Dysphagia

Upper digestive tract evaluation and imagingDysphagiaEvaluation and ManagementEvaluation of dysphagiaThree-stage event of swallowing: oral, pharyngeal, and esophageal. The oral stage consists of two phases: oral preparatory and oral transport. bolus passage are the result of increased or decreased pressures within the upper airway. The changes are associated with function of the lips, tongue, soft palate, pharyngeal walls, vocal folds, and upper esophageal sphincter (UES), as well as anterior-superior displacement of the hyoid bone and larynx.Clinical Evaluation of dysphagiaClinical examination of the patient who complains of difficulty with oral intake is essentially a cranial nerve examination

cranial nerves (CNs) V, VII, IX, X, and XII because these nerves contribute to the afferent and/or efferent function of the face, mouth, larynx, and pharynx during mastication and swallowingairway clearance best assessed by imaging of the airway primary technique used for imaging the airway during deglutition is videofluoroscopy.Physiology of SwallowingThe act of swallowing involves three phases: Oral, Pharyngeal, and Esophageal.Swallowing takes about 8-10 secondsBefore swallowing begins, Oral Preparation of the bolus must occur.

Physiology of Swallowing:

Oral PhasePharyngeal PhasePhysiology of SwallowingPharyngeal and Esophageal Phase:

Evaluation of DysphagiaHistoryReview of system Physical ExamImaging StudiesHistoryDuration dietary changes, weight loss OdynophagiaSolids or Liquids Level of sensation of dysphagiaPast surgery to head and neck, trauma, ingestion of caustic substancesAssociated symptoms such as with GERD, voice changes, nasal leakage, otalgiaReview of Systems:Ask about common systemic processes associated with dysphagia:Tobacco/AlcoholMedications antihistamines, anticholinergics, antidepressants, antihypertensivesOsteoarthritisSystemic neuromuscular disordersAuto-Immune disordersPsychiatric statePhysical Exam:General: body habitus, mental status, wheezing, dyspnea, voice qualityCranial nervesInspection of the tongue and palate for strength/symmetryLaryngeal Examination: vocal fold movement, interaretynoid areaImaging Techniques

Videofluoroscopic Swallow Study (VFSS)-- The most frequently used, and often the most appropriate-- performed in the radiology department-- observation of pathophysiologic aspects of the oral and pharyngeal stages of the swallow--to identify the pathophysiologic cause(s) of dysphagiacan determine the time of the aspiration relative to bolus passage through the pharynx. For example, aspiration during the swallow may result from inadequate hyolaryngeal elevation and inadequate laryngeal closure, and aspiration after the swallow may result from residue in the pyriform sinuses due to inadequate opening of the cricopharyngeal sphincter or from poor pharyngeal constrictor function..further example:inadequate cricopharyngeal opening could be related to hypertonicity of the muscle and/or inadequate elevation of the hyolaryngeal complex. Obviously, treatment would be quite different depending on the cause of inadequate opening. In the case of inadequate cricopharyngeal opening due to hypertonicity, dilation of the UES may resolve the problem, whereas, in the case of inadequate opening due to inadequate elevation of the hyolaryngeal complex, dilation may be ineffective. The structural movements that can be observed during VFSS include movement of the following:LipsTongueJawSoft palatePharyngeal wallsHyoid boneEpiglottisThyroid cartilageArytenoidsUES

Fiberoptic Endoscopic Evaluation of SwallowingUses as a mobile tool that can be used in training patients via biofeedbackAdvantagesDisadvantagesPortableBlind spotAllows assessment of sensationCannot evaluate cricopharyngeus directlyCheapCannot eval. esophagusCan be used for pt teachingNo radiationFiberoptic Endoscopic Examination of Swallowing (FEES)FEES uses flexible endoscopy to view the pharyngeal region and the larynx before and after the swallow

Observations prior to bolus presentation include the following:The position of the velopharynx during rest as well as during the production of nasal and nonnasal phonemesSymmetry of the pharynx and the larynx at rest and during phonationAbsence or presence of excessive secretionsAppearance of the vocal folds and surrounding structuresVocal fold motion when the patient is instructed to take a deep nasal inhalationVocal fold motion and extent of closure when the patient is instructed to cough, to hold the breath normally, and to hold the breath tightlyVocal fold motion when the patient is instructed to produce and hold a series of productions of the phoneme /i/ at the habitual pitch as well as a high pitch and a low pitchAny difficulty with salivary control

Fiberoptic Endoscopic Evaluation of Swallowing

Barium EsophagramUses: structural disorders, e.g. dysphagia for solid foods. Can use air contrast.AdvantagesDisadvantagesGood anatomic detailRadiationLogistics in bedridden pts.Cannot detect dynamic disorders.Air Contrast Barium Esophagram

NormalFungal PlaquesSCINTIGRAPHYScintigraphyAlthough scintigraphic examination is not a commonly selected method of examination, it has been reported to be useful in a variety of instances examination of swallowing consists of the external monitoring of food or liquid in which radionuclides are present. Although the VFSS permits the clinician to observe structural displacements and bolus passage, it does not allow for a precise estimate of the amount of material that has been aspirated during the study

With scintigraphy, the clinician can obtain a more precise measure of the amount of material that has been aspirated but cannot present anatomic detail nor provide for observation of structural displacements.

