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Diseases of oral cavity, pharynx and oesophagus

Prof. Vörös Károly

Diff. Dx. of Dysphagia 1.

� Pain:

� Dental diseases (eg. tooth fracture, abscess, disease of periodontium, abnormal dentation)

� Inflammatory processes, abscess (oral, pharyngeal, tongue, lymphnodes)

� Foreign bodies

� Mandibular trauma

� Hyoid or temporomandibular joint disease

Diff. Dx. of Dysphagia 2.

� Muscular:

� Hyperkalaemic Periodic Paralysis

� Nutritional myodegeneration (Se)

� Polysaccharide storage myopathies

� Masseter inflammation

� Hypocalcaemic tetany

� Megaesophagus

� Rupture of rectus capitis ventralis

Diff. Dx. of Dysphagia 3.

� Obstruction:� Abscessation, inflammation, neoplasia of retropharyngeal

lymphonode

� Malformation, injury, neoplasia, oedema, cysts anywhere „on the way”

� Foreign body

� DDSP or Fourth Branchial Arch Defect (4BAD)

� Cleft palate

� Guttural pouch tympani or empyema

� Oesophageal obstruction

� Pharyngeal cicatrix

Diff. Dx. of Dysphagia 4.� Nervous system:

� V, VII, IX, X, XII cranial nerves� Guttural pouch mycosis, empyema, neoplasia� Broken bones, osteomyelitis� Retropharyngeal abscess

� Neurotoxins, toxic materials� Tetanus� Botulism� Hepatoencephalopathy � Lead poisoning

� Generalized neurophaties� Equine dysatonomia, Grass sickness� Polyneuritis equi

� CNS disorders� Intracranial edema, haemhorrhagia, neoplasia, hematome, abscess� Víral encephalitis: rabies, WND, EHV-1,� other tick borne encephalities (EEE, WEE, VEE)� Equine protozoal myeloencephalitis (EPM)

Nutritional management

� No long fiber

� Feeding foal tubes/Nasogastric tube

Oesophagostomy; pellet slurries, liquid diets

� Electrolytes substitution

(salivary loss: Na, K, Cl)

� Energy requirements: corn oil

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Dental diseases

� Riding difficulties, decreased appetite,

weight loss, nasal discharge, swellings etc.

� Diseases of the tooth radicals: caries, fracture,

foreign bodies

� Mandibular: fistula

� Maxillary: sinusitis

� Teeth wear problems

� Regular check

� Oral cavity exam., x-ray, endoscopy, CT, MRI

Congenital diseases(oral and pharyngeal cavity)

� Cleft Palate

� Soft or/and hard palate

� Dysphagia, regurgitation

� Aspiration pneumonia

� Weight loss

� Surgery

� Pharyngeal cysts

� Subepiglottal

� Soft palate

� Hypoplasia of upper lip, campylorhinus lateralis

Oral cavity ex.,endoscopy, X-ray

Diseases of oral cavity

� Non infectious:� Mechanical injuries (food, tooth, bite etc.)

� Chemical materials (eg. phenyl-butason)

� Toxic and metabolic diseases

� eg.: renal, liver failure

� Infectious

� viral (vesiculo, vaccinia)

� bacterial (eg.:Actinobacillosis)

� fungal (candidiosis, satratoxicosis)

� Autoimmune diseases

� Amyloidosis

Oral neoplasias

� Squamous cell carcinoma, fibrosarcoma, melanoma, haemangiosarcoma, rhabdomyoma, lymphosarcoma, osteosarcoma

� Biopsy

� Surgery (?)

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Hyoid apparatus and tongue

� Glossitis / oedema, injury of tongue

Signs: salivation, appetite loss, halitosis

� Fracture, inflammation, neoplasia of hyoid bones

� Temporohyoidal arthrosis, arthritis

Signs: bleedings, cranial nerve paralyses, decreased appetite, weight loss

DX: endoscopy, x-ray, CT, MRI, US

TX: ABs, NSAIDs, n-g feeding, surgery

Ulceration Injury

Paralysis

� N. hypoglossus

� Encephalitis, botulism, etc. (see dysphagia)

