Clinical approach for Dysphagia .pptx (dysphagia)

Clinical approach for Dysphagia

1. Clinical approach for Dysphagia

2. definition Dysphagia : Difficulty in swallowing due to mechanical or motor causes .

3. Swallowing (deglutition) mechanism Initiated voluntarily and completed involuntarily. Center: medulla. Stages : Buccal phase Pharyngeal phase Esophageal phase

4. Buccal phase : The front of the tongue is elevated and pressed against the hard palate Bolus is rolled backward toward the back of the tongue Then to the pharynx by contraction of the mylohyoid muscle ( skeletal muscle ) Pharyngeal phase : ( swallowing reflex ) Involuntary Stimulus : food in the pharynx Afferent: trigeminal nerve and glossopharyngeal nerve Center: medulla Efferent: trigeminal nerve, glossopharyngeal nerve, facial nerve, hypoglossal nerve Result: contraction of superior, middle, and inferior pharyngeal constrictors pushing the food to the esophagus Esophageal phase Involuntary Fluid travels by gravity Food travels by peristalsis

5. Functional grades of dysphagia There are 6 grades of dysphagia GRADE 1: Complains of dysphagia but still eating normally. GRADE 2: Requires liquid with meals. GRADE 3: able to take semisolid, but unable to take any solids. GRADE 4: able to swallow liquids only. GRADE 5: unable to swallow liquid, but able to swallow saliva. GRADE 6: unable to swallow saliva also.

6. HISTORY AGE : Cancer in old age ......post corrosive in children TYPE OF FOOD : only to solids in mechanical causes ......to both solid and fluid in motor dysphagia DURATION AND COURSE : short (inflammatory causes), intermittent (functional disorder), progressive (cancer) ASSOCIATED SYMPTOMS : severe loss of weight in cancer , manifestation of thyroid dysfunction in cases with goiter

7. ask about : onset ,course, duration type of food painless or painful associated symptoms site of obstruction transfer dysphagia acute onset ...variable course ...more to liquid with nasal regurgitation , dysphonia , neurological ma nifestations HISTORY

8. transit dysphagia: Achalasia intermittent ..may progress to long duration liquid more than to solid relived by repeated swallowing with heartburn precipitated by eating .. no marked loss of weight scleroderma Intermittent course .... both solids and liquids .. with nocturnal cough ,regurgitation NB : dysphagia that worsens on ingestion cold liquids ,improves with warm liquids suggests a motor disorder (transit dysphagia ) HISTORY

9. Obstructive dysphagia: cancer esophagus progressive .. short duration dysphagia to solids that may progress to include liquids with weight loss , chest , back pain Esophageal webs associated with iron deficiency anemia , glossitis (Plummer- Vinson syndrome) HISTORY

10. 1- oral examine Teeth: Ludwig’s Angina / Severe cellulitis “ spread infection from 2 nd , 3th moral to tonsils Tonsils: (bad  tonsillitis or quinsy ), very swollen Abscess : at the back of the throat peritonsillar abscess Examination

11. 2- neck examine Lymph nodes : enlarge due to viral , bacterial infection or cancer. Thyroid : Thyroid cancer, Pregnancy, Iodine deficiency, Hyperthyroidism (overactive thyroid) or hypothyroidism (underactive thyroid), Thyroid nodules, Hashimoto’s disease, Thyroiditis, Graves’ disease

12. 3- Cranial nerves Glossopharyngeal , vagus , accessory nerve : drink water then see any lag in swallowing or return water from his nose

13. investigation Endoscopy E sophageal stricture Schatzki ring EFI

14. Endoscopy HSV Esophagitis Esonophilic Esophagitis GERD

15. Barium Swallow Zenker’s Diverticulum Esophageal cancer

16. Barium Swallow Achalisia Diffuse Esophageal Spasm Nutcracker esophagus

17. Esophageal Manometry N ormal pressure of lower esophageal sphincter (LES) I s 15 mmHg , normally less than 10 mmHg when LES R elax to let food pass Abnormal when pressure at LES is less than 10 mmHg LES pressure is high &fails to relax after swallowing A bnormal contraction along esophagus is weak

18. Fiber-optic endoscopic evaluation of swalloing (FEES) . Ultrasound

19. B lood test : T hyroid stimulating hormone test Dysphagia secondary to hypothyroidism is believed to be associated with a hormonal effect on esophageal and gastric motility with neuromuscular incoordination; however, the underlying mechanism remains unknown.  Vit B12 Dysphagia is an uncommon manifestation of vitamin B12 deficiency that is potentially reversible if diagnosed and treated within the first six months. In case of pernicious anemia Keratine kinase Dysphagia can be one of the manifestations of inflammatory myopathies (IMs). In some patients, it can be one of the presenting symptoms or the only symptom. We present a patient with dysphagia and progressive muscle weakness who was eventually diagnosed with inclusion body myositis (IBM)

20. O ther tests Videofluoroscopy : it is currently the gold standard for the study of oropharyngeal dysphagia. Using a flexible nasopharyngolaryngoscope , one can visualize all the phases of swallowing as they occur. It can be used to precisely measure oropharyngeal transit times and diagnose laryngeal penetration Evan’s methylene blue test: it is useful to diagnose dysphagia and aspiration in tracheostomized patients. It can be performed in those tracheostomized patients who can tolerate cuff deflation and are able to either breathe spontaneously or are able to maintain continuous positive pressure ventilation. A few drops of methylene blue are instilled on the tongue in the semi-sitting position. Appearance of blue-stained secretions in the tracheal aspirations over the next few hours is an indication of aspiration.

21. Differential diagnosis 1-Transfer dysphagia ( neurogical causes, motor causes) “to both solids and fluids” Bulbar & pseudo-bulbar palsy Myasthenia gravis , myopathies & polymyositis. Stroke neuritis 2-transit dysphagia (functional , abnormal peristalsis) Achalasia Scleroderma Esophageal spasm The Commonest causes of dysphagia: Cancer, achalasia, GERD & post-corrosive .  

22. Differential diagnosis 3-obstructive dysphagia (mechanical narrowing of the esophagus) “ only to solids”   Intrinsic disease of the esophagus: Congenital anomalies as atresia. Gastro esophageal reflux disease (GORD). Stricture due to corrosive esophagitis. Tumors: Cancer esophagus, sarcoma, lymphoma Esophageal webs: Plummer Vinson syndrome Compression of the esophagus: Thyroid enlargement Left atrial enlargement Posterior mediastinal masses Zenker ’ s diverticulum Causes of mediastinal syndrome: goiter, bronchogenic carcinoma

23. Differential diagnosis 4- odynophagia (painful swallowing) Painful diseases(inflammation) of the mouth & pharynx: Stomatitis, pharyngitis, tonsillitis &retropharyngeal abscess.   5- hysterical Globus hystericus

24. prepared by Zeinab Emad Younis Abdel-Rahman Faculty of medicine King Salman International university, EGYPT E-mail: [email protected] LinkedIn : https://www.linkedin.com/in/zeinab-emad-33380423a/

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