Bolus ScintigraphyUses: follow improvement in a patient with history of aspiration, patient with achalasia.Advantages:Disadvantages:Less radiationNo anatomic detailsQuantitative count of particlesSingle bolus, not different consist. usedElectrophysiologic Techniques

ElectromyographyRespirodeglutometryPressure Measurements-- manometryElectromyography Relative to the assessment of muscle function during deglutition, used to quantify the temporal activity of a specific muscle during a particular action as well as to rule out a possible paralysis or paresis. The confirmation of muscle viability

ManometryUses: disorders in which intraluminal pressures must be measured (achalasia, esophageal spasm, etc.)AdvantagesDisadvantagesIt is the only test of pressure wave physiologyCannot diagnose visible lesionsUnpleasant for patientTechincally demandingManometry

Disorders that Cause DysphagiaForeign Bodies

Tracheostomy

Cricopharyngeal Achalasia

Cricopharyngeal Achalasia

Cricopharyngeal Myotomy:Zenkers Diverticulum

Zenkers Diverticulum

Cervical Spine Disease

Esophageal Webs and Rings

Strictures / Caustic Ingestion

Achalasia

Gastroesophageal Reflux Disease

Cancer

Systemic Disorders that Cause DysphagiaStroke present in up to 47%Amyotrophic Lateral SclerosisParkinsons DiseaseMultiple SclerosisMuscular DystrophyMyasthenia GravisAutoimmune DisordersSystemic SclerosisSystemic Lupus ErythematosisDermatomyositsMixed Connective Tissue DiseaseMucosal Pemphigoid, Epidermolysis BulosaSjogrens Syndrome (xerostomia)Rheumatoid Arthritis (cricoarytenoid joint fixation)AgingDysphagia is present in 2% > 65Poor dentitionLoss of tongue connective tissueIncreased pharyngeal transit time

Dysphagia in ChildrenNasal obstructionOral lesions clefts, ranulas, mucocelesLaryngomalacia, laryngeal clefts, TE fistulaTumors hemangiomas, lymphangiomas, papillomas, leiomyomas, neurofibromasSoal-soalB-I1. In which of the following is not encountered in tracheoesophageal fistula?CoughHoarsenessRecurrent pneumoniaDysphagiaPurulent sputumB2. Gastroesophageal reflux is etiologically implicated with..Contact granulomaCarcinoma larynxLeukoplakia vocal foldsZenkers diverticulumAll the aboveE3. Bolus fragmentation..Occurs due to flow interference by mass lessionResults from sensorimotor impairmentCan cause coronaryOccurs with equal frequency in association with liquids and solidsAll the aboveE4. Pharyngeal constrictor action is best assessed by ..Medical historyPhysical examinationCine or videopharyngogramManometric examinationalectromyogramC5. Pooled secretions in the hypopharynx are associated with..Wet voiceInspiratory wheezeCough-choke episodesZenkers diverticulumAll the aboveE6. The cricopharyngeus muscle...

Contracts during inspirationRelaxes before the conclusion of pharyngeal swallowIs predominantly comprised of smooth muscleIs predominantly comprised of skeletal muscleIs innervated by branches from the pharyngeal plexusC7. Dysphagia due to neurologic dysfunction...a. Is primarily manifested by dysphagia for liquidsb. Is primarily manifested by dysphagia for solidsc. Is accompanied by gastroesophageal refluxd. Is accompanied by esophageal dyskinesiae. Is accompanied by cricopharyngeal spasmA8. Zenkers diverticulum is accompanied by..Gastroesophageal refluxCricopharyngeal dysfunctionDysphagia for solid bolusDysphagia for liquid bolusAll the aboveE9. Dysphagia in quinsy is due to..Impaired tongue activityDefective larynx elevationCricopharyngeal dysfunctionImpaired pharyngeal constrictor actionAll of the aboveA,B10. Impaired larynx elevation may occur in all the following except..Bilateral mandibular body fracturesSupraglottic laryngectomyTracheotomyLateral medullary infarctQuinsy D11. The medial border of the pyriform fossa is partially formed by the..VelleculaHyoid boneConus elasticusThyroid cartilageAryepiglottic fold

E12. The feature of the upper airway that is unique to humans isPassavants ridgeThe laryngeal ventricleDescent of the larynx during developmentComplete glottal closure with phonationContact of the uvula with the epiglottisD ???13. Laryngeal edema is most likely to result in..HyperpneaReflex apneaInspiratory stridorExpiratory wheezingProlonged exhalationEB-IIThe pharyngeal phase of swallowing includes...Palate elevationLarynx elevationPharyngeal constrictor constractionRelaxation of the cricopharyngealAll the aboveE2. Thick tenacious pharyngeal secretion are usually indicative ofTraumaRefluxNeurological impairmentForeign bodyC3. Pharyngeal constrictor action is best assessed by..Physical examinationMedical historyVideopharyngogramManometryelectromyogramC4. Symptoms of food holding up in the neck area may be seen withHiatal hernia with spasmZenkers diverticulumEsophageal cancerAchalasiaAll the above E5. Vocal fold paralysismay be associated withPainFeverStridorWeight-lossFood hold-up

C6. Dysphagia due to neurologic dysfunction is..a. Primarily manifested by dysphagia for solidsb. Primarily manifested by dysphagia for liquidsc. Accompanied by gastroesophageal refluxd. Accompanied by esophageal spasme. Accompanied by heartburnB