This document discusses the physiology of swallowing and causes of dysphagia. It describes the three phases of normal swallowing: oral, pharyngeal, and esophageal. Swallowing involves coordinated activity of muscles in the oral cavity, pharynx, and esophagus, controlled by both voluntary and involuntary mechanisms. Dysphagia can result from congenital causes, trauma, infections, inflammatory conditions, esophageal motility disorders, neurological disorders, drugs, aging, and other miscellaneous factors. Common acquired causes include gastroesophageal reflux disease, infections like tonsillitis, and autoimmune disorders like scleroderma.
This seminar gives brief description about introduction, normal anatomy of velopharyngeal structure, different closure pattern of velopharynx, diagnostic aids used, VPI in cleft patients
surgical anatomy of nose is a humble attempt to make the anatomy of nose simpler and easy for medical students and fellow physicians. at the end of the presentation the students will be able to identify all the structures.
Ankyloglossia a congenital oral anomaly Dr Medical
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Ankyloglossia, also known as tongue-tie, is a congenital oral anomaly that may decrease mobility of the tongue tip and is caused by an unusually short, thick lingual frenulum, a membrane connecting the underside of the tongue to the floor of the mouth. Ankyloglossia or tongue-tie is the result of a short, tight, lingual frenulum causing difficulty in speech articulation due to limitation in tongue movement. Ankyloglossia is a congenital condition in which a neonate is born with an abnormally short, thickened, or tight lingual frenulum that restricts mobility of the tongue. Ankyloglossia may be associated with other craniofacial abnormalities, but is also often an isolated anomaly.
This powerpoint describes the types of maxillectomy & operative steps for total maxillectomy. It also enumerates various flaps used for reconstruction of maxillectomy defect.
short description of the process of deglutation with all the stages and their complete description and graphic view of all the things that are undergoing during the process of swallowing including an animated summary of whatever goes in the mouth for ease of understanding.
This seminar gives brief description about introduction, normal anatomy of velopharyngeal structure, different closure pattern of velopharynx, diagnostic aids used, VPI in cleft patients
surgical anatomy of nose is a humble attempt to make the anatomy of nose simpler and easy for medical students and fellow physicians. at the end of the presentation the students will be able to identify all the structures.
Ankyloglossia a congenital oral anomaly Dr Medical
https://userupload.net/h9ig9byum706
Ankyloglossia, also known as tongue-tie, is a congenital oral anomaly that may decrease mobility of the tongue tip and is caused by an unusually short, thick lingual frenulum, a membrane connecting the underside of the tongue to the floor of the mouth. Ankyloglossia or tongue-tie is the result of a short, tight, lingual frenulum causing difficulty in speech articulation due to limitation in tongue movement. Ankyloglossia is a congenital condition in which a neonate is born with an abnormally short, thickened, or tight lingual frenulum that restricts mobility of the tongue. Ankyloglossia may be associated with other craniofacial abnormalities, but is also often an isolated anomaly.
This powerpoint describes the types of maxillectomy & operative steps for total maxillectomy. It also enumerates various flaps used for reconstruction of maxillectomy defect.
short description of the process of deglutation with all the stages and their complete description and graphic view of all the things that are undergoing during the process of swallowing including an animated summary of whatever goes in the mouth for ease of understanding.
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details the deglutition or swallowing
phases and all process
theories of deglutition
components of deglutition,
stages of deglutition
deglutition reflex
features of swallow
physiology applied
Is a phenomenon of reflex sequence of muscle contractions that propels the ingested materials and pooled saliva from the mouth to the stomach.
PATTERNS
Infantile (visceral) swallow
Adult/mature swallow
ADULT SWALLOWING
Is composed of 4 stages
Voluntary
Preparatory phase
Oral or buccal
Involuntary: Controlled By Medulla and Lower Pons
Pharyngeal
b. Oesophageal
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Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
Acute scrotum is a general term referring to an emergency condition affecting the contents or the wall of the scrotum.