� Unilateral/bilateral

� Neonatal tongue and pharyngeal weakness

� inmature

� milk regurgitation

� 2-4 weeks

Pharyngitis

� Mechanical� Eg: nasogastric tubing, foreign bodies

� Chemical� Bacterial and viral and allergens

� Young horses (2-6 yrs), immunosuppression (Streptococci, Actinobacillus equuli, resp. viruses)

� chronic pharyngitis� lymphoid hyperplasia� Poor performance, resp. symptoms, pain,

swallowing difficulties, salivation� DX: endoscopy, swab� TX: inhalation of AB/NSAID/DMSO

Pharyngeal Paralysis

� Cranial nerves� N. glossopharyngeus (IX)

� N. vagus (X)

� CNS: mental status, other symptoms

� Usu. with oesophageal paralysis

� Sx: dysphagia, regurgitation

� Dx: nervous system ex., endoscopy

� Aspiration pneumonia (US, X-ray)

� Tx: ?, poor prognosis

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Diseases of salivary glands

� 12 l saliva daily

� Parotis: electrolytes, (sialoliths: calcium)

� Submandibular, sublingual glands less important

� Inflammation� Acute, chronic

� Ascending through Stenon-duct

� Haematogenous

� Traumatic

� Signs:� Pain symptoms

� Unilateral swelling

� Purulent - putrid (US: gas, Ca deposits)

� Fistula formation – saliva drains

� Chronic: fibrosis

� Tx: AB, NSAID, formalin inj.,

surgery

� Neoplasia� Adenocarcinoma, melanoma

Diseases of oesophagus

� Congenital� Intramural cysts

� Endoscopy, contrast x-ray, biopsy

� Surgery

� Megaoesophagus � Primer: muscular hypoplasia, dysplasia

� Secunder: stricture, strangulation (Botallo-duct)

� Oesophagus duplex

� Oesophageal spasm

� Cold water, fast eating

� Young, nervous, hungry horses

� Inflammatory processes, nasogastric tubing

� Cardiospasm

� Transient or followed by obstruction

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� Oesophageal obstruction/Choke� Primer: food parts, foreign bodies,

poor dentation,

after narcosis or exhausting work

� Secunder: as a consequence of

other (oesophageal) diseases

� Behind pharynx, thoracic inlet, front of diaphragm

� Signs: Discomfort, regurgitation

� Dx: palpable?, n-g tubing, X-ray, endoscopy

� Complications:� Aspiration pneumonia

� Oesophageal ulceration, mucosal necrosis, perforation

� Chronic: dehydration, hyponatraemia, hypochloraemia, hypokalaemia, metabolic acidosis

� Tx:

� Massage

� Spasmolytic (butil-scopolamin, oxytocin), painkillers (NSAID), sedatives (acepromazine, xylazine, detomidine)

� Infusion therapy

� Lavage through nasogastric tube (standing, gen. anaesthesia.)

� Surgery

� Endoscopic control after

� Diet, feeding tube

� Stricture formation!

� Oesophageal inflammation, ulceration

� Swallowing irrigative materials

� Gastric and duodenal ulcers, delayed gastric emptying: reflux oesophagitis

� Loss of appetite, teeth-grinding, dysphagia

� Dx: endoscopy, contrast x-ray

� Tx: sucralfate, ranitidine, omeprazole, metoclopramide

� Oesophageal perforation, rupture

� Nasogastric tubing, strange bodies, trauma from outside

� Chronic inflammation, obstruction

� Cervical region: putrid perioesophagitis (nerves, vessels)

� Thoracic region: mediastinitis, pleuritis – poor prognosis

� Dx: signs, endoscopy, x-ray

� Tx: surgery, NSAID, AB

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� Esophageal stricture, compression, dilatation� Stricture: secondary

� Compression: neoplasia, abscess (lymphnodes!!!)

� Dilatation: front of stricture or compression

� Diverticulum (pulsion, traction)

� Tx: surgery, balloon catether

General features ofcolic diseases

The „COLIC”:

� In most cases: symptoms of gastrointestinal pain

� Other possible causes

e.g..: urinary system,

spleen rupture, uterine torsion,

liver diseases etc.

