This document discusses dysphagia (difficulty swallowing) including its anatomy, physiology, causes, investigation, and management. It covers the anatomy of the oropharynx and hypopharynx. The physiology section describes the three phases of swallowing - oral, pharyngeal, and esophageal. Common causes of dysphagia include presbyphagia, laryngopharyngeal reflux, xerostomia, tonsillitis, epiglottitis, oropharyngeal/hypopharyngeal malignancies, and pharyngeal pouches. Investigations include endoscopy, barium swallow, and manometry. Management is tailored based on the cause and resource availability,

1. Dysphagia
A&K

2. Dysphagia
1. Anatomy of oropharynx and hypopharynx
2. Physiology of swallowing
3. Causes of dysphagia
4. Investigation
5. Management

3. Anatomy of
oropharynx
and
hypopharynx

4. Anatomy of pharynx

5. 3 parts:
1.Nasopharynx:
• From the posterior nasal
apertures to the
nasopharyngeal isthmus
2.Oropharynx:
• Nasopharyngygeal isthmus
to the upper border of
epiglottis
3.Laryngopharynx:
• From upper border of
epiglottis to lower border of
cricoid cartilage

6. Oropharynx
• Middle part of the pharynx behind oral cavity
Communicates with:
• Nasopharynx through nasopharyngeal
(pharyngeal) isthmus
• Oral cavity through the oropharyngeal isthmus
(isthmus of fauces)
• Laryngopharynx at the level of upper border of
epiglottis
“Isthmus of fauces = limit between the mouth cavity proper with the pharynx marked by
constricted aperture Palatopharyngeal and palatoglossal arches”

7. Lateral wall
• Presence of palatine tonsil which lies in the palatine fossa
• Posteriorly the wall is formed by the:
1.Superior constrictor of pharynx
2.Middle constrictor of pharynx
3.Inferior constrictor of pharynx

8. Laryngopharynx
• Lowest part
• Situated behind the larynx
• Extend from upper border of epiglottis to lower
border of cricoid cartilage
• 3 walls:
1.Anterior wall
2.Lateral wall
3.Posterior wall

10. Wall Structure
Anterior • Laryngeal inlet
• Posterior surface of cricoid and
arytenoid cartilage
Lateral • Piriform fossa:
-On each side of laryngeal inlet
-Boundaries:
Medially: aryepiglottic fold
Laterally: thyroid cartilage &
thyrohyoid membrane
Posterior • Formed by contrictor muscles
-superior constrictor m.
-middle contrictor m.
-inferior constrictor m.

11. Oesophagus
• Fibromuscular tube
• Length: 25cm
Begins from:
-Below laryngopharynx
-Cricoid cartilage
-At level C6 vertebra
Ends at:
-Cardiac orifice of stomach
-Left 7th costal cartilage
-At T10 vertebrae
• 3 parts
-cervical
-thoracic
-abdominal

12. Physiology of swallowing

13. Deglutition
• Deglutition
-phases
-control of esophageal motility
• Salivary glands
-cell types
-composition of saliva
-regulation of saliva secretion

14. Deglutition
• Swallowing
• A mechanism that moves food or liquid from the
mouth through the pharynx and esophagus into
the stomach .
• is facilitated by the secretion of saliva and mucus.
• Normal deglutition is a smooth coordinated
process that involves a complex series of voluntary
and involuntary neuromuscular contractions and
typically is divided into three distinct phases:
1)Oral
2)Pharyngeal
3)Esophageal

16. Oral phase

17. Pharyngeal phase

18. Esophageal phase

19. Phase Activity
Oral Voluntary • Food rolled into the bolus
• Tongue arches to push bolus backwards into the
oropharynx
Pharyngeal Involuntary • Elevation of the soft palate to close nasopharyngeal
passage
• Pressure of the food on the pharyngeal wall
stimulates mechanoreceptor to inhibit breathing
• Raise larynx and close glottis
• Passage of bolus downwards ,epiglottis seals off
larynx
• Wave of contraction sweep the pharyngeal muscles ,
bolus moves into esophageal sphincter
Esophageal involuntary • Reflex relaxation of UES
• Sphincter closes when bolus has passed through
• Glottic opens, breathing resumes
• Peristaltic wave moves the bolus forward
• LES relaxes through action of vasointestine peptide
hormone
• Allow entry of bolus into the stomach

20. Causes of dysphagia

21. Dysphagia

22. Dysphagia
• Difficulty in swallowing
• Sensation of obstruction of passage of food
bolus through the pharynx and oesophagus
within 15 seconds of bolus leaving the mouth
• Odynophagia  Pain with deglutition

