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DYSPHAGIA

DYSPHAGIA. DYSPHAGIA. dys (difficulty, disordered) , phagia (to eat) : sensation of hindered food or liquid in its passage from mouth to the hypopharynx or through the esophagus t o stomach Severe dysphagia can compromise nutrition, cause aspiration, and reduce quality of life

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DYSPHAGIA

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  1. DYSPHAGIA

  2. DYSPHAGIA • dys(difficulty, disordered) , phagia (to eat) : sensation of hindered food or liquid in its passage from mouth to the hypopharynxor through the esophagus to stomach • Severe dysphagia can compromise nutrition, cause aspiration, and reduce quality of life • Oral dysphagia • Pharyngeal dysphagia :Transfer dysphagia • Esophageal dysphagia • Aphagia (inability to swallow) • Odynophagia(mucosal ulceration in oropharynx or esophagus) • Globus pharyngeus(foreign body sensation) • Phagophobia(fear of swallowing)

  3. PATHOPHYSIOLOGY OF DYSPHAG • Swallowing :voluntary (oral) , transfer , esophageal phase • Subclassified: location , circumstances occurs • Oral, Pharyngeal (Oropharyngeal), Esophageal dysphagia • Normal transport (consistency ,size of the bolus, the caliber of the lumen, the integrity of peristaltic contraction, and deglutitive inhibition of both the UES and the LES)

  4. Esophageal dysphagia • Structural dysphagia: oversized bolus or a narrow lumen • Propulsive or motor dysphagia: abnormalities of peristalsis,impaired sphincter relaxation after swallowing • Scleroderma • Radiation therapy

  5. Oropharyngeal Dysphagia • Mouth, hypopharynx, and upper esophagus • Unable to initiate a swallow (food bolus from the hypopharyngealthrough UES into the esophageal body) • Poor bolus formation and control …premature spillage of food into the hypopharynx … aspiration into the trachea or regurgitation into the nasal cavity

  6. Prolonged food retention in oral cavity and may seep out of the mouth , coughing , choking , drooling, recurrent bolus impactions, aspiration , Recurrent pulmonary infection • Oral pathology: poor teeth or poorly fitting dentures, disrupt mastication … large or poorly chewed bolus

  7. Loss of salivation caused by medications, radiation, or primary salivary dysfunction : bolus difficult • Pharyngeal-phase dysphagia … retention of food in the pharynx due to poor tongue or pharyngeal propulsion or obstruction at the UES • Signs and symptoms of concomitant hoarseness or cranial nerve dysfunction may be associated with oropharyngeal dysphagia

  8. Oropharyngeal dysphagia • Neurologic : Parkinson’s disease , ALS , CVA • Structural : Zenker’s diverticulum, cricopharyngeal bar, neoplasia • Iatrogenic : surgery , radiation • Muscular • Infectious • Metabolic • Older adults dysphagia low-amplitude primary or secondary peristaltic activity

  9. Neurogenic dysphagia • Parkinson’s disease , ALS , CVA • major morbidity: aspiration and malnutrition • Medullary nuclei directly innervate the oropharynx (Lateralization of pharyngeal dysphagia : structural pharyngeal lesion or ipsilateralbrainstem nuerologic process)

  10. Structural OropharyngealDysphagia • Zenker’s diverticulum • Cricopharyngeal bar • Neoplasia

  11. Zenker’s diverticulum • Elderly patients, prevalence 1:1000 and 1:10,000 • Pathogenesis : Cricopharyngeus stenosis that causes diminished opening of the UES and results in increased hypopharyngeal pressure during swallowing with development of a pulsion diverticulum immediately above the cricopharyngeus in a region of potential weakness known as Killian’s dehiscence • Dysphagia, regurgitation of food debris, aspiration, halitosis

  12. cricopharyngeal bar • A prominent indentation behind the lower third of the cricoid cartilage, is related to Zenker’s diverticulum in that it involves limited distensibility of the cricopharyngeusand can lead to the formation of a Zenker’s diverticulum. • However, a cricopharyngeal bar is a common radiographic finding, and most patients with transient cricopharyngeal bars are asymptomatic, making it important to rule out alternative etiologies of dysphagia before treatment • Cricopharyngealbars may be secondary to other neuromuscular disorder

  13. Diagnosis • Pharyngeal phase dysphagia: occurs in less than a second, rapid-sequencefluoroscopy • Timing and integrity of pharyngeal contraction and opening of the UES with a swallow are analyzed to assess both aspiration risk and the potential for swallow therapy • The pharynx is examined to detect bolus retention, regurgitation into the nose, or aspiration into the trachea • Structural abnormalities of the oropharynx & biopsies … direct laryngoscopicexamination

  14. Esophageal Dysphagia • The adult esophagus : 18–26 cm and anatomically divided into the cervical , thoracic & abdominal esophagus • When distended, internal lumen about 2 cm in the anteroposteriorplane and 3 cm in the lateral plane • Solid food dysphagia : lumen <13 mm but also can occur with larger diameters in the setting of poorly masticated food or motor dysfunction • Circumferential lesions are more likely to cause dysphagia than partial

  15. The most common structural causes: Schatzki’srings, eosinophilic esophagitis, and peptic strictures , GERD without a stricture(perhaps on the basis of altered esophageal sensation & distensibility), or motor dysfunction • Propulsive disorders: abnormalities of peristalsis and/or deglutitive inhibition, potentially affecting the cervical or thoracic esophagus • Oropharynx and the cervical esophagus striated muscle pathology (oropharyngeal dysphagia)

