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D y s p h a g i a. นพ.โกสินทร์ ชัยชำนาญ Ent. Objectives. Normal physiology Dysphagia Definition Cause and classification History taking,physical examination and investigation Disease. Normal physiology. 4 stage Oral preparatory stage Oral stage Pharyngeal stage Esophageal stage.

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Presentation Transcript
slide1

Dysphagia

นพ.โกสินทร์ ชัยชำนาญ

Ent

slide2

Objectives

  • Normal physiology
  • Dysphagia
    • Definition
    • Cause and classification
    • History taking,physical examination and investigation
    • Disease
slide3

Normal physiology

  • 4 stage
    • Oral preparatory stage
    • Oral stage
    • Pharyngeal stage
    • Esophageal stage
slide4

Normal physiology

Oral preparatory stage

  • Prepare food for swallow
  • Mechanism of action
    • 1.lip closure to hold food in mouth anteriorly
    • 2.tension in labial&buccal musculature to close Ant&Latsulci
    • 3.rotatory motion of jaw for chewing
    • 4.lateral rolling motion of tongue position food on teeth during mastication – most important
    • 5.bulging forward of soft palate to seal oral cavity posterior and widen nasal airway
oral preparatory stage
Oral preparatory stage

1.Muscle of facial expression (VII) –oral sphincter

  • Orbicularisoris – sphincter of lip
slide6

Oral preparatory stage

2.Muscle of mastication (V) – jaw movement

  • Masseter – close jaw
slide7

Oral preparatory stage

y

3.Tongue muscle

  • Genioglossus(XII) – elevate BOT
  • Hyoglossus(XII) -- depress
slide8

Oral preparatory stage

er

Time : depend on type of food

slide9

Normal physiology

  • Move food from front oral cavity to pharynx
  • Mechanism of action
    • 1.Upward&backward by midline& Lat

margin of tongue –most important

    • 2.Backward by tension in

buccal musculature

    • 3.trigger swallowing reflex

(locate at anterior pillar)

Oral stage

slide10

Oral stage

  • buccal musculature
  • tongue

swallow

  • Styloglossus muscle
  • Hyoglossus muscle
slide11

Oral stage

swallow

trigger zone at anterior pillar

slide12

Oral stage

ri

swallow

CN IX

triggerswallowing reflex

sensory impulse at CN IX

slide13

Oral stage

swallow

Tractus solitarius nucleus/

Solitary tract nucleus

triggerswalling reflex

sensory impulse at CN IX (& Sup. Laryngeal nerve)

slide14

Oral stage

swallow

nucleus ambiguus

CN X

nucleus ambiguus to motor neuron ofCN X atpharynx

slide15

Oral stage

swallow

nucleus ambiguus

nucleus ambiguus to motor neuron ofCN X at pharynx

slide16

Oral stage

er

Time : take 1 second

slide17

Pharyngeal stage

  • Move food from pharynx to esophagus
  • Mechanism of action
    • 1.velopharyngeal closure (prevent backflow of material up nose)
    • 2.tongue base retraction (propel bolus through pharynx)
    • 3.pharynx contraction (clear redisue through pharynx)
    • 4.larynx elevate and closure (airway protection)
    • 5.cricopharyngeal opening (allow bolus to pass into esophagus)
slide20

Pharyngeal stage

  • 1.tongue

swallow

  • Styloglossus muscle
  • Hyoglossus muscle
slide21

Pharyngeal stage

swallow

  • 2.Levator @ Tensor palatini
  • Levatorpalatini
  • Tensor palatini
slide22

Pharyngeal stage

swallow

  • 3.pharyngeal constrictor muscle
  • Superior
  • Middle
  • Inferior
slide23

Pharyngeal stage

swallow

  • 4.aryepiglottic fold/true vocal fold /false vocal fold
  • AEF
  • FVF/TVF
slide24

Pharyngeal stage

er

Time : take less than 1 second

(not vary with age and gender)

slide25

Esophageal stage

  • Close UES
  • Body of esophagus
    • Outer -> longitudinal ,Inner -> circular
  • Peristalsis
    • primary peristalsis :
      • upper 1/3 striated & transitional zone
      • mix voluntary & involuntary
    • secondary peristalsis :
      • lower 2/3 smooth
      • Involuntary
  • Open LES
slide26

