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DYSPHAGIA

DYSPHAGIA. David Pothier MRCS DOHNS SpR ENT Louise Bredenkamp B Comm Path Speech Therapist. Dysphagia Definition. Difficulty in moving food from mouth to stomach.

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DYSPHAGIA

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  1. DYSPHAGIA David Pothier MRCS DOHNS SpR ENT Louise Bredenkamp B Comm Path Speech Therapist

  2. Dysphagia Definition • Difficulty in moving food from mouth to stomach. • Swallowing: entire act of deglutition from placement of food in the mouth through the oral, pharyngeal and oesophageal stages of swallowing.

  3. Context • Swallowing: complex process. • Incidence: high in certain populations Eg elderly , CVA, GORD • Associated with many different conditions. • Huge impact on QOL. • Important with relation to nutritional state. • May indicate sinister pathology.

  4. Stages of swallowing (Logemann) • Oral Preparatory • Oral • Pharyngeal • Oesophageal Duration & characteristics of each phase depends on consistency and volume of food/drink taken.

  5. Anatomy and physiology as part of the stages of swallowing

  6. Oral preparatory phase • Food is manipulated in the mouth and masticated if necessary, reducing it to a consistency ready for swallow. • Cranial nerves: • I: smell • V: Mandibular movement • VII: elevation of hyoid and tongue base • XI: tongue • XII: intrinsic & extrinsic tongue muscles

  7. Oral phase • Tongue propels food posteriorly until untill the pharyngeal swallow is triggered. • Cranial nerves: • V: soft palate elevation • VII: elevation of tongue base • Accessory:soft palate, tongue • Hypoglossal

  8. Pharyngeal phase • Pharyngeal swallow is triggered and the bolus moves through the pharynx. • Cranial nerves: • V: Elevation of larynx • VII: elevation of hyoid. • X: pharyngeal constrictors, cricopharyngeus, vocal folds • XI: pharynx • XII: hyoid and larynx

  9. Oesophageal phase • Oesophageal peristalsis carries the bolus through the cervical and thoracic oesophagus and into the stomach.

  10. Pathologies • Lesion at any of stages • Each stage can suffer a wide range of pathologies

  11. Classification • Structural • Neurological • Medication • Other • Also: • Environmental • Psychological (psychosomatic dysphagia, globus sensation etc.)

  12. Structural • Oral • Pharyngeal • Laryngeal • Oesophageal

  13. Important structural causes • Congenital (eg cleft lip/palate, laryngeal cleft, tracheo-oesophageal fistula) • Aquired • Inflammatory (eg pharyngitis, oesophagitis) • Traumatic (eg ill fitting dentures, foreign body) • Neoplastic (eg Sq Ca) • Other (GORD, pharyngeal pouches)

  14. Neurological • Congenital • Aquired • Disorders from which recovery can be anticipated: • CVA/TIA • Closed head trauma • Cervical Spinal Cord Injury • Post surgery • Poliomyelitis • Guillian-Barre • CP • Dysautonomia

  15. Neuro-degenerative diseases • parkinsons • Alzheimers • Dementia • ALS • Postpolio syndrome • MS • Myasthenia Gravis • Muscular Dystrophy • Dystonia • Dermatomiositis

  16. Medication NB: • NSAIDS • Anti-cholinergics • Sympathomimetics

  17. Other • Rheumatoid arthritis • Osteophytes

  18. Environmental & psychological • Environmental • Dislike food/drink given • Distractions in the environment • Psychological • Psychosomatic dysphagia • Globus sensation

  19. History • Age • Presenting Symptoms • Can’t recognise food, diff placing food in mouth, diff in controling food in mouth, coughing before, during or after swallow, frequent cough toward end of meal, recurring pneumonia, gurgly voice, • Which consistencies • Length of onset

  20. Associated symptoms • Otalgia • Odynophagia • Social History • Smoking, loss of weight, occupation • Past medical history • (GORD) • Medications & allergies

  21. Examination • Full ENT examination • Ears (effusion, retratcted TM) • Nose (severe sinusitis, post nasal space lesions) • Oropharynx (all mucosal surfaces) • Visualisation of the larynx • Nasoendocopy and/ indirect laryngoscopy

  22. How to investigate? • Sensation only with no risks: ? PPI and ?review • Other factors (any) Ba Swallow or ‘Panendoscopy’ • These normal - reassure

  23. Investigations • Barium swallow • Direct laryngopharyngooesophagoscopy • OGD If positive findings CT/MRI of neck. • If neurological cause suspected/known refer to medical team.

  24. Imaging studies • Ultrasound: to observe tongue function and to measure oral transit times as well as the motion of the hyoid bone. • Videoendoscopy: anatomy of oral cavity and pharynx, examine the pharynx and larynx before and after swallowing • Videofluoroscopy: most frequent used technique in the assessment of oropharyngeal swallow.

  25. Non-imaging • EMG • EGG • Cervical Auscultation • Pharyngeal manometry

  26. Treatment • Exclude malignancy • No organic cause – try PPI, SpTp, reassure • Organic cause treat specific lesion

  27. Conclusion • Thorough Examination • Appropriate Ix • Early SpTp referral • Regular review of status

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