Swallowing Disorders Flashcards

(44 cards)

1
Q

Obj: Identify the phases of swallowing and correct order

A
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2
Q

Obj: Given Signalment and CS, localize the site of dysphagia and formulate and prioritize a DDx list and Dx plan

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3
Q

Obj: Describe the clinical importance of differences in esophageal structure between species

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4
Q

Obj: Using imaging findings prioritize DDx for a patient with esophageal dysphagia

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5
Q

Obj: For specific diseases, formulate the most appropriate treatment plan and communicate complication and prognostic information to owners

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6
Q

What are the phases of swallowing

A
  • Oral
  • Pharyngeal
  • Esophageal
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7
Q

Define Dysphagia

A

Difficult or painful swallowing

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8
Q

What is the diagnostic approach for dysphagia

A
  • Complete history
  • Physical and ORAL examination
  • Observation of eating
  • Neuro Exam
  • Disease Localization
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9
Q

What happens during the oral phase of swallowing?

A
  • Voluntary control
  1. Prehension of food
  2. Separation of bolus from bulk of food with tongue
  3. Pressure of tongue on hard palate ⇢ Caudodorsal movement of bolus
  4. Bolus in the pharynx initiates the swallowing reflex
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10
Q

What are the clinical signs of Oral Dysphagia?

A
  • Ptyalism
  • Chewing on one side
  • Dropping food
  • Excessive head movements during prehension
  • Submerge muzzle to eat/drink
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11
Q

what is the diagnostic approach for Oral Dysphagia?

A
  • Sedated Exam +/- Radiographs
    • anatomic defects: Cleft palate
    • Periodontal diseases/stomatitis
    • Obstructive disease
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12
Q

What happens during the Pharyngeal phase of Swallowing?

A
  1. Reflex inhibition of breathing
  2. Pharynx narrows to move bolus caudally
  3. Relaxation of upper esophageal sphincter (UES)
  4. Constriction of pharynx ⇢ Bolus forced into caudal pharynx/through UES
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13
Q

What are the clinical signs of Pharyngeal/Cricopharyngeal Dysphagia?

A
  • Repeated swallowing attempts
  • Excessive neck movements during swallowing
  • Gagging
  • Coughing or immediate reflux of food/water
  • Ptyalism
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14
Q

What is the diagnostic approach for Pharyngeal/Cricopharyngeal Dysphagia

A
  • Radiographs (Oral/skull, cervical)
  • Contrast Fluoroscopy
    • Congenital cricopharyngeal achalasia
    • Neuropathies: central or peripheral
    • NMJ disorders: Myasthenia gravis
    • Muscle disorders: muscular dystrophy, myositis
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15
Q

What is Cricopharyngeal Achalasia/Asynchrony?

A
  • Congenital neuromuscular disorder in which the UES either:
    • fails to relax (achalasia)
    • Relaxation is discordant with pharyngeal contraction (asynchrony)
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16
Q

What is the common signalment of Cricopharyngeal Achalasia/Asynchrony?

A
  • Young: weaning
  • Breeds:
    • Golden Retriever
    • Cocker and Springer Spaniels
    • Miniature Dachshunds
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17
Q

What are the clinical signs of Cricopharyngeal Achalasia/Asynchrony?

A
  • Pharyngeal/Cricopharyngeal dysphagia
  • Poor BCS, slow growth
  • Aspiration pneumonia
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18
Q

How is Cricopharyngeal Achalasia/Asynchrony diagnosed?

A
  • Contrast Radiography
  • Fluoroscopy
  • +/- serum creatine kinase, EMG, muscle biopsies
19
Q

What is the treatment for Cricopharyngeal Achalasia/Asynchrony?

A
  • Surgical myotomy of cricopharyngeal muscle
  • Botulinum toxin injection
  • Supportive care:
    • Nutrition - Esophageal/gastric feeding tubes
    • Pneumonia treatment
20
Q

What happens during the Esophageal phase of Swallowing

A
  1. Constriction of UES (after bolus passes)
  2. Initial peristaltic wave moves from UES through entire esophageal length (Primary peristalsis)
  3. Incomplete food clearance ⇢ Esophageal distention ⇢ Secondary peristalsis
  4. Reflex relaxation of lower esophageal sphincter (LES)
21
Q

Describe the structure of the Esophagus

A
  • UES: Striated muscle
  • Body:
    • Dog – striated muscle
    • Cat – Proximal ⅓ striated, distal ⅓ smooth muscle
  • LES: smooth muscle
  • Innervation: Vagus n. and branches
22
Q

What is the diagnostic approach for Esophageal Dysphagia?

A
  • Thorough history (Regurgitation*)
  • Complete PE and Neuro eam
  • Radiographs (cervical, thoracic)
    • Generalized esophageal dilation: Megaesophagus
    • Focal dilation: Stricture, diverticulum, vascular ring anomaly
    • Radiopaque structure: foreign body
    • Normal/non-diagnostic
      • Fluoroscopy: performed in sternal recumbency
        • Stricture
        • Intraluminal mass
        • Dysmotility or gastroesophageal reflux
        • Normal → Esophagoscopy
23
Q

What is the difference between Megaesophagus and Esophageal Dysmotility?

A
  • Megaesophagus:
    • diffuse esophageal dilation and association of peristalsis
  • Dysmotility:
    • Decreased esophageal peristalsis or retrograde movement of food bolus w/out diffuse dilation
24
Q

What are the Etiologies of Generalized Megaesophagus?

