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DYSPHAGIA

Dept of Otorhinolaryngology – Head & Neck Surgery

Padjadjaran University Medical School

Hasan Sadikin General Hospital

Bandung

Nur Akbar A.

Mini Lecture

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ANATOMY ESOPHAGUS

• • Neuromuscular tube• Segment - Upper third I - Middle third II - Lower third III• Natural constriction - Cricopharyngeus - Aorta & left bronchus anteriorly cross - Lower Esophageal Sphincter

Adapted from www.barrettsinfo.com. 2002

ANATOMY ESOPHAGUS

I

II

III

I = Inferior thyroidII = Thoracic aortaIII = Left gastric, left inferior phrenic

Adapted from Graney OD. Anatomy Esophagus. In: Otolaryngology-Head and Neck Surgery. Vol 3. 2 nd. Ed. Cumming CW. Mosby year book. 1993.

VASCULARIZATIONVASCULARIZATION

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HISTOLOGY ESOPHAGUS

Layers of the Esophagus

• Outer musculer• Middle submucosa• Inner mucosal

Adapted from www.barrettsinfo.com. 2002

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HISTOLOGY ESOPHAGUS

The Esophageal Mucosal Layer

**

*

Adapted from www.barrettsinfo.com. 2002

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ANATOMY AND PHYSIOLOGY OF DEGLUTITION

Oropharyngeal Stage Contraction the tongue and masticator Mix the food bolus with saliva Propel it from the anterior oral cavity into the OP Trigger the involuntary swallowing reflex The motor tract N. V, VII, XII One second Posterior OP muscular contractions to relax Soft palate elevates to close NP Epiglottis moves downward cover the airway Pharyngeal muscle contraction to move food bolus past the cricopharyngeus muscle One second The motor and sensory tract. N. IX, X

ANATOMY AND PHYSIOLOGY OF DEGLUTITION

The tongue initially forms the food bolus (green) with compression against the hard palate.

Displacement of the food bolus into the pharynx by the tongue initiates deglutition.

Relaxation of the cricopharyngeal muscle (the physiological upper esophageal sphincter) permits movement of the food bolus into the proximal esophagus. FIGURE 1.

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ANATOMY AND PHYSIOLOGY OF DEGLUTITION

Esophageal Stage

• Involuntary contraction muscle the upper esophagus • Force bolus through the mid and distal esophagus • The medulla controls the involuntary swallowing reflex• LES relaxes• 8 to 20 seconds

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TABLE 1. Differential Diagnosis of Dysphagia

Diseases of the central nervous system - Cerebrovascular accident - Parkinson diseases - Brain stem tumors - Degenerative diseases - Amyotrophic lateral sclerosis - Multiple sclerosis - Huntington’s diseases - Poliomyelitis - Syphilis

Diseases of the peripheral nervous system - Peripheral neuropathy - Motor end plate dysfunction - Myasthenia gravis - Myopathies - Polymyositis - Muscular dysthropy

NE

URO

MUSCULA

R

OBSTRUCTIVE

- Tumors- Inflammatory masses- Trauma / surgical resection- Zenker’s diverticulum- Extrinsic structural lesions- Anterior mediastinal masses - Cervical spondylosis

OROPHARYNGEAL

DYSPHAGIA

Reproduced with permission from Castell DO.Approach to the patients with dysphagia. In: Yamada T, ed. Textbook of gastroenterology. 2d ed.Philadelpia: Lippincott William & Wilkins, 1995.

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Intrinsic structural lesions - Tumors - Strictures - Peptic - Radiation induced - Chemical induced - Medication induced - Lower esophageal rings (Schatzki’s rings) - Esophageal webs - Foreign bodies

Extrinsic structural lesions - Vascular compression - Enlarge aorta or left atrium - Aberrant vessels - Mediastinal masses - Lymphadenopathy - Substernal thyroid

OBSTRUCTIV

E

NE

UROMUSCULAR

- Achalasia

- Spastic motor disorders : Diffuse esophageal spasm

Hypertensive LES

Nutcrackers esophagus

- Scleroderma

ESOPHAGEAL

DYSPHAGIA

Reproduced with permission from Castell DO.Approach to the patients with dysphagia. In: Yamada T, ed. Textbook of gastroenterology. 2d ed.Philadelpia: Lippincott William & Wilkins, 1995.