� Colic like behaviour

e.g. nervous system diseases

Common features of the pathogenesis

of colic diseases

Non-strangulating Strangulating disorders Enteritis

• Muscle spasm

•Intestinal damage

• Tense mesenterium

Pain, exhaustion

•Local circulatorydisorder

•Fluid sequestration

Hypovolaemia

•Wall permeability

•Dysbacteriosis

Endotoxinemiavasoconstrictionsplenic contractionsweating

inflamm. mediatorsDIC, organ dysfunctionvessel dilatationSIRS MODS

Peripherial circulatory failure

[--] tissue perfusion, haemoconcentration, metabolic acidosis, uremia

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Drugs

� Non-strangulating, enteritis, colitis: conservative

� Strangulating: surgery

Pain, exhaustion, motility� Spasmolytic (butil-

scopolamin)� Analgesics (NSAIDs,

lidocaine)� Sedatives

(alpha2agonists)� Prokinetics

(neostigmine, metoclopramide, etc)

Hypovolaemia

•Infusions (saline, ringer, ringer-lactate, hetastarch, colloids, plasma)

Laxatives

•Mineral oil

•Na/MgSO4

Endotoxinemia

/DIC

•Hyperimmune plasma

•PolimixinB

•Corticosteroids

•Pentoxifilin

•DMSO

•Heparine, aspirine

Steps of establishing Dx and Tx

� Define cardiovascular and metabolic status

� Define exact diagnosis and causative agents (if possible)

� Decide about hospitalisation

� Decide about surgery

� Define measures of conservative tx and monitoring techniques

� If surgery, prepare to minimalize risk and time for general anaesthesia, define type of general anaesthesia

� When not sure, do not hesitate rather operate!

History

� Season, weather

� Sex, age, breed, use

� Previous treatments (NSAID, anthelmintics) and diseases, abdominal surgery

� Feeding and stabling technology, pasture (eg: grass sickness, atropine toxicities)

� Duration of colic (level of intestinal injury), how serious, reaction for treatments

sex

„management” age

breed

sport

Physical examination 1: General impression

� Facial expression

� Sweating

� Signs of colic injuries

� Abdominal distension

� Muscle tremor (electrolyte disturbances, pain)

� Body position

� Behaviour (colic, apatic)

Physical examination 2.: Pain

� One of the most important „parameters”

� Age, temperament, surroundings

� Level� Serious: not reacting to outside stimuli, no effect

of painkillers (max. 3-5 mins.), usu. surgery

� Medium: calms down when walking or transport, effect of painkillers 2-4 hours

� Mild: outside stimuli draws attention easily, effect of painkillers 8-12 hours

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Colic pain

Physical examination 3.: Definition of basic clinical values and cardiovascular status

� Body temperature: 39°C< no surgery, acute infectious or other inflammatory process (endotoxaemia)

� Respiratory rate: endotoxaemia, increased diaphragmatic pressure, hypovolaemia, diaphragmatic hernia

� Pulse rate: not correlates with pain but cardiovascular system (eg.: endotoxin shock)

� CRT, mucus membrane, venous refill, arrhythmias, skin temperature

� Rapid worsening of cardiovascular parameters= indication for surgery (after stabilization)

Color of mucus membrane Physical examination 4.: Gastrointestinal organs

� Shape of abdomen: determine site of gas (fluid or content) accumulation

� Abdominal stretch

� Auscultation: min. 5 mins., type and strength of borborygmi (eg.: fluid/gas-steel band effect, sand-10-25 cm behind xyphoideus scratch-like), how it reacts for treatment (prokinetics), no borborygmi surgery

� Percussion, auscultation with simultaneous percussion: gas in caecum or large colon

� Palpation, ballotation: in foals less then 4 weeks

Additional diagnostic methods: Rectal examination

� Systematic examination:

� urinary and reproductive organs, inguinal rings, pelvic flexure, (ventral ?) and dorsal part of colon, taenias, spleen, left kidney, nephrosplenic space, mesentery, aorta, small intestine (?), small colon, head of caecum, ventral and medial taenia, peritoneum

� Exact diagnosis not always possible/ necessary

� Indications for surgery: gas distended small intestines, displaced and gas distended large colon, enteroliths

� Euthanasia: rupture of intestines or stomach, rectal tear-GI content in abdominal cavity

Additional diagnostic methods: Nasogastric tubing

� Life-saving, always wash till empty, abnormal fermentation, gastroesophageal reflux at surgery, pressure on diaphragm

� Quantity: 4 l > (10 l< proximal enteritis!)

