DYSPHAGIA

dr. Ery Olivianto

Child Health Department Faculty of Medicine Airlangga University / dr Soetomo General Hospital

Introduction

Dysphagia typically refers to difficulty in eating as a result of disruption in the swallowing process Dysphagia risk of aspiration pneumonia, malnutrition, dehydration, weight loss, and airway obstruction. A number of etiologies have been attributed to dysphagia in populations with neurologic and nonneurologic conditions

introduction

Dysphagia may affect the oral, pharyngeal, or esophageal phases of swallowing. Thorough history taking and careful physical examination are important in the diagnosis and treatment The bedside physical should include examination of the neck, mouth, oropharynx, and larynx. A neurologic examination also should be performed.

introduction

Certain factors make dysphagia in children unique. Successful oral feeding and growth in infants and children depend not only on functional deglutition but also on a broad range of neurodevelopmental skills involving sensory systems, cognition, communication, and gross and fine motor behaviors

Normal swallowing physiology

Food or liquid bolus is transported from the mouth through the pharynx and esophagus into the stomach. Normal deglutition is a smooth coordinated process that involves a complex series of voluntary and involuntary neuromuscular contractions, and typically is divided into distinct phases: (1) oral, (2) pharyngeal, and (3) esophageal.

Oral phase

the oral preparatory phase the oral propulsive phase contractions of the tongue and striated muscles of mastication (coordinated fashion) mix the food bolus with saliva and propel it into the oropharynx involuntary swallowing reflex. Lasts about 1 second.

Pharyngeal phase

A rapid sequence of overlapping events. The soft palate rises. The hyoid bone and larynx move upward and forward. The vocal folds move to the midline, and the epiglottis folds backward to protect the airway. The tongue pushes backward and downward into the pharynx to propel the bolus down. The tongue is assisted by the pharyngeal walls, which move inward with a progressive wave of contraction from top to bottom.

Pharyngeal phase

The upper esophageal sphincter relaxes during the pharyngeal phase and is pulled open by the forward movement of the hyoid bone and larynx. This sphincter closes after passage of the food, and the pharyngeal structures then return to reference position. Involuntary and totally reflexive Lasts approximately 1 second,

Esophageal phase

The bolus is propelled by peristaltic movement. 8-20 seconds may be required for contractions to drive the bolus into the stomach.

Pathophysiology

In children and infants, may present with feeding difficulties. Nasal obstruction : nasal masses, choanal atresia, and choanal stenosis fall in this category. Oral lesions : cleft lip or palate, mucoceles, ranulas, and Warthin's duct stenosis may cause dysphagia. Upper aerodigestive tract anomalies : laryngomalacia, vocal cord paralysis, tracheo-esophageal fistula, or vascular rings of the aorta or pulmonary arteries that compress the esophagus or trachea Tumors of the aerodigestive tract : hemangiomas, lymphangiomas, papillomas, leiomyomas, and neurofibromas.

Signs and symptoms

Oral or pharyngeal dysphagia

Coughing or choking with swallowing Difficulty initiating swallowing Food sticking in the throat Sialorrhea Unexplained weight loss Change in dietary habits Recurrent pneumonia Change in voice or speech (wet voice) Nasal regurgitation
Sensation of food sticking in the chest or throat Oral or pharyngeal regurgitation Change in dietary habits Recurrent pneumonia

Esophageal dysphagia

Causes

Prematurity by itself and neurologic impairment (eg, cerebral palsy) are common causes. Children with cerebral palsy typically manage solid boluses more easily than liquid boluses and small liquid boluses more easily than large liquid boluses. Congenital structural lesions (eg, choanal atresia, cleft lip and palate, craniofacial syndromes) GERD Childhood achalasia

Physical examination

During the physical examination, look for oralmotor and laryngeal mechanisms. Testing of cranial nerves V and VII-XII is essential for determining physical evidence of oropharyngeal dysphagia. Direct observation of lip closure, jaw closure, chewing and mastication, tongue mobility and strength, palatal and laryngeal elevation, salivation, and oral sensitivity is necessary. Check the patient's level of alertness and cognitive status because they can impact the safety of swallowing Dysphonia and dysarthria are signs of motor dysfunction of the structures involved in oral and pharyngeal swallowing.

Physical examination

Inspect the oral cavity and pharynx for mucosal integrity and dentition. Examine the soft palate for position and symmetry during phonation and at rest. The gag reflex is elicited by stroking the pharyngeal mucosa with a tongue depressor. Cervical auscultation becomes part of the clinical evaluation of dysphagic patients. Assess sound strength and clarity, timing of apneic episode, and speed of swallowing. Assessing respiratory function The final step in physical examination is direct observation of the act of swallowing.

Laboratory evaluation

Obtain a CBC to screen for infectious or inflammatory conditions. Nutritional assessment may aid in determining serum protein and albumin levels. Thyroid function studies may help in detecting dysphagia associated with hypothyroidism or hyperthyroidism.

Imaging studies

Chest radiography is a simple assessment for pneumonia. Ultrasonography depicts only the region of the tongue posterior to the hyoid and may aid in the evaluation of submucosal and extramural lesions of the esophagus. CT and MRI provide excellent definition of structural abnormalities, particularly when used to evaluate patients with suspected CNS causes of dysphagia.

Special studies

Videofluorographic swallowing study Fiberoptic endoscopic examination of swallowing Scintigraphy Reflex cough test Swallowing electromyography Laryngeal EMG Manometry Esophageal pH monitoring Endoscopy

TREATMENT

Management of pediatric dysphagia requires a special approach. Cognitive, developmental, and behavioral issues can affect the treatment options. Treatment does not necessarily imply feeding therapy. Hypoxemia can occur while a child with dysphagia eats, so pulse oximetry during mealtime can be useful.

TREATMENT

Dietary modification

Nutritional supply Hydration Oral hygiene and dental care

Viscosity and texture

TREATMENT
Other techniques

Enteral feeding methods Nasoenteric tube feeding (NGT) Percutaneous endoscopic gastrostomy (PEG) Oroesophageal tube feeding