TABLE 1. Differential Diagnosis of Dysphagia

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HISTORY

Coughing or choking or the abnormal sensation of food sticking in the back of the throat or upper chest when they are trying to swallow The onset, duration and severity Variety of associated symptoms Wet voice, drooling, breathy voice Long term illnesses, prescribed medications, alcohol & tobacco use Patient history should answer two general questions : (1) Is the oropharyngeal or esophageal dysphagia ? (2) Is it caused by mechanical obstruction or neuromuscular motility disorder ?

PHYSICAL EXAMINATION

Neurologic evaluation - Mental status - Motor & sensory functioning - Deep tendon reflex - Cranial nerve : Motor N. V, VII, IX, X and XII Sensory N. V, VII, IX and X - Cerebellar examination - Decreased gag reflex Increased risk aspiration - “Wet voice” long term laryngeal aspiration Evaluated NPOP - Adequate saliva production - Indirect inspection of the soft palate & VC mobility - Nasopharyngoscopy - Bimanual palpation (the mouth, tongue, and lips) - Evaluation the teeth

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Observing the patients swallowing - Control to chew food - Mix food bolus with saliva - Propel bolus to the posterior pharynx choking or coughing - Elevation of the larynx cephalad Thyroid masses and lymphadenopathy obstructive dysphagia Chest and abdomen COPD Masses Organomegaly

PHYSICAL EXAMINATION

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LABORATORY EVALUATION

Limited to specific studies based on History and Physical Examination

Complete blood count screens Infection or Inflammatory

Stools : occult bleeding

SPECIAL STUDIES

Plain X-Ray Studies- Neck Soft Tissue AP & Lateral

Barium StudiesEndoscopy - Rigid and FlexibleVideoradiographic Studies Manometry pH MonitoringOther Imaging Techniques

- Plain radiographic chest or neck - USG - CT scan - Radionuclide studies - MRI scan

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MANOMETRY

90% Esophageal diseases Symptoms: Heartburn, epigastric & retrosternal pain After meal (20 minutes to 2 hours), nausea, vomiting, dysphagia, hoarseness Precipitating factor : Fatty, spicy food or large meal, postural changes Mechanism : - Incompetence of LES - Decreases Esophageal clearance (gravity, peristaltic, salivation) - Increases Gastric volume - Delayed gastric emptying - Tissue resistance Test : pH monitor, barium swallow, endoscopy

GASTROESOPHAGEAL REFLUX DISEASE (GERD)

Treatment

- Elevate the head of the bed

- Weight reduction

- Avoiding chocolate, fat, peppermint,

cigarettes, coffee

- Smaller meals

- Medications

- Surgery Complications GERD

- Erosive, stricture, ulceration esophagus

- Hemorrhage

- Respiratory disorder

- Posterior laryngitis

- Carcinoma

GASTROESOPHAGEAL REFLUX DISEASE (GERD)

G E R D

ACHALASIA

Neuromuscular disorder degeneration ganglion cells Aurbach’s plexus Pathophysiology : Aperistaltic, esophageal dilatation, failure LES to relaxSymptoms: Intermittent dysphagia, slowly progressive, chest & epigastric pain, regurgitation, cough, aspiration Ages 30 – 70 Test : Esophagogram, esophagoscopy Treatment : Dietary habits, medications, dilatation, surgery

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ACHALASIA

Contrast Esophagogram demonstratesA massive dilatation associated with achalasia

Adapted from Shockley W., Jewet BS.Esophageal Disorder. In: Head & NeckSurgery-Otolaryngology. 2nd. Ed: Bailey BJ.Lippincot-Raven.1998.781-800

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ESOPHAGEAL WEBS & RINGS

Webs Thin membrane (mucosa, submucosa) Rings Thicker (mucosa, submucosa, muscularis) Symptoms : Solid food dysphagia, Heartburn Location : - Cervical esophageal webs post cricoid region - Mid or lower esophageal webs Single or multiple - Lower esophageal ring (Schatzki’s ring) Squamocolumnar junction, asymptomatic or intermittent dysphagia Test : Barium swallow, esophagoscopy, videoradiography Treatment : Endoscopic rupture, dilatation

