dysphagia 2001 11 slides
TRANSCRIPT
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Dysphagia
Evaluation and Management
Shashidhar Reddy, MDMatthew W. Ryan, MD
November 21, 2001
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Physiology of Swallowing
The act of swallowing involves three phases: Oral, Pharyngeal,and Esophageal.
Swallowing takes about 8-10 seconds Before swallowing begins, Oral Preparation of the bolus must
occur.
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Physiology of Swallowing:
Oral Phase Pharyngeal Phase
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Physiology of Swallowing
Pharyngeal and Esophageal Phase:
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Evaluation of Dysphagia
History
Review of Systems Physical Exam
Imaging Studies
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History
Duration dietary changes, weight loss
Odynophagia
Solids or Liquids Level of sensation of dysphagia
Past surgery to head and neck, trauma,ingestion of caustic substances
Associated symptoms such as with GERD,voice changes, nasal leakage, otalgia
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Review of Systems:
Ask about common systemic processesassociated with dysphagia:
Tobacco/Alcohol
Medications antihistamines, anticholinergics,antidepressants, antihypertensives
Osteoarthritis
Systemic neuromuscular disordersAuto-Immune disorders
Psychiatric state
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Physical Exam:
General: body habitus, mental status,drooling, wheezing, dyspnea, voice quality
Cranial nerves Inspection of the tongue and palate for
strength/symmetry
Laryngeal Examination: pooled secretions,vocal fold movement, interaretynoid area
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Imaging Studies
Should be chosen to suit the patientssymptoms and to confirm a finding.
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Plain Film
Uses:Suspected infectious cause of dysphagia with gross
displacement of structures.
Advantages Disadvantages
cheap Radiation
Fast Poor anatomic detail
No assessment of swallow
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Plain Film
(Epiglottitis)
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Barium Esophagram
Uses: structural disorders, e.g. dysphagiafor solid foods. Can use air contrast.
Advantages Disadvantages
Good anatomic detail Radiation
Logistics in bedridden pts.
Cannot detect dynamicdisorders.
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Air Contrast Barium Esophagram
Normal Fungal Plaques
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Manometry
Uses: disorders in which intraluminalpressures must be measured (achalasia,
esophageal spasm, etc.)
Advantages Disadvantages
It is the only test of pressure
wave physiology
Cannot diagnose visible
lesions
Unpleasant for patient
Techincally demanding
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Manometry
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Bolus Scintigraphy
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Ultrasound
Uses: Portable tool for dynamic studies,especially in children
Advantages: Disadvantages:
No radiation Not widely available
Portable Poor anatomic detail
Normal Food can be used
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Ultrasound
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Modified Barium Swallow
Uses excellent to evaluate dynamic (e.g.neuromuscular, aspiration) swallow
disorders.
Advantages Disadvantages
Gives good anatomic detail Radiation
Evaluates all phases ofswallowing
Does not directly testsensitivity
Logistics
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Fiberoptic Endoscopic
Evaluation of Swallowing Uses as a mobile tool that can be used in
training patients via biofeedbackAdvantages Disadvantages
Portable Blind spot
Allows assessment of sensation Cannot evaluatecricopharyngeus directly
Cheap Cannot eval. esophagus
Can be used for pt teaching
No radiation
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Fiberoptic Endoscopic
Evaluation of Swallowing
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Disorders that Cause Dysphagia
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Foreign Bodies
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Tracheostomy
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Cricopharyngeal Achalasia
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Cricopharyngeal Achalasia
Cricopharyngeal Myotomy:
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Zenkers Diverticulum
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Cervical Spine Disease
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Esophageal Webs and Rings
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Strictures / Caustic Ingestion
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Diffuse Esophageal Spasm
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Aging
Dysphagia is present in 2% > 65
Poor dentition
Loss of tongue connective tissue Increased pharyngeal transit time
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Case Review
50 year old man presents with 6 monthhistory of progressive dysphagia.
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Case Report
His dysphagia is worse for solid foods. Additionally he notes that he hears gurgling
noises when he swallows, and occasionallychokes on his food.
When he chokes, he often ends upvomitting his food back up.
He has lost about 6 lbs over the past 6
months. He drinks socially but gave up tobacco
x10yrs
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Case Report
Physical exam reveals a thin whitegentleman in no apparent distress.
Neck exam reveals nothing unusual.
Indirect Laryngoscopy is difficult becauseof frothy secretions in his hypopharynx and
piriform sinus.
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