23. Globus pharyngeus
• Sensation of lump or tightness in throat with no
organic causes
• Hypothesis
• GERD
• Oesophageal Dysmotility
• Psychogenic origin
• Common in middle age, no sex preponderance
• No true dysphagia, no weight loss, continual need
to swallow

24. Presbyphagia
• Physiological changes that occurs in deglutition with ageing
• Reduction in muscle mass and strength
• Resulting in chronic dysphagia a/w malnutrition and
aspiration
• Manage by modifying consistency of food and swallowing
therapy
• Commonly affect the oesophageal phase and its location
involved is usually oesophagus

25. Laryngopharyngeal Reflux (LPR) vs GERD
LPR GERD
Has laryngeal scarring, odynophagia Has heartburn, chest pain
Daytime / Upright Refluxer Nocturnal / Supination Refluxer
Normal Oesophageal Motility Oesophageal dysmotility
Normal gastric acid clearance Prolonged gastric acid clearance
Not associated with oesophagitis Associated with oesophagitis
Primary Defect is Upper
Oesophageal Sphincter
Primary Defect is Lower
Oesophageal Sphicter
Increased risk of upper aerodigestive
tract cancer
Increased risk of oesophageal
cancer
Has globus pharyngeus Has retching and regurgitative
sensation

26. Laryngopharyngeal Reflux (LPR) vs GERD

27. Classification of dysphagia
• Oropharyngeal Dysphagia
• Oesophageal Dysphagia

28. Oropharyngeal Dysphagia
- Difficulty initiating deglutition
- Associated with coughing, choking, regurgitation,
aspiration, sensation of food in the pharynx
- Pathological site
- Oropharynx
- Oral dysfunction signs
- Drooling of saliva
- Hypersalivation (Sialorrhea)
- [Reason: compensatory mechanism for dysphagia]
- Piecemeal swallow
- Pharyngeal dysfunction signs
- Coughing
- Choking
- Regurgitation

30. Xerostomia
• Dry mouth
• Hyposalivation
• Causes dysphagia and difficulty in proper
pronounciation
• Advise for regular drinking of water

31. Causes of Xerostomia
1. Physiologic (Sleep, Age, Dehydrated, Anxiety)
2. Radiotherapy
3. Trauma to salivary glands
4. Drug/Toxic induced
- Anticholinergic, diuretics and sympathomimetics
- Alcohol
5. Sjögren's syndrome
6. Systemic causes
- DM, Hyperparathyroidism, Renal Failure

32. Acute Tonsilitis
• Inflammation of tonsils
• Can cause narrowing if too enlarge and can
obstruct food bolus going down
• Irritation by the food cause odynophagia
• Diagnosed by tonsillar surface swab
• Treatment includes pain relief (PCM), preventing
further inflammation (NSAIDs) and antibiotic
treatment.
• Tonsillectomy in indicated cases.

33. Acute Epiglottitis
• Inflammation of supraglottic region of the
oropharynx (epiglottis, arytenoid, aryepiglottic
folds)
• Food bolus going down the pharynx can irritate
the epiglottis and can cause odynophagia
• Manage by intubating to protect airway,
cricothyroidotomy in severe cases.

34. Malignancy of
Oropharynx and Hypopharynx
Oropharynx
Tonsils, base of tongue, soft palate, posterior
pharyngeal wall to hyoid bone level
Hypopharynx
From hyoid bone level to inferior border of
cricoid cartilage, including piriform fossae,
posterior pharyngeal wall, postcricoid region

35. Malignancy of
Oropharynx and Hypopharynx
Squamous cell carcinomas are the most common
neoplasm.
• Progressive dysphagia
• Weight loss
• Vocal cord palsy  Dysphonia
• Aspiration
• Referred Otalgia
• Neck metastasis
• Airway compromise
• Can be painless in oropharynx

36. Malignancy of
Oropharynx and Hypopharynx
• Investigation
• Rigid endoscopy under GA (Map tumour extend)
• CT Neck and Chest
• MRI Neck and Chest
• Management
Non Invasive
• Nutritional and diet control
• Swallowing therapy
• Nasogastric tube insertion for nutritional supply
• Gastrostomy for cases unable to apply NGT
Invasive
• Surgery or
• Laser therapy
• Concurrent chemoradiotherapy

37. Pharyngeal pouch
• AKA Zenker’s Diverticulum
• Natural weakness in posterior aspect of
hypopharynx between the fibres of
thyropharyngeus and cricopharyngeus of
inferior pharyngeal constrictor.
• Pulsion diverticula form at the area with least
support, at Killian’s dehiscence.

