Dysphagia

A&K

Dysphagia

1. Anatomy of oropharynx and hypopharynx

2. Physiology of swallowing

3. Causes of dysphagia

4. Investigation

5. Management

Anatomy of oropharynx

and hypopharynx

Anatomy of pharynx

3 parts:

1.Nasopharynx:

• From the posterior nasal apertures to the nasopharyngeal isthmus

2.Oropharynx:

• Nasopharyngygeal isthmus to the upper border of epiglottis

3.Laryngopharynx:

• From upper border of epiglottis to lower border of cricoid cartilage

Oropharynx

• Middle part of the pharynx behind oral cavity

Communicates with:

• Nasopharynx through nasopharyngeal (pharyngeal) isthmus

• Oral cavity through the oropharyngeal isthmus (isthmus of fauces)

• Laryngopharynx at the level of upper border of epiglottis

“Isthmus of fauces = limit between the mouth cavity proper with the pharynx marked by constricted aperture Palatopharyngeal and palatoglossal arches”

Lateral wall

• Presence of palatine tonsil which lies in the palatine fossa

• Posteriorly the wall is formed by the:

1.Superior constrictor of pharynx

2.Middle constrictor of pharynx

3.Inferior constrictor of pharynx

Laryngopharynx

• Lowest part

• Situated behind the larynx

• Extend from upper border of epiglottis to lower border of cricoid cartilage

• 3 walls:

1.Anterior wall

2.Lateral wall

3.Posterior wall

Wall Structure

Anterior • Laryngeal inlet

• Posterior surface of cricoid and

arytenoid cartilage

Lateral • Piriform fossa:

-On each side of laryngeal inlet

-Boundaries:

Medially: aryepiglottic fold

Laterally: thyroid cartilage &

thyrohyoid membrane

Posterior • Formed by contrictor muscles

-superior constrictor m.

-middle contrictor m.

-inferior constrictor m.

Oesophagus• Fibromuscular tube

• Length: 25cm

Begins from:

-Below laryngopharynx

-Cricoid cartilage

-At level C6 vertebra

Ends at:

-Cardiac orifice of stomach

-Left 7th costal cartilage

-At T10 vertebrae

• 3 parts

-cervical

-thoracic

-abdominal

Physiology of swallowing

Deglutition

• Deglutition

-phases

-control of esophageal motility

• Salivary glands-cell types

-composition of saliva

-regulation of saliva secretion

Deglutition

• Swallowing

• A mechanism that moves food or liquid from the mouth through the pharynx and esophagus into the stomach .

• is facilitated by the secretion of saliva and mucus.

• Normal deglutition is a smooth coordinated process that involves a complex series of voluntary and involuntary neuromuscular contractions and typically is divided into three distinct phases:

1)Oral

2)Pharyngeal

3)Esophageal

Oral phase

Pharyngeal phase

Esophageal phase

Phase Activity

Oral Voluntary • Food rolled into the bolus

• Tongue arches to push bolus backwards into the

oropharynx

Pharyngeal Involuntary • Elevation of the soft palate to close nasopharyngeal

passage

• Pressure of the food on the pharyngeal wall

stimulates mechanoreceptor to inhibit breathing

• Raise larynx and close glottis

• Passage of bolus downwards ,epiglottis seals off

larynx

• Wave of contraction sweep the pharyngeal muscles ,

bolus moves into esophageal sphincter

Esophageal involuntary • Reflex relaxation of UES

• Sphincter closes when bolus has passed through

• Glottic opens, breathing resumes

• Peristaltic wave moves the bolus forward

• LES relaxes through action of vasointestine peptide

hormone

• Allow entry of bolus into the stomach

Causes of dysphagia

Dysphagia

Dysphagia

• Difficulty in swallowing

• Sensation of obstruction of passage of food bolus through the pharynx and oesophaguswithin 15 seconds of bolus leaving the mouth

