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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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Dysphagia

นพ.โกสินทร์ ชัยชำนาญ

Ent


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Objectives

  • Normal physiology

  • Dysphagia

    • Definition

    • Cause and classification

    • History taking,physical examination and investigation

    • Disease


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Normal physiology

  • 4 stage

    • Oral preparatory stage

    • Oral stage

    • Pharyngeal stage

    • Esophageal stage


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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


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Oral preparatory stage

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

  • Orbicularisoris – sphincter of lip

  • Buccinator – compress [email protected] cheek


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Oral preparatory stage

2.Muscle of mastication (V) – jaw movement

  • Lateral pterygoid – [email protected]

  • Temporalis – [email protected]/P move

  • Masseter – close jaw

  • Medial pterygoid – [email protected]


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Oral preparatory stage

y

3.Tongue muscle

  • Palatoglossus(X) – down soft [email protected] BOT

  • Genioglossus(XII) – elevate BOT

  • Hyoglossus(XII) -- depress


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Oral preparatory stage

er

Time : depend on type of food


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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


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Oral stage

  • buccal musculature

  • tongue

swallow

  • Styloglossus muscle

  • Hyoglossus muscle


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Oral stage

swallow

trigger zone at anterior pillar


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Oral stage

ri

swallow

CN IX

triggerswallowing reflex

sensory impulse at CN IX


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Oral stage

swallow

Tractus solitarius nucleus/

Solitary tract nucleus

triggerswalling reflex

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


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Oral stage

swallow

nucleus ambiguus

CN X

nucleus ambiguus to motor neuron ofCN X atpharynx


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Oral stage

swallow

nucleus ambiguus

nucleus ambiguus to motor neuron ofCN X at pharynx


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Oral stage

er

Time : take 1 second


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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)


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t


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Pharyngeal stage

  • 1.tongue

swallow

  • Styloglossus muscle

  • Hyoglossus muscle


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Pharyngeal stage

swallow

  • 2.Levator @ Tensor palatini

  • Levatorpalatini

  • Tensor palatini


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Pharyngeal stage

swallow

  • 3.pharyngeal constrictor muscle

  • Superior

  • Middle

  • Inferior


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Pharyngeal stage

swallow

  • 4.aryepiglottic fold/true vocal fold /false vocal fold

  • AEF

  • FVF/TVF


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Pharyngeal stage

er

Time : take less than 1 second

(not vary with age and gender)


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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


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Esophageal stage

er

Time : take 8 to 20 seconds

(depend on food influence by

peristalsis&gravity)


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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


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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


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Dysphagia

  • Hx. Of radiation

  • Medications

  • In children

    • Feeding

    • Growth

    • Development

History


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Dysphagia

  • Complete examination

  • Head and neck

    • Mass

    • Thyroid

    • Lymph node

    • Salivary gland

    • Oral mucosa

  • Gag reflex, Cough reflex

Physical examination


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Dysphagia

  • Procedure to evaluate -- major

    • 1.Fluoroscopy

    • 2.Endoscopy

    • 3.Manometry

    • 4.Ultrasonography

Investigation


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Dysphagia

  • Barium swallow

    • conventional barium swallow

    • modified barium swallow

Fluoroscopy


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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


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Dysphagia

  • Modified barium swallow

    • View in lat. plane with fluoroscope tube

    • Focus on lips & C7th

Fluoroscopy


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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


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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


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Dysphagia

Fluoroscopy


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Dysphagia

  • Achalasia(failure to relax)(bird's beak appearance)

  • A:Contrast penetrate laryngeal vestibule within boundary of vocal cord

  • B:aspirate tracheobronchial tree


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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


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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


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Dysphagia

  • Used assess anatomy & physiology of tongue during swallowing (oral stage )

  • Can not examine pharynx or larynx because of skeletal interference

Ultrasonography


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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


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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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