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Medicine II > Swallowing Disorders > Flashcards

Swallowing Disorders Flashcards

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
Q

What are the clinical signs of Generalized Megaesophagus?

A
  • Regurgitation: time after eating varies
  • Weight loss and poor BCS
    • normal to increased appetite
  • Aspiration pneumonia
  • +/- systemic or neurologic disease
26
Q

What is the diagnostic approach to Esophageal Dysmotility or Megaesophagus?

A
  • 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
Q

What is Regurgitation?

A
  • 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
Q

What is the treatment for Megaesophagus/Esophageal Dysmotility

A
  • 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
Q

Why is Cisapride not given to dogs for megaesophagus

A
  • Prokinetic that increase LES tone may worsen clinical signs and are generally not recommended in dogs with idiopathic megaesophagus
30
Q

What is the prognosis of generalized megaesophagus?

A
  • MST 90days
  • Worse with aspiration pneumonia and older age
  • Variable but generally better for esophageal dysmotility w/out generalized megaesophagus
31
Q

What are the common locations for Esophageal foreign bodies?

A
  • Upper Esophageal sphincter
  • Thoracic inlet (fishhooks)
  • Heart base
  • Immediately proximal to lower esophageal sphincter
32
Q

What are the clinical signs of Esophageal foreign bodies?

A
  • Acute onset dysphagia, gagging, regurgitation, hypersalivation
33
Q

How is an esophageal foreign body diagnosed?

A
  • Thorough oral examination
  • Cervical/thoracic radiographs +/- contrast if radiolucent
    • Do NOT use Barium, use Iohexal if concerned for perforation
  • Esophagoscopy
34
Q

When is surgery indicated for Esophageal Foreign Bodies?

A
  • Esophageal perforation
  • Extraluminal foreign body
35
Q

What is the management for Esophageal Foreign Body following removal with moderate to severe esophagitis?

A
  • Food/water restriction 12-24hr
  • Low-fat, high protein diets
  • Medications: Sucralfate, proton-pump inhibitors
  • +/- PEG tube placement if severe esophageal damage
36
Q

What are the possible complications of removal of a Esophageal Foreign Body?

A
  • 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
Q

What is Esophagitis? Etiologies?

A
  • 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
Q

What are the clinical signs of Esophagitis?

A
  • Mildly affected patients may be asymptomatic
  • Non-specific:
    • Anorexia
    • Esophageal dysphagia
    • Painful swallowing
    • ptyalism
39
Q

How is Esophagitis diagnosed?

A
  • 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
Q

What is the treatment for esophagitis?

A
  • 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
Q

What is an Esophageal Stricture? Etiologies?

A
  • 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
Q

What are the clinical signs associated with esophageal stricture?

A
  • Regurgitation, multiple swallowing attempts
  • May better tolerate liquids than solid food
  • Ravenous appetite with weight loss
43
Q

how are esophageal strictures diagnosed

A
  • Contrast radiography or fluoroscopy
  • Esophagoscopy
44
Q

What is the treatment for Esophageal Strictures?

A
  • Endoscopic or fluoroscopic-guided balloon dilation or bougienage
    • repeated procedures often needed
    • intra-luminal steroid injection may help decrease recurrence
  • Supportive care for esophagitis

Medicine II (46 decks)

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