. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Approach To DysphagiaApproach To Dysphagia

Fuad Ridha MahabotFuad Ridha Mahabot

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. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 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

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. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 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

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. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 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

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5stage Istage I stage IIstage II

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stage IIIstage III

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 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)

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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

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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

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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

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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

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tongue ulcertongue ulcer

Ludwing’s AnginaLudwing’s Angina

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• 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

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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 time15

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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

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Exudative TonsillitisExudative Tonsillitis Hypopharynx MalignancyHypopharynx Malignancy

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• other causes of oropharyngeal dysphagia - neuromyogenic

stroke

head trauma

Parkinson's disease and parkinsonism

amyotrophic lateral sclerosis

multiple sclerosis

 myasthenia gravis

 myopathies (inflammatory, metabolic)

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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

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mucosal rings and webs

• Schatzki's ring

• multiringed esophagus (eosinophilic esophagitis)

ii. carcinoma

primary (squamous, adenocarcinoma)

secondary (e.g. breast, melanoma)

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iii. disorders related to systemic diseases

pemphigus and pemphigoid conditions

Lichen planus

scleroderma (multifactorial)

intramural lesions

leiomyoma

granular cell tumor

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iv. extramural lesions

aberrant right subclavian artery (dysphagia lusoria)

mediastinal masses

bronchial carcinoma

v. anatomical abnormalities

hiatal hernia

esophageal diverticulum

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vi. motility disorders

achalasia and achalasia-like disorders

idiopathic (classic) achalasia

atypical disorders of lower esophageal sphincter relaxation

Chaga’s disease

pseudoachalasia

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Ca OesophagusCa Oesophagus Gastro Oesophageal Reflux DiseaseGastro Oesophageal Reflux Disease

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foreign bodyforeign bodyAchalasia CardiaAchalasia Cardia

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 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

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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

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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

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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.

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• 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

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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 hypopharynx32

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• if one or more of these four symptoms are present then the cause of

dysphagia is probably oropharyngeal, either structural or

neuromyogenic

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Oropharyngeal vs. Oesophageal DysphagiaOropharyngeal vs. Oesophageal Dysphagia

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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

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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

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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.

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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.

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• 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

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. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 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

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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

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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

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. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 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

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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

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Barium Swallow Barium Swallow in Achalasia in Achalasia CardiaCardia

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Endoscopies

i. direct laryngoscopy

ii. flexible nasopharyngoscopy

iii. bronchosocpy

iv. oesophagoscopy

give direct examination of pharyngeal as well as oesophageal mucosa

permits biopsy

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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

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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)

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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

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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

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Swallow Carefully!!!Swallow Carefully!!!Thank YouThank You

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