tbl 1 clinical approach to dysphagia Flashcards
What are common structural causes of oropharyngeal dysphagia in addition to osteophytes and skeletal abnormalities, congenital (cleft palate, diverticula, pouches etc)
Cricopharyngeal bar, Zenker’s diverticulum, Cervical webs
Myopathic causes of oropharyngeal dysphagia?
- _______
- ________
- ________
- Myotonic dystrophy
- Oculopharyngeal dystrophy
- Polymyositis
- Sarcoidisis
- Paraneoplastic syndromes
Connective tissue disease (overlap syndrome), dermatomyositis, myasthenia gravis
What are neurological causes of oropharyngeal dysphagia?
- _____
- ______
- ________
- cerebral palsy
- Guillain- Barre syndrome
- Huntington disease
- Multiple sclerosis
- Multiple sclerosis
- Polio
- Post polio syndrome
11: Tardive dyskinesia - Metabolic encephalopathies
- Amyotrophic lateral sclerosis
- . Parkinson disease
15: dementia
brainstem tumours; head trauma; stroke
What are iatrogenic causes of oropharyngeal dysphagia?
- medication side effects (chemotherapy, ____ etc)
- postsurgical muscular or neurogenic
- radiation
- corrosive (pill injury, intentional)
neuroleptics
Infectious causes of oropharyngeal dysphasia?
- ____________
- Diptheria
- Botulism
- Lyme disease
- Syphillis
Muscositis (herpes, cytomegalovirus, Candida etc)
Metabolic causes of oropharyngeal dysphasia?
- _________
- Cushing’s syndrome
- Thyrotoxicosis
- Wilson disease
Amyloidosis
Common intrinsic causes of oesophageal dysphagia?
Benign tumours, caustic esophagitis/ stricture, diverticula, malignancy
Extrinsic causes of oesophageal dysphagia are often due to compression of aberrant nearby structures on the oesophagus. Examples include ________, cervical osteophytes, enlarged aorta, enlarged left atrium, mediastinal mass (lymphadenopathy, lung cancer etc), post surgery (laryngeal, spinal)
aberrant subclavian artery
What are the motility disorders that cause oesophageal dysphagia
Achalasia, Chagas disease, primary motility disorders, secondary motility disorders
what is the definition of functional dysphagia?
absence of structural or motility disorders
What does changes in speech (slurred, nasal speech, dysarthria, dysphonia) + oropharyngeal dysphagia suggests?
neuromuscular dysfunction
What does weak cough, hoarseness of voice + oropharyngeal dysphagia suggests?
vocal cord paralysis
What does oropharyngeal dysphagia developing late in a meal suggest?
myasthenia gravis
What does elderly age, blood in mouth, weight loss + oropharyngeal dysphagia suggests?
possible malignancy
What does otalgia (ear pain) + oropharyngeal dysphagia suggests?
hypopharyngeal lesion/ cancer
What does odynophagia + oropharyngeal dysphagia suggests?
inflammation, infection, or cancer
What does dry mouth, dry eyes + oropharyngeal dysphagia suggests?
- inadequate salivary production: sjogren’s syndrome
- history of head and neck radiotherapy
- medication e.g. anticholinergics, anti histamines
Evaluation of oropharyngeal dysphagia
- Bedside swallowing test
- Physical examination – examination of the oral cavity, head and neck and supraclavicular region
o Neurological examination of the _____ nerves
- Laboratory and imaging – additional tests may be warranted to determine aetiology
o E.g. MRI brain/brainstem (stroke, multiple sclerosis), auto-antibodies against acetylcholine receptors (in _________)
Further evaluation:
- Nasopharyngeal laryngoscopy: rule out structural lesion in the _________________
- Fibreoptic endoscopic evaluation of swallowing (FEES) or Video fluoroscopy with modified barium swallow: Functional assessment of swallowing Assesses degree of dysfunction and risk/severity of aspiration
- Manometry of upper oesophageal sphincter (UES): To detect UES dysfunction
Identify those who may benefit from ______ – surgical procedure to sever the cricopharyngeal muscle:
cranial ; myasthenia gravis; oropharynx, hypopharynx and larynx; cricopharyngeal
myotomy
Complications and management of oropharyngeal dysphagia
- Complications – aspiration, pneumonia, mortality
o A decrease in deglutition (swallowing) safety, leading to ________ which results in aspiration pneumonia and can lead to death
o Goal of management – improve food transfer and prevent aspiration.