� Quality: colour, odour, consistency, pH� Food particles

� Greenish-brown, fluid, bad smell

� Orange, fluid (culture)

� Bloody, reddish, or blood only with test paper

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Nasogastric tubingAdditional diagnostic methods: Abdominocentesis� Not better for routine treatments� General site or ultrasound guide, serial sampling� Quality, quantity (colour, turbidity, cells: Ht, sediment,

etc.)� Protein: 2,5 g/dl>� Cell count 5000-10,000/µl (foal 1500),

2:1=neutrophyl: mononuclear� Protein RBC+fibrinogen WBC

(transudate→exudate)� Cytology: wbc, rbc, bacteria, neoplastic cells, food

particles� Culture� Biochemistry: pH (7,3>), glucose (30 mg/dl>), fibrinogen

� GGT, lipase, amylase� LDH, CK, ALKP

Abdominocentesis Hematology

� PCV: � Hypovolaemia (intestinal wall injury,

endotoxaemia)

� Spleen contraction (30%)

� Nephrosplenic entrapment

� Increasing even with therapy – surgery

� Decreasing: intraabdominal bleeding

� TPP:� Reflects more reliably the hypovolaemia

� Serious permeability disorders: increases then falls

� Primary decrease: peritonitis, severe, acute enteritis

Hematology

� CBC:

� Endotoxaemia, Gr- sepsis, Salmonellosis: neutropenia (toxic)

� Stress-leukogram: low wbc, relativ neutrophilia, lymphopenia

� Neutrophilia: e.g..:mesenterial abscess, subacute or chronic processes

� Thrombocytopenia: DIC

� Negative

Acid-base parameters and ionogram

� Na +↓ ,K+↓:small intestinal ileus, diarrhoea

� Cl-↓: not absorbed gastric content, reflux, sweating (metabolic alkalosis?)

� Ca++↓:no absorption from gut, sweating, abnormal sensitivity to PTH, intracellular sequestration, Ca-bind to albumin, ionised

� Metabolic acidosis: peripheral shock, loss of bicarbonates in intestinal fluids, ischemic intestinal wall lactacidosis

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Biochemistry

� Protein: albumin↓, globulin↑

� Glucose: increase then decrease - stress, endotoxaemia

� Creatinine: hypovolaemia and kidney

� Liver enzymes: general anaesthesia, in large colon displacement and in enteritis (pancreas enzymes also)� Alterations usu. after surgery

Additional diagnostic methods:X-ray

� Foals, ponies (140 kg>): site and degree of gas distension, necrosis of intestinal wall

� Contrast material: po., per rectum barium-sulfate 5ml/ttkg (30%)� Po: gastric emptying, invagination, ileus

� Per rectum: small colon and colon transverse obstipation, obturation

� Adult horses: limited� Sand, enteroliths, diaphragmatic hernia

X-ray Additional diagnostic methods: ultrasonography

� Foals: umbilical remnants, bladder, invaginations, necrotizing enteritis, hernias

� Adults: limited� Intraabdominal abscesses, neoplasia

� Invaginations

� Intestinal strangulation: motility, wall thickness

� Nephrosplenic entrapment

� Hernias (diaphragmatic, inguinal, scrotal)

� Peritonitis

� Peritoneal fluid: quality, quantity

� Enteroliths

� Spleen rupture

Ultrasonography Additional diagnostic methods: CT?

� Ponies and foals

� Genera anaesthesia

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Additional diagnostic methods: endoscopy

� 3 m long flexible endoscope

� oesophagus, stomach, small intestine

� Rectum, ampulla

� Biopsy

� Rather in chronic cases

Endoscopy

Additional diagnostic methods: laparoscopy

� Chronic cases or for diagnostics

� Standing or general anaesthesia

� Adhesions, neoplasias, biopsies, etc.

Additional diagnostic methods: scintigraphy

� Gamma-camera images increased density of radioactive material (iv.)

� Increased uptake on inflammatory areas (20 hrs later)� Right dorsal colitis

� Abscesse

� Neoplasias

� Gastric emptying

� Bile flow