DYSPHAGIA

1. Lianne Beck, MD Assistant Professor Emory Family Medicine DYSPHAGIA

2. Objectives • Define dysphagia • Know the 2 main types and how to differentiate them • Learn the major causes of dysphagia • Understand how to work up a patient with dysphagia • Become familiar with the treatment options

3. INTRODUCTION • Dysphagia—difficulty with swallowing—is a common condition • Reported by 7-10% of the general population aged over 50 years, • 16% of the elderly • Up to 25% of hospitalized patients • Oropharyngealdysphagia, is even more common in the chronic-care setting; up to 60% of nursing-home occupants have feeding difficulties that include dysphagia.

4. ESOPHAGEAL ANATOMY

5. SWALLOWING • Involves the actions of 26 muscles and 5 cranial nerves • CN V -- both sensory and motor fibers; important in chewing • CN VII -- both sensory and motor fibers; important for sensation of oropharynx & taste to anterior 2/3 of tongue • CN IX -- both sensory and motor fibers; important for taste to posterior tongue, sensory and motor functions of the pharynx • CN X -- both sensory and motor fibers; important for taste to oropharynx, and sensation and motor function to larynx and laryngopharynx; important for airway protection • CN XII -- motor fibers that primarily innervate the tongue • A normal adult swallows unconsciously 600 times a day

8. Esophageal Anatomy • Upper one-third is composed of skeletal muscle • Distal two-thirds is smooth muscle • NO SEROSA • Outer longitudinal, inner circular muscle layer • Myenteric plexus of Auerbach, parasympathetic ganglion cells, interspersed among the muscle layers • Submucosa – blood vessels/lymphatics, myenteric plexus of Meissner (parasympathetic ganglion cells) • Mucosa – stratified squamous epithelium

9. REVIEW • The outermost collection, lying between the inner circular and outer longitudinal smooth-muscle layers of the gut, is called the myenteric (or Auerbach's) plexus. • Neurons of this plexus regulate the peristaltic waves, consisting of polarized muscular activity, that move digestive products from oral to anal openings. • In addition, myenteric neurons control local muscular contractions that are responsible for stationary mixing and churning. • The innermost group of neurons is called the submucosal (or Meissner's) plexus. This group regulates the configuration of the luminal surface, controls glandular secretions, alters electrolyte and water transport, and regulates local blood flow

11. Swallowing Stage 1 • Oral • Food ingested, prepared (mastication) and modified (lubrication) • Voluntary control • Frequently results from weakness – lips, tongue, cheeks • Unable to organize food into well formed bolus and move posteriorly • Xerostomia – difficulty breaking down solids

12. Stage 2 • Pharyngeal • Prevented from entering nasopharynx, larynx rises, retroflexion of epiglottis and vocal fold closure, synchronized contraction of middle and inferior constrictors, and synchronized relaxation of the cricopharyngeal muscle -Involuntary • Timing – neurologic – epiglottis doesn’t protect larynx - leads to cough/aspiration • Weakness – neurologic injury/cancer – residual food after swallow – can lead to aspiration

13. Stage 3 • Esophageal • Begins with crico-pharyngeal relaxation • Involuntary • Most common • Sensation of food sticking at base of throat/chest • Peristalsis, tumor, stricture

14. HISTORY • Taking a careful history is vital for the evaluation of dysphagia. • The history will yield the likely underlying -pathophysiologic process -anatomic site of the problem in most patients - 80% • Crucial for determining whether subsequently detected radiographic or endoscopic 'anomalies' are relevant or incidental.

15. HISTORY • First, establish whether or not dysphagia is actually present • Globus sensation (in b/w meals), • Xerostomia-lose the lubrication properties and stimulus • Odynophagia- pain w/swallowing, transient than dysphagia, and persists only during the 15–30s that a bolus takes to traverse the esophagus. • Second, determine whether the site of the problem is esophageal or oropharyngeal. • Third , distinguish a structural abnormality from a motor disorder. • The history will also dictate whether the next diagnostic procedure should be endoscopy or barium swallow.

16. Where is the site of bolus hold-up? • Retrosternal bolus hold-up indicates that the disorder lies within the esophagus. • However, the patient's perception of an apparent bolus hold-up in the neck has low diagnostic specificity, and cervical localization per se does not help the clinician to distinguish pharyngeal from esophageal causes of dysphagia. • Owing to viscerosomatic referral, in 30% of cases the perceived site of hold-up is above the suprasternal notch when the actual hold-up is within the esophageal.

