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Dysphagia

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Slide 1 :

Dysphagia Evaluation and Management Shashidhar Reddy, MD Matthew W. Ryan, MD November 21, 2001

Slide 2 :

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.

Slide 3 :

Physiology of Swallowing: Oral Phase Pharyngeal Phase

Slide 4 :

Physiology of Swallowing Pharyngeal and Esophageal Phase:

Slide 5 :

Evaluation of Dysphagia History Review of Systems Physical Exam Imaging Studies

Slide 6 :

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

Slide 7 :

Review of Systems: Ask about common systemic processes associated with dysphagia: Tobacco/Alcohol Medications – antihistamines, anticholinergics, antidepressants, antihypertensives Osteoarthritis Systemic neuromuscular disorders Auto-Immune disorders Psychiatric state

Slide 8 :

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

Slide 9 :

Imaging Studies Should be chosen to suit the patient’s symptoms and to confirm a finding.

Slide 10 :

Plain Film Uses: Suspected infectious cause of dysphagia with gross displacement of structures.

Slide 11 :

Plain Film (Epiglottitis)

Slide 12 :

Barium Esophagram Uses: structural disorders, e.g. dysphagia for solid foods. Can use air contrast.

Slide 13 :

Air Contrast Barium Esophagram Normal Fungal Plaques

Slide 14 :

Manometry Uses: disorders in which intraluminal pressures must be measured (achalasia, esophageal spasm, etc.)

Slide 15 :

Manometry

Slide 16 :

Bolus Scintigraphy Uses: follow improvement in a patient with history of aspiration, patient with achalasia.

Slide 17 :

Bolus Scintigraphy

Slide 18 :

Ultrasound Uses: Portable tool for dynamic studies, especially in children

Slide 19 :

Ultrasound

Slide 20 :

Modified Barium Swallow Uses – excellent to evaluate dynamic (e.g. neuromuscular, aspiration) swallow disorders.

Slide 21 :

Modified Barium Swallow Neurogenic Dysphagia Normal Barium Swallow

Slide 22 :

Fiberoptic Endoscopic Evaluation of Swallowing Uses – as a mobile tool that can be used in training patients via biofeedback

Slide 23 :

Fiberoptic Endoscopic Evaluation of Swallowing

Slide 24 :

Disorders that Cause Dysphagia

Slide 25 :

Foreign Bodies

Slide 26 :

Tracheostomy

Slide 27 :

Cricopharyngeal Achalasia

Slide 28 :

Cricopharyngeal Achalasia Cricopharyngeal Myotomy:

Slide 29 :

Zenker’s Diverticulum

Slide 30 :

Zenker’s Diverticulum

Slide 31 :

Cervical Spine Disease

Slide 32 :

Esophageal Webs and Rings

Slide 33 :

Strictures / Caustic Ingestion

Slide 34 :

Achalasia

Slide 35 :

Diffuse Esophageal Spasm

Slide 36 :

Gastroesophageal Reflux Disease

Slide 37 :

Cancer

Slide 38 :

Systemic Disorders that Cause Dysphagia Stroke – present in up to 47% Amyotrophic Lateral Sclerosis Parkinson’s Disease Multiple Sclerosis Muscular Dystrophy Myasthenia Gravis

Slide 39 :

Autoimmune Disorders Systemic Sclerosis Systemic Lupus Erythematosis Dermatomyosits Mixed Connective Tissue Disease Mucosal Pemphigoid, Epidermolysis Bulosa Sjogren’s Syndrome (xerostomia) Rheumatoid Arthritis (cricoarytenoid joint fixation)

Slide 40 :

Aging Dysphagia is present in 2% > 65 Poor dentition Loss of tongue connective tissue Increased pharyngeal transit time

Slide 41 :

Dysphagia in Children Nasal obstruction Oral lesions – clefts, ranulas, mucoceles Laryngomalacia, laryngeal clefts, TE fistula Vascular rings, Foregut malformations Tumors – hemangiomas, lymphangiomas, papillomas, leiomyomas, neurofibromas

Slide 42 :

Globus Hystericus Imagined dysphagia Somatization

Slide 43 :

Case Review 50 year old man presents with 6 month history of progressive dysphagia.

Slide 44 :

Case Report His dysphagia is worse for solid foods. Additionally he notes that he hears gurgling noises when he swallows, and occasionally chokes on his food. When he chokes, he often ends up “vomitting” his food back up. He has lost about 6 lbs over the past 6 months. He drinks socially but gave up tobacco x10yrs

Slide 45 :

Case Report Physical exam reveals a thin white gentleman in no apparent distress. Neck exam reveals nothing unusual. Indirect Laryngoscopy is difficult because of frothy secretions in his hypopharynx and piriform sinus.

Slide 46 :

Case Report Case Report Barium Esophagram

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Stroke – present in up to 47%; Amyotrophic Lateral Sclerosis; Parkinson’s Disease; Multiple Scleros more Stroke – present in up to 47%; Amyotrophic Lateral Sclerosis; Parkinson’s Disease; Multiple Sclerosis; Muscular Dystrophy; Myasthenia Gravis … less