Dysphagia Flashcards
define dysphagia and the two types
difficulty swallowing
oropharyngeal vs esophageal
define oropharyngeal dysphagia
problems with transferrence of food bolus from the oropharynx to the upper esophagus (disease involving the pharynx, upper esophagus or upper esophageal sphincter)
define esophageal dysphagia
impairment of the food bolus through the body of the esophagus (problems with lower esophagus, lower esophageal sphincter or cardia)
causes of oropharyngeal dysphagia
- neurologic disorders
- -brainstem CVA, mass lesion
- -pseudobulbar palsy
- -ALS
- -MS
- -poliomyelitis
- -myasthenia gravis - muscular disorders
- -myopathies
- -polymyositis
- -hypothyroidism - motility disorders
- -UES dysfunction - structural defects
- -zenkers diverticulum
- -malignancy
- -surgery
- -radiation of oropharynx
causes of esophageal dysphagia
- mechanical disruption
- -schatzki’s ring
- -esophageal stricture
- -esophageal cancer - motility disorder
- -achalasia
- -diffuse esophageal spasm
- -scleroderma
what are the three phases of oropharyngeal portion of swallowing
oral preparatory
pharyngeal
esophageal
what do you need for the oral preparatory phase
proper mastication
adequate salivary production
intact mucosa
neuromuscular coordination
what types of diseases interfere with the oral preparatory phase of swallowing
poor dentition
decreased salivary flow (sjogrens, meds)
parkinsons
mucositis
apthous ulcers
oral herpes
anything affecting CNs V, VII, XII
what nerves control the pharygeal peristalsis required for the pharyngeal phase of swallowing
CN V, X, XI, XII
what signs suggest the problem is with the esophageal phase of swallowing
coughing, choking, regurgitation through nose as soon as swallowing initiated
liquids more difficult to swallow than solids
associated dysphonia and dysarthria
neuro signs pointing to CVA, MG, ALS, MS
associated heartburn or odynophagia
patients often point to their cervical region to ID this problem
in problems with the esophageal phase of swallowing, which is more difficult to swallow, liquids or solids?
liquids
what signs suggest esophageal (vs oropharyngeal) dysphagia
symptoms occur several second after initiating swallowing
patients often extend arms and neck to reposition themselves properly
often point towards suprasternal notch or behind sternum as the area causing their symptoms
what suggests a mechanical lesion causing the esophageal dysphasia
recurrent and progressively worsens so that fluids may become involved (initially usualyl just solids)
if over 50 and progressive think cancer
if intermittent and not progressive think schatskis ring
patient has esophageal dysphasia that is intermittent and not progressive, liquids better than solids
think schatskis ring
patient has esophageal dysphasia that is associated with heartburn and progressive
think peptic stricture
patient has esophageal dysphasia that is progressive, patient is over 50
think esophageal cancer
what signs suggest a motility disorder is behind esophageal dysphasia
fluids and solids are equally hard to swalloe
unpredictable
episodic
progresses slowly or not at all
patient has esophageal dysphasia, both solids and liquids are affected and it is progressive
think achalasia (scleroderma)
patient has esophageal dysphasia, associated with chest pain and not progressive
think diffuse esophageal spasm
patient has esophageal dysphasia, chronic heartburn and raynaud’s phenomenon
think scleroderma
what questions to ask to elicit dysphagia history
- problems initiating swallowing (oropharyngeal) vs food getting stuck a few seconds after swallowing (esophageal)
- is there coughing or choking or is food coming back through your nose?
- liquids, solids or both?
- how long have you had the problem? have the symptoms progressed or stayed the same, or are they intermittent?
- can you point to where the food/liquid is getting stuck?
- other symptoms, B symptoms, loss of appetite, weight loss, N/V, regurgitation, heartburn, hematemesis, chest pain?
- PMHx
- previous surgery on larynx, esophagus, stomach, c spine?
- alcohol, iron deficiency, smoking?
what to ask specifically on PMHx for dysphagia
previous dysphagia GERD scleroderma cancer radiation diabetes sjogrens AIDs stroke myasthesia gravis ALS parkinsons MS
what should you look for specifically on exam for dysphagia
cranial nerves V, VII, X, XII
examine oral cavity, head and neck, supreclavicular region looking for lymph nodes, masses, facial mucle weakness, poor dentition, thyroid enlargement
generalized neuro exam looking for CVA, MS, ALS, MG
hypothyroidism exam
signs of scleroderma
abdo exam
what constitutes a hypothyroidism exam
dry skin brady delayed return of deep tendon reflexes thinning hair slow speech hoarseness thickening of tongue facial puffiness hard pitting edema