There are a number of conditions that present acutely, predominantly with pain and/or swelling
A careful and detailed history and examination, and in some cases, investigations allow differentiation between these diagnoses. A prompt diagnosis is essential as the patient may require urgent surgical intervention
Testicular torsion refers to twisting of the spermatic cord, causing ischaemia of the testicle.
Testicular torsion results from inadequate fixation of the testis to the tunica vaginalis producing ischemia from reduced arterial inflow and venous outflow obstruction.
The prevalence of testicular torsion in adult patients hospitalized with acute scrotal pain is approximately 25 to 50 percent
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
1. Dr Kaushik Sarangi
PG / 1ST Year
Dept of ENT
Scbmch
PHYSIOLOGY OF
SWALLOWING AND
DYSPHAGIA
2. SWALLOWING PHYSIOLOGY
INTRO
SEQUENCE OF EVENTS IN NORMAL SWALLOW
ORAL PHASE
PHARYNGEAL PHASE
ESOPHAGEAL PHASE
NEURAL CONTROL
RESPIRATION AND SWALLOWING
3. PHYSIOLOGY OF SWALLOWING-
INTRODUCTION
Swallowing involves coordinated activity of muscles of
oral cavity, pharynx, and esophagus.
The whole process is partly under voluntary control &
partly reflexive in nature
Swallowing by definition involves passage of bolus of
food (solid / liquid) from the oral cavity to stomach via
the pharynx and esophagus, passing over the entrance
to laryngeal vestibule.
Basic musculature of Swallowing controls the jaw,
tongue, degree of constriction and length of pharynx
and closure of laryngeal inlet.
4. Components of Deglutition
1. Passage of bolus from oral cavity to stomach
2. Protection of airway
These two mechanisms also serve to inhibit air entry into
the stomach.
5. Deglutition - phases
Three stages have been traditionally described by
Magendie for the sake of convenience. They help in
the better understanding of the physiological process
involved.
Oral
Pharyngeal
Esophageal
6. Oral phase
In this phase food is
prepared for swallowing
Tongue plays a vital role
in this process.
This phase is under
voluntary control.
This phase is divided into
oral preparatory phase and
oral phase proper
7. Oral preparatory phase
This phase involves breaking down of food in the
oral cavity
During this phase the food is chewed and mixed with
saliva making it into a bolus which can be swallowed
The elevators of lower jaw play an important role in
bolus preparation.
Tongue
Intrinsic muscles which alters its shape.
Extrinsic muscles changes its position within the oral cavity
8. Oral preparatory phase (contd..)
Occlusal of the lips help in creating an effective seal
preventing the bolus from dribbling out of the oral
cavity
The action of buccinator muscle helps in pushing the
bolus out of the vestibule into the oral cavity proper
Salivary Glands produce saliva which contains
mucin.
Mucin binds the food together and helps in bolus
formation.
9. Bolus formation
This is the most important function of preparatory
phase
This involves repeated transfer of food from oral
cavity to oropharyngeal surface of tongue.
Bolus accumulates on the oropharyngeal surface
of tongue due to repeated cycles of upward &
downward movement of the tongue.
10. Oral phase proper
During this phase the bolus is moved
towards the back of the tongue.
The contraction of soft palate prevents
nasal regurgitation, also prevents
premature movement of bolus into the
oropharynx.
Once the bolus is of suitable
consistency the transit from mouth to
oropharynx just takes one to two
seconds.
Tongue plays a vital role during this
phase also.
Its intrinsic muscles contracts and
reduces its size,
while genioglossus muscle elevates
the tongue towards the palate
12. Pharyngeal phase
This phase of deglutition is reflexive in nature (as the
bolus passes the palatoglossal & palatopharyngeal
folds the act of swallowing becomes reflexive)
Airway protective mechanisms are activated in advance
of passing the bolus.
As bolus reaches back of tongue a sequence of events
initiated-
1. Contraction of diaphragm is inhibited making simultaneous
breathing & swallowing impossible
2. Soft palate is elevated in order to seal off the nasopharynx (T.
palatini & L.palatini )
3. Vocal cords starts to adduct protecting the airway (aryepiglottic
ms.).
