? Cause
or effect)
• ESR or C-Reactive Protein raised in
malignancy or chronic inflammatory
process
• LFT, RFT along with S. Calcium when
nutrition is impaired or metastasis is
suspected
• Thyroid function tests if dysphagia is
caused by goiter or malignancy of thyroid
26. SPECIAL INVESTIGATIONS
• Barium swallow
• Chest radiograph
• CT scan examination of neck, chest and abdomen.
• MRI is indicated when there are neurological causes
such as multiple sclerosis, cerebral tx, nasopharyngeal
ca.
• Rigid endoscopy
• Flexible endoscopy
• Manometry
• Other Investigations. Bronchoscopy (for bronchial
carcinoma), cardiac catheterization (for vascular
anomalies),thyroid scan (for malignant thyroid) may be
required, depending on the case.
31. (RIGHT) DYSPHAGIA
LUSORIA.
This very rare cause of
dysphagia is due to an aberrant
right subclavian artery coursing
posterior to the esophagus,
causing a spiral filling defect.
38. 24-HOUR AMBULATORY PH
MONITORING
• The most direct method of measuring
increased REFLUX (esophageal exposure
to gastric juice ) is by an indwelling pH
electrode, or more recently via a radio-
telemetric pH monitoring capsule that
can be clipped to the esophageal mucosa.
39.
40. ENDOSCOPIC ULTRASOUND
tumor confined to
the esophageal
wall
an advanced esophageal
carcinoma penetrating
through all layers
Used for dysphagia due
to carcinoma
esophagus
for staging
Biopsycan also be
taken
41. FUNCTIONAL ENDOSCOPIC
EXAMINATION OF SWALLOWING
(FEES)
a) Visualization of pharynx before and after swallow
b) Uses different consistencies with or without food coloring
c) Good for detection of penetration, aspiration, pooling, retained
secretions, effectiveness of cough
d) Examination Start with pharyngeal squeeze (high-pitched strained
phonation in rising crescendo).
• Start with water/ice chips and progress to puree then crackers
• Pre-swallow Secretion level: assess amount and location of secretion
prior to swallow
• Can indicate patients who are at high risk for aspiration due to open
glottis during bolus formation and transit
42. • Post swallow Assess whether food contents have penetrated larynx
or if the patient aspirated the contents.
• Location of residue (velleculae, pharyngeal wall, pyriform).
• Can be used in conjunction with compensatory maneuvers to test for
benefit.
• Limitation is that one cannot visualize oral phase, events during
swallow or upper esophageal sphincter function
44. KEY POINTS
• Age suggests most likely cause of
dysphagia
• Globus pharyngeus rarely associated with
any serious disease
• Dysphagia of short duration in elderly
patient who smoke or drink and which
progress from solids to liquids is a classic
case of malignancy
• Referred otalgia with dysphagia is a
sinister symptom and poor prognostic sign
45. KEY POINTS (2)
• Neurological causes of dysphagia mostly
affect orpharyngeal phase
• Ingested foreign bodies tend to lodge at sites
of constriction
• Barium study is contraindicated in patients
with suspected perforation of oesophagus
46.
47. ZENKERS DIVERTICULUM
• Esophageal diverticula, or outpouchings of the lumen,
include pharyngoesophageal (Zenker) diverticulum,
midesophageal diverticulum, and epiphrenic
diverticulum.
• Zenker diverticulum is the most commonly encountered
esophageal diverticulum and is the most likely to be
symptomatic.
• The outpouching occurs between the inferior
pharyngeal constrictor muscle and the
cricopharyngeus, in an area called Killian dehiscence.
• This pulsion diverticulum likely results from
cricopharyngeal dysfunction.
• ZD is more prone to herniate to the Left.
48.
49. PRESENTATION
SYMPTOMS:
• Progressive Dysphagia(.>90%)
• Regurgitation Of Food Even Hours
After A Meal,
• Unprovoked Aspiration
• Noisy Deglutition (Borborygmi)
• Belching,
• Hypopharyngeal Mucous
Collection,
• Halitosis,
• Choking
• Coughing,
• Hoarseness,
• Globus Pharyngeus,
• Weight Loss,
• Recurrent Respiratory Infections
SIGNS:
• mucous pooling in the
hypopharynx that initially clears
with swallowing then recurs,
• Emaciation
• Dehydration
• Boyce sign—a swelling in the
neck that gurgles on palpation
50. PATHOPHYSIOLOGY
• Ludlow in Bristol, England, gave the first anatomic description of a pulsion
diverticulum of the hypopharynx in 1769.
• Bell who proposed in 1816 that incoordination of the inferior constrictor muscle
against a closed cricopharyngeal muscle resulted in this type of outpouching
at regions of inherent weakness.
• The congenital theory describes an unusually weak or large Killian triangle
from birth that with time herniates with normal pharyngeal contraction
• Patterson first proposed cricopharyngeal achalasia as an etiology for ZD in
1919.
• Spasm or persistently elevated resting tone of the cricopharyngeus secondary
to reflux could cause ZD, although others refuted a direct causal association.
• Lerut in 1988 proposed a structural abnormality of the cricopharyngeal muscle
itself.
• Cook et al in 1992 suggested partial, incomplete opening of the
cricopharyngeal muscle because of fibroadipose tissue replacement as an
etiology.