Esophageal stage

er

Time : take 8 to 20 seconds

(depend on food influence by

peristalsis&gravity)

slide27

Dysphagia

  • Onset & Site
  • Cough or choke or food coming back through your nose
  • Liquid or solid or both
    • Liquid and solid motility disorder
    • Solid progress to liquid benign or malignant stricture
  • Progression

History

slide28

Dysphagia

  • Other symptoms
    • Loss of appetite,weight loss ,N/V regurgitation,heart burn,weakness, hematemesis,pain
  • Medical problems
    • DM, HT, cancer
  • Hx. Of surgery

History

slide29

Dysphagia

  • Hx. Of radiation
  • Medications
  • In children
    • Feeding
    • Growth
    • Development

History

slide30

Dysphagia

  • Complete examination
  • Head and neck
    • Mass
    • Thyroid
    • Lymph node
    • Salivary gland
    • Oral mucosa
  • Gag reflex, Cough reflex

Physical examination

slide31

Dysphagia

  • Procedure to evaluate -- major
    • 1.Fluoroscopy
    • 2.Endoscopy
    • 3.Manometry
    • 4.Ultrasonography

Investigation

slide32

Dysphagia

  • Barium swallow
    • conventional barium swallow
    • modified barium swallow

Fluoroscopy

slide33

Dysphagia

  • Modified barium swallow
    • Gold standard
    • Examine oral cavity & pharyngeal swallowing
    • Ba(1/3 teaspoon per swallow) & vary food consistency
    • Seated upright in normal eating position

Fluoroscopy

slide34

Dysphagia

  • Modified barium swallow
    • View in lat. plane with fluoroscope tube
    • Focus on lips & C7th

Fluoroscopy

slide35

Dysphagia

  • Modified barium swallow
    • Purpose restore oral intake as quickly
      • 1.define oral&pharyngeal disorder during swallow
      • 2.identify aspiration of any food consistency
      • 3.assess speed of swallow to determine adequate nutrition
      • 4.assess effect of Tx eg.postural change ,heightened sensory input ,Tx procedure (swallowing maneuvers)

Fluoroscopy

slide36

Dysphagia

  • convention barium swallow
    • Examine anatomy & motility esophagus
    • Ba(a cup of barium)(250 cc)swallow repeatedly
    • Lies in supine position
    • View in anteroposterior plane

Fluoroscopy

slide37

Dysphagia

Fluoroscopy

slide38

Dysphagia

  • Achalasia(failure to relax)(bird\'s beak appearance)
  • A:Contrast penetrate laryngeal vestibule within boundary of vocal cord
  • B:aspirate tracheobronchial tree
slide39

Dysphagia

  • Via transnasal placement of flexible fiberoptic scope
  • Can not examine oral stage & during swallow
  • May be identified residual food in pharynx after swallow

Endoscope

slide40

Dysphagia

  • Used examine esophageal peristalsis & function of UES & LES
  • Swallow soft tube contain 3 pressure sensor
    • First register --- UES
    • Second register – body of esophagus
    • Third register – pressure in LES
  • No information on aspirate or function in oral cavity or larynx

Manometry

slide45

Dysphagia

  • Used assess anatomy & physiology of tongue during swallowing (oral stage )
  • Can not examine pharynx or larynx because of skeletal interference

Ultrasonography

slide46

Dysphagia

  • Plain film : film lateral neck(soft tissue technique) -- FB,Infection
  • CT/MRI
  • 24 hrs.pH monitoring วัดภาวะกรดด่างในหลอดอาหาร คนปกติจะมี pH<4 ที่เหนือกล้ามเนื้อหูรูดล่าง 5 cm ไม่เกิน 1 hr./วัน

Other investigate

slide47

Dysphagia

  • Scintigraphy
    • Nuclear medicine test
    • Swallow several selected bolus of radioactive material
    • Gamma camera detect amount radiation passing
    • Oropharyngeal anatomy not visible
    • Aspiration – two trial material swallows
      • One to esophagus
      • Another to airway

Other investigate

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