• Odynophagia Pain with deglutition

Globus pharyngeus

• Sensation of lump or tightness in throat with no organic causes

• Hypothesis• GERD• Oesophageal Dysmotility• Psychogenic origin

• Common in middle age, no sex preponderance

• No true dysphagia, no weight loss, continual need to swallow

Presbyphagia

• Physiological changes that occurs in deglutition with ageing

• Reduction in muscle mass and strength

• Resulting in chronic dysphagia a/w malnutrition and aspiration

• Manage by modifying consistency of food and swallowing therapy

• Commonly affect the oesophageal phase and its location involved is usually oesophagus

Laryngopharyngeal Reflux (LPR) vs GERD

LPR GERD

Has laryngeal scarring, odynophagia Has heartburn, chest pain

Daytime / Upright Refluxer Nocturnal / Supination Refluxer

Normal Oesophageal Motility Oesophageal dysmotility

Normal gastric acid clearance Prolonged gastric acid clearance

Not associated with oesophagitis Associated with oesophagitis

Primary Defect is Upper

Oesophageal Sphincter

Primary Defect is Lower

Oesophageal Sphicter

Increased risk of upper aerodigestive

tract cancer

Increased risk of oesophageal

cancer

Has globus pharyngeus Has retching and regurgitative

sensation

Laryngopharyngeal Reflux (LPR) vs GERD

Classification of dysphagia

• Oropharyngeal Dysphagia

• Oesophageal Dysphagia

Oropharyngeal Dysphagia

- Difficulty initiating deglutition

- Associated with coughing, choking, regurgitation, aspiration, sensation of food in the pharynx

- Pathological site- Oropharynx

- Oral dysfunction signs- Drooling of saliva- Hypersalivation (Sialorrhea)

- [Reason: compensatory mechanism for dysphagia]- Piecemeal swallow

- Pharyngeal dysfunction signs- Coughing- Choking- Regurgitation

Xerostomia

• Dry mouth

• Hyposalivation

• Causes dysphagia and difficulty in proper pronounciation

• Advise for regular drinking of water

Causes of Xerostomia

1. Physiologic (Sleep, Age, Dehydrated, Anxiety)

2. Radiotherapy

3. Trauma to salivary glands

4. Drug/Toxic induced

- Anticholinergic, diuretics and sympathomimetics

- Alcohol

5. Sjögren's syndrome

6. Systemic causes

- DM, Hyperparathyroidism, Renal Failure

Acute Tonsilitis

• Inflammation of tonsils

• Can cause narrowing if too enlarge and can obstruct food bolus going down

• Irritation by the food cause odynophagia

• Diagnosed by tonsillar surface swab

• Treatment includes pain relief (PCM), preventing further inflammation (NSAIDs) and antibiotic treatment.

• Tonsillectomy in indicated cases.

Acute Epiglottitis

• Inflammation of supraglottic region of the oropharynx (epiglottis, arytenoid, aryepiglottic folds)

• Food bolus going down the pharynx can irritate the epiglottis and can cause odynophagia

• Manage by intubating to protect airway, cricothyroidotomy in severe cases.

Malignancy of Oropharynx and Hypopharynx

Oropharynx

Tonsils, base of tongue, soft palate, posterior pharyngeal wall to hyoid bone level

Hypopharynx

From hyoid bone level to inferior border of cricoid cartilage, including piriform fossae, posterior pharyngeal wall, postcricoid region

Malignancy of Oropharynx and Hypopharynx

Squamous cell carcinomas are the most common neoplasm.

• Progressive dysphagia

• Weight loss

• Vocal cord palsy Dysphonia

• Aspiration

• Referred Otalgia

• Neck metastasis

• Airway compromise

• Can be painless in oropharynx

Malignancy of Oropharynx and Hypopharynx• Investigation

• Rigid endoscopy under GA (Map tumour extend)• CT Neck and Chest• MRI Neck and Chest

• ManagementNon Invasive• Nutritional and diet control• Swallowing therapy• Nasogastric tube insertion for nutritional supply• Gastrostomy for cases unable to apply NGTInvasive• Surgery or• Laser therapy• Concurrent chemoradiotherapy

Pharyngeal pouch

• AKA Zenker’s Diverticulum

• Natural weakness in posterior aspect of

hypopharynx between the fibres of

thyropharyngeus and cricopharyngeus of

inferior pharyngeal constrictor.

• Pulsion diverticula form at the area with least

support, at Killian’s dehiscence.

