Dysphagia

Question 1

Definition of dysphagia

Answer 1

• having difficulty in swallowing from mouth to stomach
• disruption of swallowing

Question 2

Diagnostic approach dysphagia

Answer 2

• dysphagia solid food : mechanical obstruction
• dysphagia occur within a sec of onset : oropharyngeal cause
• swallowing associated with gurgling noise / neck bulge : pharyngeal pouches (Zenker’s diverticulum)
• dysphagia is constant and painful : malignant stricture
• dysphagia with difficulty in initiating swallowing + choking sensation : oropharyngeal cause
• sensation of stopping or sticking of bolus : esophageal cause

Question 3

defect in which 3 phases of swallowing that can lead to dysphagia

Answer 3

• oral phase (oral preparatory phase and oral transit phase)
• pharyngeal phase
• esophageal phase

Question 4

Oropharyngeal dysphagia vs Esophageal dysphagia

Answer 4

oropharyngeal dysphagia :
- difficulty in preparing and transport food bolus through oral cavity
- difficulty in initiating the swallow
- may be associated with aspiration and nasopharyngeal regurgitation

esophageal dysphagia
- complain of food sticking in their lower throat, neck, retrosternal discomfort / epigastrium

Question 5

Signs and symptoms of oral / pharyngeal dysphagia

Answer 5

• coughing / choking with swallowing
• diffuculty initiating swallowing
• food sticking in throat ??
• sialorrhea (excessive salivation)
• unexplained weight loss
• change in dietary habits
• recurrent pneumonia aspiration (food into airways)
• change in voice or speec (wet voice)
• nasal regurgitation (swallow food comes up into nose)

Question 6

Signs and symptoms of esophageal dysphagia :

Answer 6

• sensation of food sticking in the chest / throat
• change in dietary habits
• symptoms of GERD (gastroesophageal reflux disease)

Question 7

Associated symptoms of dysphagia

Answer 7

• Regurgitation
• Pain on swallowing / deglutition (odynophagia)
• Hoarseness of voice
• Otalgia (ear pain)
• Coughing after eating
• Frequent chest infectons
• General weakness
• Mental status change

Question 8

Possibe causes of dysphagia (Age)

Answer 8

children
- Foreign body
- Congenital malformation

middle aged patients
- Reflux esophagitis
- hiatus hernia (when part of stomach squeezes up into chest through an opening of diaphragm - hiatus )
- anemia
- achalasia (nerves in esophagus become damaged and esophagus becomes paralyzed and dilatd overtime eventually loses its ability to squeeze down food into stomach )
- globus syndrome (lump in the throat)

elderly patients
- malignancy
- stricture formation from longstanding reflux
- pharyngeal pouch
- motility disorders associated with aging
- neurological disorders

Question 9

Acquired causes of dysphagia

Answer 9

Traumatic
- accidental and iatrogenic
- blunt trauma
- penetrating injuries and compression effects
- direct damage and injury to cranial nerves
- head injury

Infections
- acute pharyngitis, tosillitis, quinsy
- glandular fever
- acute supra glotitis (herpetic, fungal, cmv mucosal lesions)
- candidiasis
- tuberculois
- submandibular, para pharyngeal, retropharyngeal abscesses

Inflammatory
- GERD with or without stricture formation
- Patterson Brown-Kelly syndrome (Plummer Vinson syndrome)
- Autoimmune disorders like Sjorens disease, rheumatoid arthritis, scleroderma

Esophageal motility disorders
- Achlasia
- diffuse esophagus motility
- nutcracker esophagus (motility disorder with achalasia and spasms)

Neoplastic
- leukemia and lymphomas
- enlarged mediastinal lymph nodes
- benign and malignant tumor of oral cavity, pharynx, esophagus
- nasopharyngeal carcinoma
- skull base tumors

Neurological
- CVA (Stroke)
- Parkinson’s disease
- Myasthenia gravis
- multiple sclerosis
- motor neuron disease

Drug induced
- Swallowing tablets with insufficient water or just before going to bed can cause esophagitis
- Dysphagia can be a complication of drugs like antihypertensive, ACE Inhibitors,
anticholinergics, anti emetics, antihistamines, diuretics, and opiates by causing
xerostomia
- Drugs causing esophagitis
- Esophagus at the level of aortic arch most vulnerable to contact by acid
producing drugs (with pH less than 3) such as tetracycline, doxycycline, vitamin C
and ferrous sulphate
- Broad-spectrum antibiotics and chemotherapeutic agents may cause secondary viral ulceration or fungal infections
- Stevens-Johnson syndrome is a more serious complications of antibiotic therapy with an acute erosive pharyngitis/ esophagitis as well as delayed esophageal strictures
- Excitatory side effects of drugs like cisapride and metoclopramide.

Miscellaneous
- Presbydysphagia (refers to age related changes in the oropharyngeal and esophageal swallowing of healthy adults
- patients with tracheostomy
- foreign bodies
- caustic strictures
- pharyngeal pouch

Question 10

Treatment of dysphagia

Answer 10

Treat the specific underlying cause
Special care given to pt with neurological disorders with special attention to dietary texture, body, head and neck position and size and frequency of food bolus and administration
- bolus size should be small in sips and bites
- thick fluids and pudding texture is better than clear liquids
- avoid spices, acidic food and coffee, tea and alcohol
- pt should be in upright positon for at least 1-3 hours after meal (avoid aspiration)
- head end should be elevated while resting and sleeping

Question 11

Congenital causes of dysphagia

Answer 11

congenital
- choanal atresia (nasal choanae are occluded by soft tissue and due to failed recanalisation during fetal development)
- cleft lip and palate
- unilateral vocal cord paralysis
- laryngeal cleft
- tracheo-esophageal fistula
- oesophageal atresia
- vascular rings (unusual congenital anomalies occur early in development of aortic arch and great vessels related to structures that are encircled by ring, chiefly the trachea, and oesophagus)