Dysphagia

Departemen THT-KL
Fakultas Kedokteran
Universitas Padjadjaran
2016
 Introduction
• Definition
– dys·pha·gi·a, dysphagy (dis-fā'jē-ă, dis'fă-jē).
– Dysphagia (from the Greek dys, meaning
with difficulty, and phagia, meaning to eat)
arises when transport of liquid or a bolus of
food along the pharyngoesophageal conduit
is impaired by mechanical obstruction or
neuromuscular failure that disrupts
peristalsis
 Introduction
• Swallowing disorders can occur in all age
groups, resulting from congenital
abnormalities, structural damage, and/or
medical conditions.
• Incidence of dysphagia is higher in
the elderly, in patients who have
had Strokes, and in patients who are admitted
to acute care hospitals or Chronic
care facilities.
Anatomy and Physiology Of
Swallowing
 Swallowing Phase
• Oral Phase
• Pharyngeal Phase
• Esophageal phase
 Nerve suply
 The swallow reflex is a complex neurologic event
involving participation of high cortical centers,
brain stem centers such as the tract of the
nucleus solitarius and nucleus ambiguous, and
cranial nerves V, VII, IX, X, and XII.

 Neurologic deficits in any of these areas can

result in dysphagia.
 Dysphagia Classification
• Oropharyngeal Dysphagia
• Esophageal Dysphagia
 Oropharyngeal Dysphagia
• Abnormality related to the movement of
a food bolus from the hypopharynx to
the esophagus
• Arises from disease of the upper
esophagus, pharynx, or UES.
 Oropharyngeal Dysphagia
• Typically present with difficulty
initiating a swallow and immediately
experience coughing, choking,
gagging, or nasal regurgitation when
attempting to swallow
 Oropharyngeal Dysphagia
• most common caused by disruptions in
swallowing secondary to neuromuscular
dysfunction
• this setting, the symptoms may be more
severe when swallowing liquids
• The history and physical examination
should focus on neurologic signs and
symptoms
 Oropharyngeal Dysphagia
• Etiology
– Neuromuscular
Dysfunction
• Cerebrovascular accidents
 Stroke
• Amyotrophic Lateral
Sclerosis (AML)
• Parkinson's disease
• Myasthenia gravis
• Tardive dyskinesia
 Oropharyngeal Dysphagia
• Etiology
– Rarely, structural
abnormalities caused
such as
♥ cervical
osteophytes
♥ hypopharyngeal
diverticulum
(Zenker's diverticulum)
♥ tumors
♥ postcricoid webs
 Esophageal Dysphagia
• the difficulty in propagating food down the
esophagus
• arises within the body of the esophagus either
due to a mechanical or a motility disturbance.
 Esophageal Dysphagia
• Achalasia
• Nonachalasia Motility Disorders
• Strictures
• Rings/Webs
• Gastroesophageal Reflux Disease
• Extraesophageal GERD
 Esophageal Dysphagia
• Neoplasia
• Esophageal Diverticula
• Foreign Bodies
• Pill-Induced Injury
• Infectious Esophagitis
• Caustic Injury
 Achlasia
• Failure of relaxation of LES
during swallowing due to
degeneration of myenteric
plexus.
• Presentation long standing
dysphagia and regurgitation
• Barium swallow: Dilated
esophagus with a smooth
tapering stricture at its lower
end
• Esophageal manometry:
Synchronous contractions and
failure to relax
• 24 Hour pH measurement:
Confirms reflux
 Esophageal Carcinoma
• EC is increasing in faster
• Squamous cell ca
 Clinical Examination
• Complete Head and neck examination
– Inspection of oral cavity
– Dentition
– Oropharynx
– IDL
– Nasolaryngoscopy
– Cranial nerve examination ( tongue, gag and cough
reflex, hoarseness, vocal cord mobility)
– Neck for lymph nodes, neck masses, thyroid
enlargement, loss of laryngeal crepitus and
integrity of laryngeal cartilages.
 Special Investigations
• Blood tests to exclude anaemia (? Cause or
effect)
• ESR or C-Reactive Protein raised in malignancy
or chronic inflammatory process
• LFT, RFT along with S. Calcium when nutrition
is impaired or metastasis is suspected
• Thyroid function tests if dysphagia is caused
by goiter or malignancy of thyroid
 Special Investigations
• Barium swallow
• Chest radiograph
• CT scan examination of neck, chest and
abdomen.
• MRI is indicated when there are neurological
causes such as multiple sclerosis, cerebral tx,
nasopharyngeal ca.
• Rigid endoscopy
• Flexible endoscopy
• Manometry
 Clinical Examination of Swallow
• Background information
– Active medical problems, therapies, nutrition/hydration status, overall
health status, life expectancy
• Description of the problem
– Onset, duration, frequency, progression, speech
• Clinical observation/mental status exam
– Speech, language, voice status, cognitive status
• Oral mucosa and dentition
• Sensory motor exam of oro-facial structures
• Test swallow observations
– Duration of oral stages, oral residue, cough, self feeding ability
 Instrumental Examination of Swallow
Function
• Videoflurographic swallowing study (VSS)
– AKA: modified barium swallow, cookie swallow test
– Considered to be the “gold standard”
– Allows observation of outline of structures from oral cavity to stomach, this is
a dynamic assessment

• Fiberoptic endoscopic evaluation of swallow (FEES)

– Allows direct observation of structures: nasal cavity, nasopharynx,
oropharynx, larynx, hypopharynx
Videofluoroscopy
FEES (Fiberoptic endoscopic evaluation
of swallow)
 Three Major Goals of Dysphagia
Intervention
• 1. To maintain or improve nutrition and
hydration.
• 2. To prevent or reduce the risk of aspiration.
• 3. To maintain or restore the highest level of
functional ability and maximize quality of life.
 Nutritional Support

Enteral vs. parenteral routes of administration

Long-term vs. short-term use
Complete nutritional replacement vs. partial support
 Possible Benefits of Artificial Feeding

Promotion of healing
Improved resistance to infection
Decreased skin breakdown
Decreased aspiration
Prolonged life

Artificial feeding does not reverse or cure dysphagia

 Key Points
• Age suggests most likely cause of dysphagia
• Globus pharyngeus rarely associated with any
serious disease
• Dysphagia of short duration in elderly patient
who smoke or drink and which progress from
solids to liquids is a classic case of malignancy
• Referred otalgia with dysphagia is a sinister
symptom and poor prognostic sign
 Key Points (2)
• Neurological causes of dysphagia mostly affect
orpharyngeal phase
• Ingested foreign bodies tend to lodge at sites of
constriction
• Barium study is contraindicated in patients with
suspected perforation of oesophagus