15. At this stage pharynx
constricts behind the
bolus as the superior
constrictor contracts.
Bolus carried down the
pharynx by a
coordinated peristaltic
wave of three
constrictors in
appropriate sequence.
16. Laryngeal inlet (formed by
sup margin of
quadrangular membrane)
itself is never actually fully
closed.
If food enters laryngeal
vestibule the true and
false cord guard the
airway
Then cough reflex
initiated to remove the
object.
17. Pharyngeal phase ( contd..)
During this phase Ventilatory and alimentary streams
cross each other.
Dynamic separation of these streams is possible due
to the co-ordination of reflex phase that occurs.
It just takes a second for the bolus to traverse the
pharynx and reach the cricopharyngeal area.
18.
19. Functions of Trigger Points
Stimulation of trigger points
present in the oropharynx
starts off the pharyngeal
reflexive stage of swallowing.
Present at the faucial arches
& mucosa of the posterior
pharyngeal wall.
Innervated by
glossopharyngeal nerve (CN
IX).
20. Functions of Trigger Points…
Stimulation of these trigger points causes
1. Dilatation of pharynx due to relaxation of the
constrictors, and
2. Elevation of pharynx & larynx due to contraction of
longitudinal muscles(palatopharyngeus &
stylopharyngeus)
3. The pharynx constricts behind the bolus thereby
propelling it.
4. Contraction of the inferior constrictor moves the bolus
towards the esophagus.
21. Importance of laryngeal elevation during
pharyngeal stage
It narrows the laryngeal
inlet
It ensures better sealing of
the laryngeal inlet by the
downturned epiglottis
The laryngeal inlet is
closed due to the actions
of interarytenoid,
aryepiglottic and
thyroepiglottic muscles
22. Role of epiglottis in the pharyngeal phase
The movement of epiglottis
occurs in two stages (by
thyroepiglotticus ms.)
The epiglottis moves from
vertical – horizontal
position
The upper third of
epiglottis moves below the
horizontal to a slightly
lower level to cover the
narrowed laryngeal inlet
23. Esophageal stage
This is purely reflexive
In this phase
cricopharyngeus relaxes
and the anterior superior
movement of the
laryngohyoid complex acts
to open the upper
oesophageal
sphincter(UES).
The bolus passes through
the sphincter and moves
along the esophagus by
peristalsis.
24. Contd..
The levator and tensor veli palatini relax lowering the
soft palate
The laryngeal vestibule opens, the hyoid drops and
the vocal cords open
This opening of the glottis at the very end of
oropharyngeal swallow sequence is part of the
airway protection mechanism
25. Neural control of swallowing
Two areas of brain are involved
1. Cerebral Cortex – for initiation
2. Brain Stem – for regulation
26. Neural control (Initiation)
Initiation of swallow is voluntary.
Bilateral prefrontal, frontal and parietal cortices are
involved.
Swallowing is initiated when food comes into contact
with certain trigger areas like fauces / mucosa of
posterior pharyngeal wall.
Afferent nerve is the glossopharyngeal nerve (CN
IX)
27. Neural control (initiation)..contd.
Medulla -Nucleus tractus solitarius &
spinal nucleus of trigeminal nerve
play a vital role in receiving
touch & pressure sensation
from trigger zones.
Efferents involve several cranial
nerve nuclei which include
NUCLEUS AMBIGUUS (muscles of
palate, pharynx and larynx) – by CN
X
HYPOGLOSSAL NUCLEUS supplying
the muscles of the tongue, by CN XII
MOTOR NUCLEI OF TRIGEMINAL AND
FACIAL NERVES supplying the
muscles of face, jaws and lips by CN
V & VII
28. Cortical asymmetry
In most people swallowing control is asymmetrical
with one hemisphere dominating.
This explains prevalence of swallowing problems and
recovery following stroke over a period of weeks.
Damage to hemisphere with greater projection accounts for
initial difficulty.
Recovery occurs as the intact projection from undamaged
hemisphere is reorganized.
29. Role of medulla
Cortical areas are not imp for coordinated swallow,
which can occur in significant brain damage.