Management
o Treatment of underlying disorder
o Swallowing rehabilitation
o Dietary modification e.g. thickened fluids/feeds
o Cricopharyngeal myotomy or ______ (rare) – if there is cricopharyngeal dysfunction
o Enteral feeding e.g. nasogastric tube, percutaneous gastrostomy tube – if assessed to be at high risk of aspiration and not safe for oral feeding
tracheobronchial aspiration; botulinum toxin injection
Functional dysphagia – when all tests are normal
- Functional dysphagia (Rome IV diagnostic criteria) is defined as:
o A sense of solid and/or liquid food lodging or passing abnormally through the oesophagus
o No oesophageal mucosal or structural pathology
o No GERD or ________
o No major esophageal motility disorder
o All criteria must be fulfilled for the past 3/12 with symptom onset at least 6/12 prior to the diagnosis
o Avoid precipitating factors and chew well
- If there are severe symptoms – use _______, cholinergic agent, antidepressant, anxiolytic, or smooth-muscle relaxant
eosinophilic esophagitis (EoE); calcium channel blocker
oesophageal dysphagia + heartburn suggests ?
peptic sticture
oesophageal dysphagia + caustic ingestions, radiation therapy suggests?
benign stricture
oesophageal dysphagia + anaemia, lost of appetite, loss of weight suggests?
malignant strictures
oesophagial dysphagia + odynophagia suggests?
ulceration/ inflammation
infectious oesophagitis can be caused by which viruses (2)?
HSV, CMV
What medication can induce oesophagitis?
tetracycline, doxycycline, bisphosphonates
Diagnostic tests – evaluation of oesophageal dysphagia
- __________ : direct visualisation of oesophageal mucosa to rule out obstructive luminal lesions, obtain biopsies, and to determine the underlying cause
- When OGD is unrevealing and mechanical obstruction is suspected – OGD may not be sensitive enough to pick up early oesophageal compression
o Barium swallow – can demonstrate ______ or extrinsic oesophageal compression that can be missed by an OGD
o Computed tomography (CT) thorax – can
demonstrate ______________ e.g. aberrant subclavian artery (dysphagia lusoria), mediastinal mass, lymph nodes
- When OGD is unrevealing and motility disorder is
suspected – oesophageal manometry can be used
Oesophagogastroduodenoscopy (OGD); oesophageal web/rings; extrinsic compression on oesophagus
Acute onset of oesophageal dysphagia, occurring soon after ingesting meat
food bolus retention
Non acute onset of oesophageal dysphagia, Both solids and liquids from the onset of symptoms (motility disorder), progressive
Achalasia
Non acute onset of oesophageal dysphagia, Both solids and liquids from the onset of symptoms (motility disorder), intermittent/ non progressive
Oesophageal motility disorders
Non acute onset of oesophageal dysphagia, Solids only (mechanical obstruction), progressive from solids to liquids
- Peptic stricture (slowly progressive)
- Malignant stricture (more rapid)
Non acute onset of oesophageal dysphagia, Solids only (mechanical obstruction), intermittent/ non progressive
oesophageal rings, eosinophilic oesophagitis, extrinsic compression from vascular anomalies (e.g. aberrant vessels)
What are disorders of gastroesophageal junction (GEJ)?
Achalasia
GEJ outflow obstruction
What are major disorders of peristalsis?
Distal oesophageal spasms
Hypercontractile (Jackhammer) oesophagus
Absent contractility
What are minor disorders of peristalsis?
Ineffective oesophageal motility
Fragmented peristalsis