Pharyngeal pouch

• Signs and symptoms• Progressive dysphagia

• Weight loss

• Regurgitation of undigested food (in the pouch)

• Halitosis

• Coughing

• Gurgling sound during swallowing on neck

• X-Ray Finding• Rising Tide sign

Management• Small – Observe

• Large – Endoscopic Stapling

• Large and difficult to staple – Excise pouch

Oesophageal Dysphagia

- Difficulty swallowing several seconds afterinitiating first swallow

- Associated with sensation of food stuck in oesophagus

- Pathological site- Oesophagus body

- Lower oesophageal sphincter

- Cardia of the stomach

Oesophageal Dysphagia

- Intrinsic (Mechanical)

- Extrinsic (Compressive)

- Motility Disorder

Intrinsic (Mechanical)

- Reflux induced stricture

- Oesophageal carcinoma

- Oesophageal diverticulitis

- Foreign body

Extrinsic (Compressive)

- Mediastinal Tumour

- Vascular Compression 2˚ Hypertension

- Cervical Osteophytes

Oesophageal Motility Disorders

- Achalasia

- Oesophageal Spasm

- Lower Oesophageal Sphincter Malfunction

- Gastroesophageal Reflux Disorder (GERD)

Oesophageal Achalasia

• Due to impaired oesophageal peristalsis and

lack of lower oesophageal sphincter relaxation

during deglutition

• Common in 20 – 60 years old

• Dysphagia affect both solid and liquid food

• Complication: Cough, aspiration pneumonitis

and chest pain

Oesophageal Achalasia

• Investigation: Barium swallow,

endoscopy and manometry

• Treatments : Balloon dilation, chemical

denervation and surgical myotomy of

lower oesophageal sphincter

Retained level of barium

Bird beak’s appearance

Investigation

Investigation

• Oesophagogastroduodenoscopy (OGDS)

• OGDS Guided Biopsy

• Barium Swallow Oesophagography

• Radiofluoroscopy Swallowing Study

• Computed Tomography (CT) Scan

• Oesophageal Manometry

• Functional Endoscopic Sinus Surgery (FESS)

• Endoscopic Ultrasonography (Detect Tumour and LN Staging)

Management

History Taking

• What kind of food produces dysphagia?• Liquid

• Solid

• Nature of dysphagia• Intermittent• Continual

• Progressive

• Associated SSx• Coughing• Regurgitation

• Choking

Physical Examination

• Profound weight loss (Malignancy or Achalasia)

• Glossopharyngeal nerve (CN IX)

• Vagus nerve (CN X)• Uvula movement• Palatal movement

• Gag reflex• Cough reflex (Rarely done)

• Neck Examination – Thyroid Malignancy

• Inspection of Limbs – Scleroderma, Weakness

(Neuromuscular Disorder)

Goals of Management

• Improve food transfer to the stomach

• Prevent aspiration pneumonitis

• Treat underlying causes

Treatment method is based on aetiologicalapproach.

Management Cascade

• Oropharyngeal Dysphagia

Status of Centre Management Option(s)

Limited Resources Swallowing Rehabilitation

- Head and Body Posture

- Air-way closure maneuver

Diet Modification

Importance of Oral Hygiene

Feeding Tube

Better Resources Surgical Gastrostomy

Percutaneous Gastrostomy

Endoscopic Gastrostomy

Management Cascade

• Oesophageal Dysphagia

Status of Centre Management Option(s)

Limited Resources Acid Suppressive Medication (GERD)

- H2R Antag

- Proton Pump inhibitors

Smooth Muscle Relaxants (Spasm)

- Nifedipine 10 mg TDS

Better Resources Surgery (Antireflux, Myotomy)

Endoscopic Balloon Dilation

BOTOX Injection

Chemoradiotherapy (Tumour)

Palliative Therapy (Late stage tumour)

Management Cascade

• Achalasia

Status of Centre Management Option(s)

Limited Resources Pneumatic Balloon Dilation

Muscle Relaxant

- Nifedipine 10 mg Preprandial

Better Resources Laparoscopic Surgery

- Myotomy

- Heller’s Operation

Oesophagectomy