Between the afferent and efferent system there are
two groups of neurons in the medulla which are
necessary for coordination & regulation of
swallowing.
Lateral medullary swallowing centers. converge
sensory input – lie in the dorsal medulla above the
nucleus of the solitary tract(NTS) -
Medial medullary swallowing centers distributes
output – The second group lie in the ventral medulla
around nucleus ambiguus(NA)-
31. Role of central pattern generator
Important for correct sequencing of events.
Since the process of swallowing and breathing are
interlinked there is a certain degree of central co-
ordination taking place
Concept of central pattern generation is that afferent
activity is not necessary to evoke rhythmic activity ..
Thus these neurons act like a cardiac pacemaker.
Thus Swallowing, Ventillation and Masticatory
movements are all interconnected.
32. Phase of respiration & swallowing
Swallowing occurs during expiratory phase of
respiration
This helps in clearing food material left in the
vestibule. Thus it should be considered to be a
protective phenomenon.
33. C A U S E S
A P P R O A C H
I N V E S T I G A T I O N
DYSPHAGIA
35. CONGENITAL CAUSES OF DYSPHAGIA
Choanal Atresia
Neonate is an obligate nasal breather
When partial presents withFeeding difficulty at birth, unable to suckle
adequately
When complete – respiratory distress
Diagnosis –
Lack of air pasage at nostril
Failure to pass nasopharyngeal catheter
Axial CT after nasal decongestion
Cleft Lip And Palate
Inefficient Suckling due to inadequate lip and nasopharynx seal
Laryngomalacia
MC cause of stridor in 1st year of life
Diagnosis bt nasolaryngoscopy
36. Congenital causes of dysphagia..contd
Unilateral & Bilateral Vocal Cord Paralysis
u/l – swallowing difficulty, hoarseness, aspiration
b/l - stridor
Laryngeal cleft
Asso with dysphagia
There is an asso between these and TEF
Diagnosis – by endoscopy under GA
Tracheoesophageal fistula and esophageal atresia
Vascular rings
Due to anomaly of great vessels,
subclavian(dysphagia lusoria) – may present with dysphagia in adulthood
double aortic arch,
anomalous left pulmonary artery
Diagnosis – endoscopy, barium swallow, CT, MRI
38. Traumatic causes
Accidental and iatrogenic
Blunt trauma, penetrating injuries and compression
effects
Direct injuries and cranial n. damage
Head injuries – imp bcoz may not become apparent
until pt resumes consciousness, starts feeding again
and aspirates.
39. INFECTIONS causing Dysphagia
1.Acute pharyngitis,tonsilitis, quinsy
MC cause
Despite appropriate antibiotic therapy tonsilitis can progress to peritonsillar
abscess
2.Glandular fever
by EBV
Painful dysphagia with marked cervical lymphadenopathy
3.Acute supraglottitis - Now rare due to Hib immunisation
Epiglottitis – sd be suspected if child becomes rapidly unwel with fever,
stridor, painful dysphagia and drooling.
4.Herpetic, fungal, or CMV mucosal infection
Usually seen in immunocompromised pts( on chemotherapy or head & neck
RT, Diabetes
Candidal infections are common in pts on broad spectrum antibiotics and
steroids
40. INFECTIONS causing Dysphagia
5.Candidiasis
Oral – diagnosed clinically
Hypopharynx - endoscopy
Esophagus –
barium swallow (shaggy mucosal appearance)
Esophagoscopy
6.Tubercuosis
Mucosal lesion – endoscopic biopsy
Compression by LN – axial CT chest
7.Abscesses
In head & neck can cause severe painful
dysphagia with drooling, fever, torticolis
MC is peritonsillar abscess follwed by
submandibular & parapharyngeal abscess
41. Inflammatory causes of Dysphagia
GERD
One of the MC causes
Complaints are - tightness in lower neck, constant throat
clearing, retrosternal discomfort & hoarseness
Clinical exam – erythema & edema of posterior larynx and
lower pharynx
Invetigation - Flexible esophagoscopy, 24hr ambulatory
esophageal pH monitoring(most accurte)
Barrett esophagus (BE) is a potentially serious complication of
long-standing GERD.