40. Pharyngeal pouch
• Signs and symptoms
• Progressive dysphagia
• Weight loss
• Regurgitation of undigested food (in the pouch)
• Halitosis
• Coughing
• Gurgling sound during swallowing on neck
• X-Ray Finding
• Rising Tide sign

42. Management
• Small – Observe
• Large – Endoscopic Stapling
• Large and difficult to staple – Excise pouch

43. Oesophageal Dysphagia
- Difficulty swallowing several seconds after
initiating first swallow
- Associated with sensation of food stuck in
oesophagus
- Pathological site
- Oesophagus body
- Lower oesophageal sphincter
- Cardia of the stomach

44. Oesophageal Dysphagia
- Intrinsic (Mechanical)
- Extrinsic (Compressive)
- Motility Disorder

45. Intrinsic (Mechanical)
- Reflux induced stricture
- Oesophageal carcinoma
- Oesophageal diverticulitis
- Foreign body

46. Extrinsic (Compressive)
- Mediastinal Tumour
- Vascular Compression 2˚ Hypertension
- Cervical Osteophytes

47. Oesophageal Motility Disorders
- Achalasia
- Oesophageal Spasm
- Lower Oesophageal Sphincter Malfunction
- Gastroesophageal Reflux Disorder (GERD)

48. Oesophageal Achalasia
• Due to impaired oesophageal peristalsis and
lack of lower oesophageal sphincter relaxation
during deglutition
• Common in 20 – 60 years old
• Dysphagia affect both solid and liquid food
• Complication: Cough, aspiration pneumonitis
and chest pain

49. Oesophageal Achalasia
• Investigation: Barium swallow,
endoscopy and manometry
• Treatments : Balloon dilation, chemical
denervation and surgical myotomy of
lower oesophageal sphincter
Retained level of barium
Bird beak’s appearance

50. Investigation

51. Investigation
• Oesophagogastroduodenoscopy (OGDS)
• OGDS Guided Biopsy
• Barium Swallow Oesophagography
• Radiofluoroscopy Swallowing Study
• Computed Tomography (CT) Scan
• Oesophageal Manometry
• Functional Endoscopic Sinus Surgery (FESS)
• Endoscopic Ultrasonography (Detect Tumour and
LN Staging)

52. Management

53. History Taking
• What kind of food produces dysphagia?
• Liquid
• Solid
• Nature of dysphagia
• Intermittent
• Continual
• Progressive
• Associated SSx
• Coughing
• Regurgitation
• Choking

54. Physical Examination
• Profound weight loss (Malignancy or Achalasia)
• Glossopharyngeal nerve (CN IX)
• Vagus nerve (CN X)
• Uvula movement
• Palatal movement
• Gag reflex
• Cough reflex (Rarely done)
• Neck Examination – Thyroid Malignancy
• Inspection of Limbs – Scleroderma, Weakness
(Neuromuscular Disorder)

55. Goals of Management
• Improve food transfer to the stomach
• Prevent aspiration pneumonitis
• Treat underlying causes
Treatment method is based on aetiological
approach.

56. Management Cascade
• Oropharyngeal Dysphagia
Status of Centre Management Option(s)
Limited Resources Swallowing Rehabilitation
- Head and Body Posture
- Air-way closure maneuver
Diet Modification
Importance of Oral Hygiene
Feeding Tube
Better Resources Surgical Gastrostomy
Percutaneous Gastrostomy
Endoscopic Gastrostomy

57. Management Cascade
• Oesophageal Dysphagia
Status of Centre Management Option(s)
Limited Resources Acid Suppressive Medication (GERD)
- H2R Antag
- Proton Pump inhibitors
Smooth Muscle Relaxants (Spasm)
- Nifedipine 10 mg TDS
Better Resources Surgery (Antireflux, Myotomy)
Endoscopic Balloon Dilation
BOTOX Injection
Chemoradiotherapy (Tumour)
Palliative Therapy (Late stage tumour)

58. Management Cascade
• Achalasia
Status of Centre Management Option(s)
Limited Resources Pneumatic Balloon Dilation
Muscle Relaxant
- Nifedipine 10 mg Preprandial
Better Resources Laparoscopic Surgery
- Myotomy
- Heller’s Operation
Oesophagectomy