A
  • Congenital:
    • Idiopathic: Possible Vagal n. defect
    • Congenital Myasthenia gravis (MG) or Hypothyroidism
  • Acquired:
    • Idiopathic
    • Endocrine disease
    • Neurologic disease
    • Esophagitis
    • Toxicity
    • Thymoma (paraneoplastic)
25
What are the clinical signs of Generalized Megaesophagus?
* Regurgitation: time after eating varies * Weight loss and poor BCS * normal to increased appetite * Aspiration pneumonia * +/- systemic or neurologic disease
26
What is the diagnostic approach to Esophageal Dysmotility or Megaesophagus?
* Generalized: Thoracic Radiographs * Dysmotility: Fluoroscopy * Select cases: * MG - Acetylcholine receptor antibodies * T4 +/-TSH * Baseline cortisol +/-ACTH stimulation test * Muscle biopsy for congenital Myasthenia gravis * Post-mortem - intercostal muscle * Patients have generalized neurologic signs * Esophagoscopy for evaluation of esophagitis
27
What is Regurgitation?
* Passive process * Lack of lip-licking, retching, abdominal contractions * “silent” action (lack of vocalization) * Inability to predict timing * if it contains food, poorly digested * Usually does NOT contain bile
28
What is the treatment for Megaesophagus/Esophageal Dysmotility
* Treat predisposing disease if present * Feeding adjustments * Upright: Bailey chair * remain upright 15-30 minutes after feeding → highly variable/adjust based on patient tolerance of food * Adjust texture * small meatballs, pate, ThickIT for liquid-intolerant patients * Small, frequent meals * Nutrient content * Low-fat, easily digestible * calorically-dense food may help reduce total volume needed to feed * Percutaneous endoscopic gastrostomy (PEG)-tube placement * does **not decrease** the risk of regurgitation/aspiration of saliva * Medicaitons: * treatment trial for esophagitis if recent history of vomiting or anesthesia * Cisapride (Cats) * Sildenafil (Dogs w/ congenital Megaesophagus)
29
Why is Cisapride not given to dogs for megaesophagus
* Prokinetic that increase LES tone may worsen clinical signs and are generally not recommended in dogs with idiopathic megaesophagus
30
What is the prognosis of generalized megaesophagus?
* MST 90days * Worse with aspiration pneumonia and older age * Variable but generally better for esophageal dysmotility w/out generalized megaesophagus
31
What are the common locations for Esophageal foreign bodies?
* Upper Esophageal sphincter * Thoracic inlet (fishhooks) * Heart base * Immediately proximal to lower esophageal sphincter
32
What are the clinical signs of Esophageal foreign bodies?
* Acute onset dysphagia, gagging, regurgitation, hypersalivation
33
How is an esophageal foreign body diagnosed?
* Thorough oral examination * Cervical/thoracic radiographs +/- contrast if radiolucent * Do NOT use Barium, use Iohexal if concerned for perforation * Esophagoscopy
34
When is surgery indicated for Esophageal Foreign Bodies?
* Esophageal perforation * Extraluminal foreign body
35
What is the management for Esophageal Foreign Body following removal with moderate to severe esophagitis?
* Food/water restriction 12-24hr * Low-fat, high protein diets * Medications: Sucralfate, proton-pump inhibitors * +/- PEG tube placement if severe esophageal damage
36
What are the possible complications of removal of a Esophageal Foreign Body?
* Esophagitis * Aspiration pneumonia * Uncommon: * Esophageal perforation * esophageal stricture * Pneumothorax * pneumomediastinum * bronchoesophageal fistula * cardiopulmonary arrest * death * longer time to removal increases risk of severe esophagitis and perforation
37
What is Esophagitis? Etiologies?
* Acute or Chronic Inflammation of esophageal mucosa * Etiologies: * Chemical Injury * Ingestion of corrosive substances (doxycycline in cats) * Gastroesophageal reflux * secondary to general anesthesia or gastroesophageal reflux disease * Less common: frequent, severe vomiting; Hiatal hernea and impaired acid protection * Esophageal Foreign body
38
What are the clinical signs of Esophagitis?
* Mildly affected patients may be asymptomatic * Non-specific: * Anorexia * Esophageal dysphagia * Painful swallowing * ptyalism
39
How is Esophagitis diagnosed?
* **Survey radiographs:** * normal, +/- esophageal dilation with severe disease, often focal and just proximal to LES * **Esophagoscopy:** * Mucosal erythema, erosions, alterations in mucosal texture * Lesions most common in distal esophagus near the LES * Lesions often appear striated de to gastric acid exposure pattern when esophagus is relaxed * **Esophageal Biopsies**: rarely performed
40
What is the treatment for esophagitis?
* Nutritional management * low-fat, high protein diet to facilitate gastric emptying and increase LES tone * Small, frequent meals * Medications: * Sucralfate * Proton-pump inhibitors * Prokinetics to increase LES tone and facilitate gastric emptying
41
What is an Esophageal Stricture? Etiologies?
* Circular band of scar tissue within the esophageal wall, causing circumferential narrowing of the lumen * Etiologies: * Any cause of severe esophagitis * Most common: Esophageal foreign bodies, secondary to gastroesophageal reflux * 1-3 wks post-inciting event
42
What are the clinical signs associated with esophageal stricture?
* Regurgitation, multiple swallowing attempts * May better tolerate liquids than solid food * Ravenous appetite with weight loss
43
how are esophageal strictures diagnosed
* Contrast radiography or fluoroscopy * Esophagoscopy
44
What is the treatment for Esophageal Strictures?
* Endoscopic or fluoroscopic-guided balloon dilation or bougienage * repeated procedures often needed * intra-luminal steroid injection may help decrease recurrence * Supportive care for esophagitis