42. Inflammatory causes of Dysphagia..contd
Patterson Brown-Kelly or Plummer-
Vincent syndrome
Dysphagia mostly affects middle-aged or
elderly women
triad that consists of
proximal esophageal webs,
iron deficiency anemia, and
dysphagia.
Dysphagia is due to hyperkeratinisation with
web formation in the post cricoid region
Web can be seen on Barium swallow, but may
be missed on rigid endoscopy.
Iron supplement treats hyperkeratinisation
and dysphagia, but the web needs dilatation.
Associated with post cricoid carcinoma in
small percentage.
43. Inflammatory causes of Dysphagia..contd
Systemic autoimmune disorders
Most of them are associated with dysphagia
diagnosis is by clinical picture & auto-antibody profile(ANA,
RF)
t/t with steroid and immuno supressives does not improve
dysphagia
Scleroderma and CREST( Calcinosis, Raynaud’s,
Esophageal involvement, Sclerodactyly, Telengiectasia)
May include atrophy and fibrosis of smooth muscles
Often affect lower esophagus resulting in poor peristalsis,
severe GE reflux with stricture formation & Barrett’s.
44. Inflammatory causes of Dysphagia..contd
SLE
Mainly affects skin, joints, internal organs.
Dysphagia is mild
Dermatomyositis
Mainly affects skin, skeletal muscles
High percentage of pts are asso with malignancy
Dysphagia is due to hypopharyngeal and upper esophagus
involvement
Mixed connective tissue disorder
45. Inflammatory causes of Dysphagia..contd
Benign Pemphigoid and Epidermolysis Bullosa
Subepidermal and submucosal blisters respectively
Leads to scarring and obstruction of pharynx and esophagus
Good response to steroids and dilatation
Primary and secondary Sjogren’s Syndrome
Xerostomia causes dysphagia
Rheumatoid arthritis
May involve cricoarytenoids causing hoarseness & dysphagia
Crohn’s
Sarcoid
Compression of esophagus by lymph nodes
47. Esophagial Motility Disorders..contd
Achalasia(cardiospasm)
Failure of relaxation of lower esophageal sphincter
with progressive dilation and hypertrophy of
esophageal wall above.
Due to degeneration or absence of ganglion cells of
auerbach’s myenteric plexus in esophageal wall.
Pt c/o progressive dysphagia to fluids and then
solids. and eventually regurgitation of undigested
food
Diagnosis –
Barium swallow
Initially smooth “Bird’s beak” tapering of
esophagogastrc junction
Later associated with dilated esophagus
Manometry
Early diagnosis can be made before barium
appearance.
Shows failure of relaxation of LES, absence of
esophageal peristalsis and a raised resting
pressure of esophagus.
48. Esophagial Motility Disorders..contd
Diffuse Esophagial Spasm
Causes angina like chest pain in the
presence of normal coronal arteries
and dysphagia
Diagnosis
Barium swallow
Nonpropulsive peristaltic wave
(cocksrew appaearance)
Manometry
Repititive nonperistaltic multipeaked
contractions of high amplitude of
body of esophagus
With intermittent normal peristalsis
49. Esophagial Motility Disorders..contd
Nutcraker Esophagus
Noncardiac chest pain with dysphagia
Diagnosis
Manometry – shows normal peristatic waves of high amplitude in
the distal esophagus
50. Neoplastic causes of Dysphagia
Both benign and malignant tumors – by mechanical
obstruction and also by neuromuscular invasion.
IN ORAL CAVITY
Most are malignant- 95% of these are SCC.
Presentation - Lump or ulcer causing odynophagia.
Dysphagia is caused by tongue fixation.
In OROPHARYNX
Most are malignant and of SCC type
Usually ulcerative (lymphoma may present as smooth lump)
and visible clinically.
Presentation – sore throat, referred otalgia or dysphagia
51. Neoplastic causes of Dysphagia.. contd
In HYPOPHARYNX
Rare benign tumors ( leimyoma, lipoma, fibrolipoma)
Most are malignant of SCC type – 60% occuring in Pyriform
fosa.