17. Does the patient report symptoms that are predictive of oropharyngeal dysfunction • 4 symptoms have high specificity for oropharyngeal dysfunction: • delayed or absent oropharyngeal swallow initiation • deglutitive postnasal regurgitation or egress of fluid through the nose during swallowing • deglutitive cough indicative of aspiration • the need to swallow repetitively to achieve satisfactory clearance of swallowed material from the hypopharynx. • If one or more of these four symptoms are present then the cause of dysphagia is probably oropharyngeal, either structural or neuromyogenic

18. OROPHARYNGEAL VS ESOPHAGEAL

19. Associated Symptoms and Possible Etiologies of Dysphagia • Progressive dysphagia -> Neuromuscular dysphagia • Sudden dysphagia -> Obstructive dysphagia, esophagitis • Difficulty initiating swallow -> Oropharyngeal dysphagia • Food "sticks" after swallow -> Esophageal dysphagia • Cough Early in swallow -> Neuromuscular dysphagia • Cough Late in swallow -> Obstructive dysphagia • Weight loss In the elderly -> Carcinoma • Weight loss with regurgitation -> Achalasia • Progressive symptoms Heartburn -> Peptic stricture, scleroderma • Intermittent symptoms -> Rings and webs, diffuse esophageal spasm, nutcracker esophagus

20. Associated Symptoms and Possible Etiologies of Dysphagia cont… • Pain with dysphagia -> Esophagitis: Postradiation, Infectious (HSV, monilia), Pill-induced • Pain made worse by: Solids only -> Obstructive dysphagia • Pain made worse by: Solids and liquids -> Neuromuscular dysphagias • Regurgitation of old food -> Zenker's diverticulum • Weakness and dysphagia -> Cerebrovascular accidents, muscular dystrophies, myasthenia gravis, multiple sclerosis • Halitosis -> diverticulum • Dysphagia relieved with repeated swallows -> Achalasia • Dysphagia made worse with cold foods -> Neuromuscular motility disorders

21. Selected Medications That May Affect Swallowing • Oropharyngeal function • Sedation, pharyngeal weakness, dystonia • Benzodiazepines • Neuroleptics • Anticonvulsants • Myopathy • Corticosteroids • Lipid-lowering drugs • Inflammation/swelling • Antibiotics • Xerostomia • Anticholinergics • Antihypertensives • Antihistamines • Antipsychotics • Narcotics • Anticonvulsants • Antiparkinsonian agents • Antineoplastics • Antidepressants • Anxiolytics • Muscle relaxants • Diuretics

22. Selected Medications That May Affect Swallowing cont… • Esophageal function • Inflammation (resulting from irritation by pill) • Tetracycline, Doxycycline (Vibramycin) • Iron preparations • Quinidine • Nonsteroidal anti-inflammatory drugs • Potassium • Impaired motility or exacerbated gastroesophageal reflux • Anticholinergics • Calcium channel blockers • Theophylline • Nitrates • Esophagitis (related to immunosuppression) • Corticosteroids

23. Etiology of Oropharyngeal Dysphagia • Structural/Obstructive • Head or neck tumors • Postsurgical/Radiation stenosis • Cervical spondylosis • Zenker's diverticulum • Cricopharyngeal web • Infectious (tonsilar hypertrophy/abscess) • Extrinsic compression (goiter)

24. Etiology of Oropharyngeal Dysphagia • Neuromuscular • CVA • Alzheimer’s, Parkinson's disease • Brain stem tumors • Degenerative/Demylenating diseases • ALS, MS, Huntington's • Acute transverse myelitis, ADEM, and acute hemorrhagic leukoencephalitis • Sjogren’s • Postinfectious • Poliomyelitis, Syphilis • Peripheral nervous system • Peripheral neuropathy • Motor end-plate dysfunction • Myasthenia Gravis • Botulism • Eaton-Lambert Syndrome • Myopathies • Polymyositis • Dermatomyositis • Muscular dystrophy (myotonic dystrophy, oculopharyngeal dystrophy) • Thyroid myopathy • Amyloidosis • Cricopharyngeal (upper esophageal sphincter) • Sarcoidosis • Paraneoplastic Syndromes

25. Causes of Esophageal Dysphagia • Structural disorders • Inflammatory and/or fibrotic strictures • Peptic • Caustic • Pill-induced • Radiation-induced • Mucosal rings and webs • Schatzki's ring • Multiringed esophagus (eosinophilic esophagitis) • Foreign body • Carcinoma • Primary (squamous, adenocarcinoma) • Secondary (e.g. breast, melanoma) • Disorders related to Systemic Diseases • Pemphigus and pemphigoid conditions • Lichen planus • Scleroderma (multifactorial) • Intramural lesions • Leiomyoma • Granular cell tumor • Sarcoidosis • Extramural lesions • Aberrant right subclavian artery (dysphagia lusoria) • Mediastinal masses (thyroidomegaly) • Bronchial carcinoma • Anatomical abnormalities • Hiatal hernia • Esophageal diverticulum

26. Causes of Esophageal Dysphagia • Neuromuscular/Motility disorders • Achalasia (idiopathic or secondary) • Spastic motor disorders • Diffuse esophageal spasm • Hypertensive lower esophageal sphincter • Nutcracker esophagus • Diabetes • Amyloidosis

27. ESOPHAGEAL • Is it a structural vs motility disorder?

28. Is the dysphagia for solids or liquids • Patients who have a motor disorder will describe dysphagia for BOTH liquids and solids. • Patients who have structural disorders will describe dysphagia for solids only. • Once a solid bolus becomes impacted, the patient will report dysphagia for liquids and solids.