  16. Diseases affecting smooth muscle involve both the thoracic esophagus and the LES • Absent peristalsis, either the complete absence or nonperistaltic contraction , disordered contractions • Achalasia : absent peristalsis combined with failure of deglutitive LES relaxation(Hyperpressure LES) • Diffuse esophageal spasm (DES): LES function is normal, with the disordered motility restricted to the esophageal body • Scleroderma: absent peristalsis combined with severe weakness of the LES(nonspecific pattern)

  17. APPROACH TO THE PATIENT • History: presumptive diagnosis or at least restricting the differential diagnoses • Key elements: localization, the circumstances of dysphagia ,other symptoms, and progression • Dysphagia that localizes to the suprasternalnotch: oropharyngeal or an distal esophageal • Dysphagia that localizes to the chest is esophageal in origin • Nasal regurgitation and tracheobronchial aspiration manifest by coughing with swallowing are hallmarks of oropharyngeal dysphagia • Severe cough with swallowing may also be a sign of a tracheoesophagealfistula

  18. Hoarseness :important diagnostic clue , precedes dysphagia, the primary lesion is usually laryngeal; after dysphagia may result from compromise of the recurrent laryngeal nerve by a malignancy • The type of food : Intermittent dysphagia with solid food structural dysphagia • Constant dysphagia with liquids and solids: motor abnormality • Progressive Dysphagia : neoplasia

  19. Solids Episodic dysphagia over years :benign disease such as a Schatzki’s ring or eosinophilic esophagitis • Food impaction: inability to pass an ingested bolus even with liquid structural dysphagia • Chest pain & dysphagia: motor disorders, structural disorders, or reflux • Heartburn preceding dysphagia … peptic stricture esophageal….. adenocarcinoma • A history of prolonged nasogastric intubation, esophageal or head and neck surgery, ingestion of caustic agents or pills, previous radiation or chemotherapy, or associated mucocutaneous diseases may help isolate the cause of dysphagia.

  20. With accompanying odynophagia: ulceration, infectious or pill-induced esophagitis • In AIDS or other immunocompromisedstates, esophagitis due to opportunistic infections such as Candida, herpes simplex virus, or cytomegalovirus and to tumors such as Kaposi’s sarcoma and lymphoma • A strong history of atopy :eosinophilic esophagitis

  21. PHYSICAL EXAMINATION Evaluation of oral and pharyngeal • Signs of bulbar or pseudobulbarpalsy: dysarthria, dysphonia, ptosis, tongue atrophy, and hyperactive jaw jerk, in addition to evidence of generalized neuromuscular disease • A careful inspection of the mouth and pharynx should disclose lesions • Missing dentition can interfere with mastication and exacerbate dysphagia • The neck should be examined for thyromegaly

  22. DIAGNOSTIC PROCEDURES • Dysphagia is a cardinal symptom of several malignancies, an important symptom • Cancer may result in dysphagia due to intraluminal obstruction(esophageal or proximal gastric cancer, metastatic deposits), extrinsic compression (lymphoma, lung cancer), or paraneoplasticsyndromes

  23. Fluoroscopic swallow in oral or pharyngeal dysphagia • Otolaryngoscopic and neurologic evaluation • Upper endoscopy : esophageal dysphagia • Endoscopy allows better visualization of mucosal lesions than does barium radiography and also allows one to obtain mucosal biopsies , Schatzki ring, GERD , Eo.Eso • Furthermore, therapeutic intervention with esophageal dilation

  24. Eosinophilic esophagitis(dysphagia in both children and adults) esophageal mucosal biopsies • Endoscopy in esophageal motility disorders: initial evaluation… neoplastic and inflammatory conditions • Esophageal manometry :not adequately explained by endoscopy or suspected esophageal motor disorder • Barium radiography : esophageal strictures, prior esophageal surgery, esophageal diverticula or paraesophagealherniation • In specific cases : CT and EUS may be useful.

  25. TREATMENT • Treatment depends on both the locus and the specific etiology • Oropharyngeal dysphagia from functional deficits neurologic disorders …. treatment focuses on utilizing postures or maneuvers devised to reduce pharyngeal residue and enhance airway protection learned under the direction of a trained swallow therapist. • Aspiration risk may be reduced by altering the consistency of ingested food and liquid • Dysphagia due to CVA usually spontaneously improves within the first few weeks • More severe and persistent : gastrostomy and enteral feeding

  26. Myasthenia gravis and polymyositismedical treatment • Surgical intervention with cricopharyngeal myotomyis not helpful, exception of specific disorders, cricopharyngeal bar, Zenker’s diverticulum, and oculopharyngeal muscular dystrophy • Chronic neurologic disorders ,Parkinson’s disease, and ALS (severe oropharyngealdysphagia):NG tube or an endoscopically placed gastrostomy tube …..these maneuvers do not provide protection against aspiration of salivary secretions or refluxed gastric contents.

  27. Esophageal dysphagia :esophageal dilatation using bougie or balloon dilators • Cancer and achalasia : surgically or endoscopic techniques (palliation and primary therapy) • Infectious etiologies : antimicrobial medications or treatment of the underlying immunosuppressive state • Eosinophilicesophagitis : treatment by elimination of dietary allergens or administration of swallowed, topically acting glucocorticoids , dillation

  28. STRUCTURAL DISORDERS • HIATAL HERNIA: sliding ,paraesophageal • RINGS AND WEBS • DIVERTICULA • TUMORS

  29. CONGENITAL ANOMALIES • Esophageal Atresia • Congenital esophageal stenosis, webs, duplications • Inlet patch (Heterotopic gastric mucosa)

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