Presentation – may only c/o feeling ‘something in the throat’,
crumb being stuck or an episode of food sticking
Diagnosis –
Clinical exam ( Barium swallow may be normal)
If symptoms persist – direct pharyngoscopy or esophagoscopy is
needed; - especially when asso with arytenoid edema or pooling of
saliva.
52. Neoplastic causes of Dysphagia.. contd
In ESOPHAGUS
Majority are SCC, though benign leiomyoma found occasionally.
Adenocarcinoma seen in lower end of esophagus arises
Either in gastric metaplasia (as in Barrette’s) or invasion of tumor from
cardiac end of stomach
Presentation – classical is “ dysphagia of short duration in an elderly
male who smokes and drinks and which progresses from solid to
liqquid”.
O/E – In advanced diseases –
wt loss,
anemia,
cervical lymphadenopathy, and
hoarseness with bovine cough.
Diagnosis is made by Barium swallow
In all pharyngeal and esophageal malignancy
Biopsy under GA – confirms the diagnosis,and staging tumor.
CT scan of neck, chest, upper abdomen – for staging, local
spread, and secondary deposits.
53. Neoplastic causes of Dysphagia.. contd
Nasopharyngeal CA
Cranial N palsy from skull base invasion
presents with speech & swallowng problems and hoarseness.
Diagnosis – by nasopharyngoscopy & CT.
Skull base tumors( craniopharyngeomas & chordomas)
By compression of parapharyngeal space or invasion of cranial
nerves
Leukemias & Lymphomas
By esophageal wall infiltration
Enlarged mediastinal LN( due to lymphoma, LN
metastasis, bronchial CA, thyroid malignancy)
By external compression
Diagnosis – barium swallow & CT chest
54. Neurological causes of Dysphagia
CVA or Stroke
MC neurological disorder causing dysphagia by affecting
Cortex or
Corticobulbar tracts ( pseudobulbar palsy ) or
bulbar nerve nuclei ( bulbar palsy )
Recovery takes place in first week in majority of pts.
Dysphagia is due to
Delayed triggering of swallowing reflex.
Cricopharyngeal dysfunction
Reduced tongue control and pharyngeal contraction and cough
Cause ASPIRATION – aspiration pneumonia being
commonest cause of death after a stroke.
55. Neurological causes of Dysphagia
Isolated recurrent nerve palsy
Cause dyphagia & aspiration by
Decresed pharyngeal gradient pressure
Decreased glottic clossure pressure
Inf. Constrictor and cricopharyngeal ms. Dysfunction
Parkinson’s disease
Oral & pharyngeal phase are affected
Oral – rigidity of tongue musculature
Pharyngeal – delayed contraction of pharyngeal muscles
Due changes in striated muscle under dopaminergic control and
smooth muscle under autonomic control.
Multiple sclerosis
Myasthenia gravis
Motor Neuron Disease( amyotrophic lateral sclerosis)
56. Drug Induced Dysphagia
Mechanisms
1. Directly causing esophagitis
2. As a part of pharmacological action
3. Normal side effects
Directly Causing Esophagitis
Tablets with insufficient water
Taking tablet just before going to bed bcoz esophageal transit time is
longer during sleep
MC injured area Esophagus at the level of Aortic Arch
Due to lack of neutralization of saliva
And contact by acid producing drugs with pH<3
• Tetracycline, Doxyycycline, Vitamin C, Ferrous Sulphate
Secondary viral and fungal infection by
• Broad spectrum antibiotics
• Chemotherapeutic drugs
Antibiotics steven-johnson’s syndrome with acute erosive pharyngitis and
esophagitis causing dysphagia and delayed esophageal strictures
57. Drug Induced Dysphagia.. contd
As a part of pharmacological action causing Xerostomia
Anti hypertensives
ACE inhibitors
Anticholinergics
Antiemetics
Antihistaminics
Opiates
58. Drug Induced Dysphagia.. contd
Normal side effects
Inhibitory By decreasing
Esophageal peristalsis
Tone of LES
Anticholinergics
TCA
Calcium channel blockers
Excitatory
Cause rapid esophageal motility and GE Reflux
Cholinergic agonist, cisapride, metoclopramide
59. Presbydysphagia
Affects all stages of swallowing by
Despite these changes barium swallow abnormality
is found in 1/3rd pts only and few complain
dysphagia
Oral phase Pharyngeal phase Esophageal phase
•Loss of teeth & tongue
connective tissue
•Reduced strength of
mastication
•Wakness of reflexes
•Decreased elevation of
larynx
•Prolongation of
pharyngeal transit time
•Prolongation of UES
relaxation time
•Increased esophageal
transit time
60. MISCELLANEOUS CAUSES
Foreign body in pharynx
Fish bone or spicules of meat bones
Sites – tonsils, base of tongue, vallecula or pyriform fossa –
MC is tonsils.