29. Motility- features • Three cardinal features of dysmotility • dysphagia (for solids and liquids) • chest pain and • regurgitation • Regurgitation during meals, as well as spontaneous regurgitation between meals or at night, is highly suggestive of dysmotility. • Unlike regurgitation that is related to GERD, the regurgitated fluid in patients with esophageal dysmotility is generally not noxious to taste.

30. Motility- features • In addition, spasm or achalasia typically cause chest pain. Although this chest pain is frequently described as 'heavy' or 'crushing', it can be indistinguishable from the typical 'heartburn' of reflux. • The pain frequently occurs during meals, but it can be quite unpredictable and sporadic or nocturnal. • Sipping antacids or even water can relieve the pain related to dysmotility, which further confuses its distinction from reflux-related pain.

31. How long has dysphagia been present? Is it intermittent? Is it progressive? • Slowly progressive, long-standing dysphagia, particularly against a background of reflux, is suggestive of a peptic stricture. • Caveat - severity of heartburn correlates poorly with esophageal mucosal damage. • A short history of dysphagia—particularly with rapid progression (weeks or months) and associated weight loss—is highly suggestive of esophageal cancer. • Long-standing, intermittent, non-progressive dysphagia purely for solids is indicative of a fixed structural lesion such as a distal esophageal ring or proximal esophageal mucosal web.

32. Physical Exam • If oropharyngeal dysphagia is suspected, evaluation for neuromuscular disorders is important. • Thorough neurological, head and neck exam • Skin should be examined for features of connective tissue disorders, particularly scleroderma and CREST syndrome. • Muscle weakness or wasting might be evident if myositis is present, and myositis can overlap with other connective tissue disorders that affect the esophagus. • Look for tremors, rigidity, fasciculations • Signs of malnutrition, weight loss and pulmonary complications from aspiration should be looked for.

33. Laboratory and Imaging • CBC to screen for infectious or inflammatory conditions • TFT’s may detect hypo- or hyperthyroid-associated causes of dysphagia ( Grave's disease or thyroid carcinoma), • Anti-acetylcholine antibodies to diagnose myasthenia gravis • Muscular enzymes to diagnose myositis • Autoimmune studies (ANA, RF, Anti-SSA, Anti-SSB, Anti-Scl-70, anti-centromere) • CT/MRI to evaluate for CVA, MS, tumors

34. Investigations • Video Fluoroscopic Swallowing Study (VFSS) • “Modified barium swallow", is the "gold standard" for diagnosing oropharyngeal dysphagia. • Dynamic test in which the patient is asked to swallow a variety of food items of different consistencies covered with barium. • A video fluoroscopic recording is made in both A/P and lateral views. Allows for observation of bolus progress throughout the different stages of the swallowing process. The presence of pooling, delayed transit and laryngeal aspiration can be detected. • The dynamic nature of this study provides an opportunity to evaluate the response to certain correctional techniques (e.g., chin tucking) during the study. • This technique requires the cooperation of an alert patient, which is the most limiting factor to performing VFSS.

35. Investigations • Video Endoscopic Swallowing Study (VESS) • Direct visualization of the oropharynx in action with and without swallowing, using a fiberoptic scope inserted nasally. • This test is valuable when VFSS can not be performed and is usually done by an otolaryngologist • Barium swallow studies • Initial recommended test if esophageal dysphagia is suspected • Suspected obstructive lesion (e.g., Schatzki's ring, tumor) • Suspected esophageal motility disorder • EGD • Suspected acute obstructive lesion (impacted food bolus) • Evaluation of the esophageal mucosa • Confirmation of a positive barium study with biopsies or cytology • Manometry • Abnormality not identified on barium study or by endoscopy

36. NO DYSPHAGIA

37. INTERMITTENT DYSPHAGIA FOR SOLIDS

38. DYSPHAGIA WITH LONG HX OF GERD

41. DYSPHAGIA FOR SOLIDS AND LIQUIDS WITH WT LOSS

42. DYSPHAGIA FOR SOLIDS AND LIQUIDS

43. Young male patients who present with intermittent dysphagia or bolus impaction

44. INTERMITTENT DYSPHAGIA FOR SOLIDS AND LIQUIDS • Numerous nonpropulsive contractions • “corkscrew/ rosary bead” esophagus

45. IRON DEFIIENCY ANEMIA

46. Due to an aberrant right subclavian artery coursing posterior to esophagus

48. Approach to OropharyngealDysphagia

49. Approach to Esophageal Dysphagia

50. Management of OropharyngealDysphagia • Treat underlying cause • Determine whether patient can obtain adequate nutrition orally and risk of aspiration • Feeding tube should be considered, although no evidence that it reduces risk of aspiration, so tracheostomy may also be needed. • Dietary modifications • Thickened liquids when tongue function is disordered or laryngeal closure is impaired. • Thin liquids are used for weak pharyngeal contraction and reduced cricopharyngeal opening. • Swallowing maneuvers • Postural adjustments • Facilitatory techniques, such as strengthening exercises, biofeedback, thermal and gustatory stimulation.