Schatzki’s ring

Multiple webs

Adapted from www.barrettsinfo.com. 2002

DIFUSSE ESOPHAGEAL SPASM

Relatively rare Uncoordinated esophageal Peristaltic Unknown etiology Symptoms : - Intermittent dysphagia (severe liquids than solids) - Chest pain - Emotional stress Test : - Barium swallow “Corkscrew pattern” - Esophagoscopy - Manometry Treatment : - Medicamentous - Surgery

ESOPHAGEAL DIVERTICULUM

Definition : Pouch or sac Herniation mucous membrane through the muscular wall True All layers False or pseudoverticulum Mucosa, submucosa Anatomic location : - Pharyngoesophageal (Zenker’s) - Mid-esophageal or mid-thoracic - Epiphrenic Symptom : - Long standing dysphagia of insidious onset - Spontaneous regurgitation - Symptom aspiration Type : Pulsion diverticulum & traction diverticulum Zenker’s diverticulum : - Pseudodiverticulum, Pulsion type - Herniation muscular weakness (Killian’s dehiscence) Lower inferior constrictor fibers – cricopharyngeus muscle - Mechanism development : increased intraluminal pressure, incoordination relaxation cricopharyngeus, premature contraction cricopharyngeus

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ESOPHAGEAL DIVERTICULUMZenker’s diverticulum

Adapted from Stell PM, Bowdler DA. Surgery for diseses of the hypopharynx. In: Head and Neck Surgery. Vol. 3.Ed. Panje WR, Heberhold C.Thieme Medical Pub. New York. 1998.

ESOPHAGEAL DIVERTICULUM

Test : Barium swallow, esophagoscopy Management : - Observation Asymptomatic - Surgery

Adapted from www.barrettsinfo.com. 2002

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BENIGN TUMORS AND CYST

Relatively rare Classified Tumor : Intramural, Extramural, Intraluminal Symptom : Asymptomatic until significantly enlarge Disorders:

Leiomyoma : - Most common benign tumor Cyst Polyps

Treatment : - Endoscopic removal - Surgical excision

ESOPHAGEAL CARCINOMA

1% all cancer Deadly disease, 3 years survival rate 11% History consumption heavy tobacco and alcohol Symptom : - Painless dysphagia ( duration 3-4 month ) - Odynophagia, weigh loss, anemia, hemorrhage, aspiration pneumonia, VC paralysis, cervical adenopathy Squamous cell carcinoma >> Test : - Chest radiographic - Esophagogram - Esophagoscopy

Treatment : - Resectable surgery, radiotherapy, chemotheraphy - Unresectable Chemoiradiation

- Brush cytology & biopsy- Endoscopic ultrasonography - CT scan chest & abdomen

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ESOPHAGEAL CARCINOMA

Adapted from www.barrettsinfo.com. 2002

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INFLAMMATORY CONDITIONS(ESOPHAGITIS)

Inflammation process Etiology : Agents physical, chemical, infectious Common cause: GERD Immunosuppressive patient opportunistic infection (Candida esophagitis) All age, rare children Symptoms : - Fever - Painful dysphagia - Weigh loss Treatment : Underlying diseases process

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Candida Esophagitis

Herpes Esophagitis

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Caustic Ingestion/ Esophageal Burns

• Rare

• Common Agents:– Alkali (pH>7): lime, laundry detergents– Corrosives or acids (pH<7): toilet bowl

cleaner, battery fluid, sulfuric acid– Bleaches (pH=7): sodium hypochlorite

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• Clinical Presentation– Dysphagia, retrosternal pain, abdominal

pain esophageal injuries– Hoarseness & Stridor supraglotic or

glottic edema, or tracheal injury– Endoscopy within first 24-48 hours

Caustic Ingestion/ Esophageal Burns

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• Treatment:– Diluting Agents: milk or water (neutral

buffer)• No more than 15 ml/kg body weight

– Steroid– Antibiotics– Dilatation

Caustic Ingestion/ Esophageal Burns

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Foreign Bodies

• Most common 2-4 years of age• Boys : Girls = 2:1• Stucked in the narrow places of

esophagus• Diagnosis:

– Anamnesis: history of ingestion of foreign body

– Symptom: vomiting, dysphagia– Ancillary Test: X-ray

• Treatment:– Extraction via endoscopy

Foreign body in Esophagus

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Foreign Bodies

Coins in the Esophagus

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Foreign Bodies

Metal Clip in theEsophagus

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