Clinical ( inspection, palpation, IL ) and endoscopes help
locate the site.
Radiograph is useful if bone is ossified.
Foreign body in esophagus
MC is coin. Others are like large piece of meat w/wo bone.
MC sites – constrictions at
Cricopharyngeous,
Level of aortic arch,
Cardia
61. MISCELLANEOUS CAUSES.. contd
Caustic stricture
Acids or alkali( caustic soda, ammonia)
Usually accidental, but may be an suicidal attampt
Effect –
Edema – of laryngopharynx causing respiratory difficulty
Superficial burns – heal completely
Deep burns – repair by fibrosis with stricture formation and
dysphagia.
Intervention –
In acute phase Flexible Esophagoscopy is mandatory to assess the
extent of damage prior to placing feeding gastrostomy
Barium swallow & esophagoscopy – done to diagnose stricture
formation
62. MISCELLANEOUS CAUSES.. contd
Pharyngeal pouch
Mucosal dehiscence between thyro &
cricopharyngeous (parts of IC)
called Killian’s dehiscence in posterior
pharynx
Pt c/o
Lump – initially when pouch is small
Dysphagia – later when pouch enlarges with food
filled pouch compressing esophagus.
Others like regurgitation of undigested food into
pharynx, and overflow into larynx causing
aspiration with bouts of coughing and then
pnumonia
Diagnosis – confirmed by Barium Swallow
63. MISCELLANEOUS CAUSES.. contd
Globus pharyngeous
Pt c/o – “constant feeling of lump in throat” which is
worse on swallowing saliva, but does not interfere
with swallowing of either fluid or food.”
Asso with GERD w/ wo esophagitis in significant
number of pts.
64. MISCELLANEOUS CAUSES.. contd
Pts having Tracheostomy
Can cause dysphagia by
interfering with laryngeal elevation during swallowing
direct pressure on esophagus if cuff is overinflated
Thyroid Disease
Due to compression of upper esophagus
Diagnosis
Barium swallow
Axial CT scan of neck and chest
Thyroid function & antibody test , FNAC, USG, thyroid
scanning
65. APPROACH..
HISTORY TAKING AND EVALUATION
Taking a careful history is vital for evaluation of
dysphagia
The history will yield
Pathophysiologic process
Anatomic site of problem in most pts – 80%
Crucial for determining whether subsequently detected
radiographic or endoscopic anomalies are relevant or
incidental
66. HISTORY TAKING AND EVALUATION
Three fundamental aims of history taking
1. To distinguish true dysphagia from
i. Globus sensation(in between meals )
ii. Xerostomia – loss of lubrication and stimulus
iii. Odynophagia – transient than dysphagia
2. To distigealnguish site of problem- esophageal or
pharygeal
3. To distinguish structural from motor disorder
History will also dictate the proper next diagnostic
procedure.
67. HISTORY TAKING AND EVALUATION
Symptoms indicating oropharyngel dysfunction
There are four symptoms that have high specificity
for oropharyngel dysfunction
1. Delayed or absent oropharyngeal swallow initiation
2. Deglutitive postnasal regurgitation or egress of fluid
through the nose during swallowing
3. Deglutitive cough indicative of aspiration
4. The need to swallow repititively to achieve
satisfactory clearance of swallowed material from
the hypopharynx
If one or more of these symptoms are present then cause
of dysphagia is probably Oropharyngeal, eithr structural
or neuromyogenic.
