Swallowing disorders Flashcards
Define swallowing
A series of sequential well-coordinated events that transport foods and liquids from the buccal cavity to the stomach
List the key anatomical structures involved in swallowing
Pharynx
Soft palate
Larynx
Oesophageal striated and smooth muscle
Gastro-oesophageal junction
Nerves:
- Sympathetic
- Parasympathetic (Vagus and recurrent Laryngeal)
Name the 3 major phases of swallowing
Oropharyngeal
Oesophageal
Gastro-oesophageal
List the main signs of swallowing disorders
- Dysphagia = difficulty swallowing
- Odynophagia = swallowing pain
- Regurgitation (not vomiting)
- Drooling saliva
- Halitosis
What are the signs of dysphagia (how can it manifest?)
Difficulty lapping up food or forming bolus
Excessive jaw or head motion
Dropping food from mouth
Drooling saliva / foaming at mouth
Persistent, ineffective swallowing
Nasal discharge
Gagging
Coughing
Failure to thrive
Reluctance to eat or pain
Halitosis
Blood-tinged saliva
Dysphagia can be divided into which two categories?
Functional = abnormal neuromuscular activity
Morphological = structural abnormality
List the possible causes of a function dysphagia
- Cricopharyngeal chalasia/achalasia
- Myasthenia gravis
- Brainstem disease
- Peripheral neuropathy
- Polymyopathy
- Hypothyroidism
- Botulism
List the possible causes of a morphological dysphagia
- Oropharyngeal inflammation
- Oropharyngeal trauma
- Foreign bodies
- Inflammation → ulceration, necrosis, secondary infection
- Neoplasia
- Congenital / developmental
List the possible congenital/developmental conditions which could lead to a morphological dysphagia
Hare-lip, lip-fold deformities
Cleft palate
Malocclusion
Craniomandibular osteopathy
Temporomandibular dysplasia
Give the term used to describe inflammation of the following anatomical locations:
- Oral mucosa
- Lips
- Tongue
- Gums
- Pharynx
- Tonsils
- Oral mucosa = stomatitis
- Lips = cheilitis
- Tongue = glossitis
- Gums = gingivitis
- Pharynx = pharyngitis
- Tonsils = tonsillitis
List some possible causes of halitosis
- Oropharyngeal disease: Inflammation, Neoplasia, Foreign body
- Oesophageal disease
- Dietary associated
- Malabsorption
- Dental disease
- Nasal cavity & sinus disease
- Uraemia
- Liver disease
- Anal sac disease
How is regurgitation different to vomiting?
Regurgitation is a passive event
Undigested food
Covered by mucus/saliva
Immediate, or delayed
Neutral pH
Define Pseudoptyalism
Failure to swallow normal volume of saliva -> drooling saliva
Define ptyalism
Increased saliva production
What are some secondary signs of oesophageal and oropharyngeal disease?
Malnutrition / dehydration
Anorexia / polyphagia
Aspiration pneumonia / tracheal compression
- Cough
- Dyspnoea
List the methods of investigating and diagnosing swallowing problems
History & physical examination
Diagnostic imaging
Endoscopy
Laboratory investigations
FNA
Biopsy
What questions might you ask if presented with an animal with vomigurgitation?
What is brought up?
When is it brought up (timing wrt feeding)?
Signs of vomiting e.g. abdominal effort
Concurrent signs
Duration of illness
Describe the physical examination of a patient with swallowing disorders
Oral cavity examination
Examine head (jaw, skull, muscles)
Palpation of neck (oesophagus)
Systemic examination
Neurological examination
Describe the radiographic examination of a patient with swallowing disorders
Survey Radiographs: Head, neck, thorax
Barium oesophagram ± fluoroscopy
- Barium mixed with food
- Iodine contrast if perforation suspected
What is the 2-M antibody lab test specific for?
Unique to the muscles of mastication
When might you perform biopsy/FNA in swallowing disorder cases?
Oropharynx c.f. oesophagus
- Mass
- Draining lymph nodes
Direct sampling or US-guided
Usually requires GA
Define the term megaoesophagus
“Oesophageal dilation with functional paralysis’’
What are the causes of megaoesophagus?
Primary idiopathic megaoesophagus = Congenital or Acquired - great dane, irish setter, pyloric stenosis in siamese cats
Secondary acquired megaoesophagus
List the causes of a secondary megaoesophagus
CNS = distemper
Neuropathies
Neuromuscular = myasthenia gravis, botulism, tetanus
Oesophagitis
Pyloric stenosis
GDV
Thymoma
How is a megaoesophagus diagnosed?
Radiography ± contrast
- Uniformly dilated, gas and/or fluid filled
- Ventral displacement of trachea
- Secondary aspiration pneumonia
How can you treat an idiopathic megaoesophagus?
- Feeding from a height: Bailey chair – utilises gravity
- Slurry, textured food, meatballs?
- Bethanecol ?
- Metoclopramide, cisapride ??
- Raise water bowl
Describe the prognosis for an idiopathic megaoesophagus
Guarded
Danger of aspiration pneumonia
List the potential causes of oesophagitis
Ingestion of caustics and irritants
Foreign bodies
Acute and persistent vomiting
Gastric reflux
List the clinical signs of Oesophagitis
Anorexia
Dysphagia
Odynophagia – pain in the oesophagus when eating
Regurgitation
Hypersalivation
How is oesophagitis diagnosed?
Clinical signs
Endoscopy
Response to empirical treatment?
Describe the symptomatic treatment of oesophagitis
(rest the oesophagus)
- Frequent small feeds
- Antibiotics
- Liquid antacids
- Local anaesthetic
- Gastrostomy tube feeding – if severe
Describe the specific treatment of oesophagitis
Sucralfate
Antacids
Metoclopramide
How is oesophageal obstruction categorised?
Intraluminal = FB
Intramural
Extramural
What are the 3 causes of an intramural oesophageal obstruction?
Neoplasm
Stricture
Granuloma
What are the 3 causes of an extramural oesophageal obstruction?
Thyroid
Thymic/mediastinum
Vascular ring
Describe the aetiology of an oesophageal stricture
Fibrosis after ulceration of mucosa by:
- Foreign body
- Caustic material
- Severe oesophagitis
- Gastric reflux: especially pooled secretions during GA
- Drug therapy e.g. doxycycline in cats
Name the 2 methods of oesophageal stricture dilation
Bougienage
Balloon dilatation
Describe the bougienage method of oesophageal stricture dilation
Forcible passage of tubes of increasing diameter; some people use endotracheal tubes.
This produces a longitudinal shear effect and has an increased risk of perforation.
Describe the balloon method of oesophageal stricture dilation
- Best method
- Radial stretch
- Stationary force
- Less risk of perforation
- Inflatable balloon
- Radial stretching less traumatic
- Use pressure gauge
Where do oesophageal foreign bodies most commonly lodge?
Lower oesophageal sphincter > heart base > thoracic inlet
Which dogs usually present with oesophageal foreign bodies?
Usually young animals
Common in greedy dogs eating chop bones Esp terriers – 40% WHWT
What should NOT be done if an oesophageal FB is suspected?
Dont give barium
How is an oesophageal FB diagnosed?
Radiography
Oesophagoscopy
How are oesophageal FBs treated?
- Peroral approach
- Flexible or rigid endoscope
- Preferably pull FB to mouth
- Or push to stomach for gastrotomy
- Check for oesophageal tear - Surgical removal
- Last resort
- Essential if large laceration
How should patients be managed post oesophageal FB removal?
Post removal oesophagitis
Radiographs (pneumomediastinum)
PEG Tube
Omeprazole
Sucralfate
