Dysphagia

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Dysphagia
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Objectives

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

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Normal physiology

• 4 stage
• Oral preparatory stage
• Oral stage
• Pharyngeal stage
• Esophageal stage

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Normal physiology
Oral preparatory stage

• Prepare food for swallow
• Mechanism of action
• 1.lip closure to hold food in mouth anteriorly
• 2.tension in labialbuccal musculature to close
  AntLat sulci
• 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

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Oral preparatory stage
1.Muscle of facial expression (VII) oral
sphincter

• Buccinator compress lip_at_flatten cheek

• Orbicularis oris sphincter of lip

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Oral preparatory stage
2.Muscle of mastication (V) jaw movement

• Lateral pterygoid open_at_grinding

• Temporalis open_at_A/P move

• Masseter close jaw

• Medial pterygoid close_at_grinding

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Oral preparatory stage
3.Tongue muscle

• Palatoglossus(X) down soft palate_at_up BOT

• Genioglossus(XII) elevate BOT

• Hyoglossus(XII) -- depress

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Oral preparatory stage

• Time depend on type of food

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Normal physiology
Oral stage

• Move food from front oral cavity to
  pharynx
• Mechanism of action
• 1.Upwardbackward by midline Lat
• margin of tongue most important
• 2.Backward by tension in
• buccal musculature
• 3.trigger swallowing reflex
• (locate at anterior pillar)

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Oral stage
swallow

• buccal musculature
• tongue

• Styloglossus muscle

• Hyoglossus muscle

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Oral stage
swallow
trigger zone at anterior pillar
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Oral stage
swallow
CN IX
trigger swallowing reflex sensory impulse at CN
IX
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Oral stage
swallow
Tractus solitarius nucleus/ Solitary tract nucleus
trigger swalling reflex sensory impulse at CN IX
( Sup. Laryngeal nerve)
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Oral stage
swallow
nucleus ambiguus
CN X
nucleus ambiguus to motor neuron of CN X at
pharynx
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Oral stage
swallow
nucleus ambiguus
nucleus ambiguus to motor neuron of CN X at
pharynx
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Oral stage

• Time take 1 second

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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)

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Pharyngeal stage
swallow

• 1.tongue

• Styloglossus muscle

• Hyoglossus muscle

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Pharyngeal stage
swallow

• 2.Levator _at_ Tensor palatini

• Levator palatini

• Tensor palatini

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Pharyngeal stage
swallow

• 3.pharyngeal constrictor muscle

• Superior

• Middle

• Inferior

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Pharyngeal stage
swallow

• 4.aryepiglottic fold/true vocal fold /false
  vocal fold

• AEF

• FVF/TVF

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er
Pharyngeal stage

• Time take less than 1 second
• (not vary with age and gender)

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Esophageal stage

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

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Esophageal stage

• Time take 8 to 20 seconds
• (depend on food influence by
• peristalsisgravity)

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Dysphagia
History

• 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

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Dysphagia
History

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

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Dysphagia
History

• Hx. Of radiation
• Medications
• In children
• Feeding
• Growth
• Development

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Dysphagia
Physical examination

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

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Dysphagia
Investigation

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

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Dysphagia
Fluoroscopy

• Barium swallow
• conventional barium swallow
• modified barium swallow

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Dysphagia
Fluoroscopy

• 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

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Dysphagia
Fluoroscopy

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

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Dysphagia
Fluoroscopy

• Modified barium swallow
• Purpose restore oral intake as quickly
• 1.define oralpharyngeal 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)

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Dysphagia
Fluoroscopy

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

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Dysphagia
Fluoroscopy
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Dysphagia

• Achalasia(failure to relax) (bird's beak
  appearance)

• AContrast penetrate laryngeal vestibule within
  boundary of vocal cord
• Baspirate tracheobronchial tree

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Dysphagia
Endoscope

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

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Dysphagia
Manometry

• 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

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Dysphagia
Ultrasonography

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

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Dysphagia
Other investigate

• Plain film film lateral neck(soft tissue
  technique) -- FB,Infection
• CT/MRI
• 24 hrs.pH monitoring ?????????????????????????
  ?????????? pHlt4 ??????????????????????????? 5 cm
  ??????? 1 hr./???

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Dysphagia
Other investigate

• 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

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The end