68. Oropharyngeal vs. Esophageal Dysphagia
Difficulty swallowing
Food sticks
during meals
Lump in throat
between meals
Globus
Neck Retrosternum
Pharynx OR Esophagus ?
Cardinal
Oropharyngeal Symptoms
Pharyngeal Esophageal
“How does it feel like ?”
“Where does it stick ?”
“Initiation?”
“Postnasal regurgitation?”
“Deglutitive cough?”
“Repetitive swallows?”
Yes No
70. Physical examination for dysphagia
Level of alertness and cognitive status, vitals
Examination of CN V and VII – XII
Complete exam of neck & chest including cervical LN
status
Assessment of Voice
Direct observation of lip & jaw closure, chewing and
mastication, tongue mobility & strength, palatal &
laryngeal elevation and salivation with oral sensitivity
Inspection of oral cavity and pharynx
71. Physical examination for dysphagia
Evaluation of laryngeal elevation by placing 2 fingers on
larynx and assessing movement during volitional
swallow
Gag reflex
Direct observation of the act of swallow, at least a few
ounces of water. After swallow, observe for 1 minute or
more for delayed cough response if present.
Skin for scleroderma and CREST syndrome
Signs of malnutrition, wt loss, pulmonary c/c
72. Blood investigations
To screen for
Infection or inflammatory conditions
Nutritional status
Fluid electrolyte imbalance
Thyroid function
73. Radiography
Chest x-ray - Mediastinum, cardiac and pulmonary
status, aspiration pneumonia, also to rule out
secondaries.
Lateral x-ray soft tissue neck – to detect any soft
tissue lesion of post cricoid or retropharyngeal space,
prevertebral widening, osteophytes, FB etc
Barium swallow
CT scan – to evaluate mass lesion in neck
MRI –
useful when neurologic disorders are suspected
Delineate mass lesion in brain
Degenerative processes inn brain & spinal cord
75. Special Tests
Videofluroscopic swallowing study (or Videofluroscopy)
aka modified barium swallow
Definitive study for evaluation of swallowing mechanism
Superior to FEES for evaluating Oral phase and aspiration
FEES – fibreoptic endoscopic evaluation of swallowing
Using a transnasal laryngoscope
Advantages –
for detection of premature bolus loss, laryngeal penetration, trachaeal
aspiration and pharyngeal residue
Helpful when VFS not feasible (critically ill, ICU pt)
Disadv – don’t demonstrate motion of food pathway str
76.
77. Special Tests
Esophageal manometry
Toassess motor function of esophagus
Esophageal pH monitoring
Standard criteria for diagnosing reflux disease
Swallowing and Laryngeal Electromyography
Scintigraphy
78. To summarize
Swallowing is NOT a stepwise progression, it is a
cyclical and irregular process.
Neural control is divided between the cortex and
brainstem.
Cortical control of swallowing is bilateral,
although one hemisphere is usually dominating.
Airway protection is activated in advance of
pharyngeal phase of swallowing.
Impaired respiration pattern will affect
swallowing and vice versa.
79. Age of patient suggests most likely cause of
dysphagia.
Globus pharyngeous is common in middle aged women
and rarely asso with serious disease.
Neurological causes of dysphagia mostly affect
oropharyngeal phase of swallowing.
Ingested FB tend to lodge at sites of constriction at
cricopharyngeous, aortic arch, and cardia.
A contrast swallow for suspected perforation
and/or aspiration should be with low MW, non-ionic,
water soluble contrast medium. Barium is
contraindicated.
80. Esophageal manometry can be helpful in atypical
chest pain and unexplained dysphagia.
24 hr ambulatory esophageal pH monitoring is
most accurate method of diagnosing GER.
A barium videofluoroscopy swallowing is gold
standard for evaluating swallowing mechanism,
particularly oral & pharyngeal phase.