• Six years later, Walters et al.proposed that ZD might be a manifestation of
central or peripheral neurologic disease.
51. MANAGEMENT
TRANSCERVICAL APPROACH.
• A transverse incision along the neck crease at the level of the cricoid
cartilage is the preferred approach. Alternatively, the incision can be made
along the anterior border of the sternocleidomastoid (SCM) muscle from
the level of the hyoid bone to the clavicle.
• Subplatysmal flaps are then raised,
• Lateral retraction of the SCM muscle.
• The fascial attachments along the anterior border are divided.
• The strap muscles may be retracted anteromedially, but for better
exposure, the anterior belly of the omohyoid muscle may be divided
inferiorly,
• As blunt dissection is carried out to expose the posterior aspect of the
pharynx, larynx, and esophagus, the recurrent laryngeal nerve is
identified. and protected before the thyroid vessels are ligated and divided.
52. • Once the diverticulum is identified and freed from the surrounding tissues
down to its base attachment to the esophagus,
• a long cricopharyngeal myotomy is performed.
• The pouch itself can then be excised, inverted, or suspended by a suturing
or stapling technique.
• For small diverticula (1 to 2 cm), a cricopharyngeal myotomy alone may
be sufficient.
• Possible significant complications from external procedures
fistula formation,
recurrent laryngeal nerve paralysis,
pneumomediastinum,
mediastinitis,
esophageal stricture
53. ENDOSCOPIC STAPLE DIVERTICULOTOMY
• Endoscopic techniques involve visualization of the ZD through a modified
laryngoscope with division of the common wall between the diverticulum
and esophagus using electrocautery, CO2 laser, ultrasonic shears, or
staples.
• A bivalved endoscope is inserted with one blade into the cervical
esophagus and the other into the diverticulum).
• The endoscope is suspended.
• Visualization is achieved with a 0-degree rigid endoscope. The
diverticulum pouch is carefully examined, and if any lesions are noted,
biopsy specimens are obtained for frozen section diagnosis.
• The “bar” between the pouch and the esophagus, whichc onsists of the
cricopharyngeus muscle, is stabilized by grasping it with alligator forceps
or by using a stitch placed with an endoscopic stitching device.
• The Endo-GIA stapler is then used to divide the party wallbetween the
esophagus and diverticulum, with several rows of staples being deposited
on each side in the process.
54.
55.
56. • Patients resume an oral diet within 24 hours.
• Compared with external approaches, endoscopic techniques result in a
shorter, if any, inpatient stay; shorter anesthesia times, which is important
in the elderly or the medically infirm; and more rapid convalescence.
• Furthermore, in patients whose diverticula have recurred after primary
external or endoscopic approaches, ESD may be performed without any
increase in technical difficulty or morbidity
57. RECURRENCE
• Incomplete division of the cricopharyngeal muscle and restenosis of the
common wall diverticulostomy from scarring.
• Reflux
• Intraoperative measures to decrease the chance of recurrence and
complications include the use of retraction sutures to help position the
common wall and allow the stapler to be placed for maximal sectioning
and the removal of any loose staples or retained sutures immediately after
the common wall is divided to prevent mucosal edge irritation and
subsequent restenosis.
• Revision ESD may not be the best option for patients with a very small
recurrent pouch (1 to 2 cm or less) who have had previous external
diverticulectomy.
• ESD RX OF CHOICE FOR BOTHN INITIAL PRESENTATION AND
RECURRENCES
58. MOTILITY DISORDERS
• These conditions include:
– Achlasia
– Scleroderma
– Diffuse Esophageal Spasm
– Nutcracker Esophagus
• Up to 30% pts with diagnosis of MI will be
found to have an esophageal cause of
pain and motility disorders account for
over 50% of these patients.
• Mainstay of investigation is manometry ,
endoscopy, barium studies
59. Achlasia
• Failure of relaxation of LES during
swallowing due to degeneration of myenteric
plexus.
• Presentation long standing dysphagia and
regurgitation
• Barium swallow: Dilated esophagus with a
smooth tapering stricture at its lower end
• Esophageal manometry: Synchronous
contractions and failure to relax
• 24 Hour pH measurement: Confirms reflux
60. Achlasia-Treatment
• Sequential dilatation of Lower
Oesophageal Sphincter with intraluminal
balloons under fluoroscopic control
• Balloon myotomy is safe, effective in 3/4th
cases and can be repeated
• Surgical myotomy (Open/laparoscopic)
reserved for failed balloon failures
• Failed myotomy can be treated with
balloon dilatation
61. DES & Nutcracker Esophagus
• Characterized by severe chest pain and
dysphagia
• Primarily involvement of lower 1/3, muscle
hypertrophy and high pressure
contractions
• Symptoms intermittent so ambulatory
manometry is required
• Treat with calcium channel blockers or
balloon dilatation
• Results disappointing
62. TREATMENT
• Life style modification
• Drug therapy
• Therapeutic
endoscopy
• Dilation
• Stentings
• Chemo-radiation
• Surgery
63. LIFE STYLE MODIFICATION
• These include
– avoidance of precipitating foods(fatty foods,alcohol, caffeine)
– Oral hygine
– avoidance of recumbency postprandially
– elevation of the head of the bed
– smoking cessation
– weight reduction.