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D y s p h a g i a

D y s p h a g i a. นพ.โกสินทร์ ชัยชำนาญ Ent. Objectives. Normal physiology Dysphagia Definition Cause and classification History taking,physical examination and investigation Disease. Normal physiology. 4 stage Oral preparatory stage Oral stage Pharyngeal stage Esophageal stage.

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D y s p h a g i a

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  1. Dysphagia นพ.โกสินทร์ ชัยชำนาญ Ent

  2. Objectives • Normal physiology • Dysphagia • Definition • Cause and classification • History taking,physical examination and investigation • Disease

  3. Normal physiology • 4 stage • Oral preparatory stage • Oral stage • Pharyngeal stage • Esophageal stage

  4. Normal physiology Oral preparatory stage • Prepare food for swallow • Mechanism of action • 1.lip closure to hold food in mouth anteriorly • 2.tension in labial&buccal musculature to close Ant&Latsulci • 3.rotatory motion of jaw for chewing • 4.lateral rolling motion of tongue position food on teeth during mastication – most important • 5.bulging forward of soft palate to seal oral cavity posterior and widen nasal airway

  5. Oral preparatory stage 1.Muscle of facial expression (VII) –oral sphincter • Orbicularisoris – sphincter of lip • Buccinator – compress lip@flatten cheek

  6. Oral preparatory stage 2.Muscle of mastication (V) – jaw movement • Lateral pterygoid – open@grinding • Temporalis – open@A/P move • Masseter – close jaw • Medial pterygoid – close@grinding

  7. Oral preparatory stage y 3.Tongue muscle • Palatoglossus(X) – down soft palate@up BOT • Genioglossus(XII) – elevate BOT • Hyoglossus(XII) -- depress

  8. Oral preparatory stage er Time : depend on type of food

  9. Normal physiology • Move food from front oral cavity to pharynx • Mechanism of action • 1.Upward&backward by midline& Lat margin of tongue –most important • 2.Backward by tension in buccal musculature • 3.trigger swallowing reflex (locate at anterior pillar) Oral stage

  10. Oral stage • buccal musculature • tongue swallow • Styloglossus muscle • Hyoglossus muscle

  11. Oral stage swallow trigger zone at anterior pillar

  12. Oral stage ri swallow CN IX triggerswallowing reflex sensory impulse at CN IX

  13. Oral stage swallow Tractus solitarius nucleus/ Solitary tract nucleus triggerswalling reflex sensory impulse at CN IX (& Sup. Laryngeal nerve)

  14. Oral stage swallow nucleus ambiguus CN X nucleus ambiguus to motor neuron ofCN X atpharynx

  15. Oral stage swallow nucleus ambiguus nucleus ambiguus to motor neuron ofCN X at pharynx

  16. Oral stage er Time : take 1 second

  17. Pharyngeal stage • Move food from pharynx to esophagus • Mechanism of action • 1.velopharyngeal closure (prevent backflow of material up nose) • 2.tongue base retraction (propel bolus through pharynx) • 3.pharynx contraction (clear redisue through pharynx) • 4.larynx elevate and closure (airway protection) • 5.cricopharyngeal opening (allow bolus to pass into esophagus)

  18. t

  19. Pharyngeal stage • 1.tongue swallow • Styloglossus muscle • Hyoglossus muscle

  20. Pharyngeal stage swallow • 2.Levator @ Tensor palatini • Levatorpalatini • Tensor palatini

  21. Pharyngeal stage swallow • 3.pharyngeal constrictor muscle • Superior • Middle • Inferior

  22. Pharyngeal stage swallow • 4.aryepiglottic fold/true vocal fold /false vocal fold • AEF • FVF/TVF

  23. Pharyngeal stage er Time : take less than 1 second (not vary with age and gender)

  24. Esophageal stage • Close UES • Body of esophagus • Outer -> longitudinal ,Inner -> circular • Peristalsis • primary peristalsis : • upper 1/3 striated & transitional zone • mix voluntary & involuntary • secondary peristalsis : • lower 2/3 smooth • Involuntary • Open LES

  25. Esophageal stage er Time : take 8 to 20 seconds (depend on food influence by peristalsis&gravity)

  26. Dysphagia • Onset & Site • Cough or choke or food coming back through your nose • Liquid or solid or both • Liquid and solid motility disorder • Solid progress to liquid benign or malignant stricture • Progression History

  27. Dysphagia • Other symptoms • Loss of appetite,weight loss ,N/V regurgitation,heart burn,weakness, hematemesis,pain • Medical problems • DM, HT, cancer • Hx. Of surgery History

  28. Dysphagia • Hx. Of radiation • Medications • In children • Feeding • Growth • Development History

  29. Dysphagia • Complete examination • Head and neck • Mass • Thyroid • Lymph node • Salivary gland • Oral mucosa • Gag reflex, Cough reflex Physical examination

  30. Dysphagia • Procedure to evaluate -- major • 1.Fluoroscopy • 2.Endoscopy • 3.Manometry • 4.Ultrasonography Investigation

  31. Dysphagia • Barium swallow • conventional barium swallow • modified barium swallow Fluoroscopy

  32. Dysphagia • Modified barium swallow • Gold standard • Examine oral cavity & pharyngeal swallowing • Ba(1/3 teaspoon per swallow) & vary food consistency • Seated upright in normal eating position Fluoroscopy

  33. Dysphagia • Modified barium swallow • View in lat. plane with fluoroscope tube • Focus on lips & C7th Fluoroscopy

  34. Dysphagia • Modified barium swallow • Purpose restore oral intake as quickly • 1.define oral&pharyngeal disorder during swallow • 2.identify aspiration of any food consistency • 3.assess speed of swallow to determine adequate nutrition • 4.assess effect of Tx eg.postural change ,heightened sensory input ,Tx procedure (swallowing maneuvers) Fluoroscopy

  35. Dysphagia • convention barium swallow • Examine anatomy & motility esophagus • Ba(a cup of barium)(250 cc)swallow repeatedly • Lies in supine position • View in anteroposterior plane Fluoroscopy

  36. Dysphagia Fluoroscopy

  37. Dysphagia • Achalasia(failure to relax)(bird's beak appearance) • A:Contrast penetrate laryngeal vestibule within boundary of vocal cord • B:aspirate tracheobronchial tree

  38. Dysphagia • Via transnasal placement of flexible fiberoptic scope • Can not examine oral stage & during swallow • May be identified residual food in pharynx after swallow Endoscope

  39. Dysphagia • Used examine esophageal peristalsis & function of UES & LES • Swallow soft tube contain 3 pressure sensor • First register --- UES • Second register – body of esophagus • Third register – pressure in LES • No information on aspirate or function in oral cavity or larynx Manometry

  40. Dysphagia • Used assess anatomy & physiology of tongue during swallowing (oral stage ) • Can not examine pharynx or larynx because of skeletal interference Ultrasonography

  41. Dysphagia • Plain film : film lateral neck(soft tissue technique) -- FB,Infection • CT/MRI • 24 hrs.pH monitoring วัดภาวะกรดด่างในหลอดอาหาร คนปกติจะมี pH<4 ที่เหนือกล้ามเนื้อหูรูดล่าง 5 cm ไม่เกิน 1 hr./วัน Other investigate

  42. Dysphagia • Scintigraphy • Nuclear medicine test • Swallow several selected bolus of radioactive material • Gamma camera detect amount radiation passing • Oropharyngeal anatomy not visible • Aspiration – two trial material swallows • One to esophagus • Another to airway Other investigate

  43. The end…

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