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Dysphagia

Evaluation and Management

Shashidhar Reddy, MDMatthew W. Ryan, MD

November 21, 2001

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Physiology of Swallowing

The act of swallowing involves three phases: Oral, Pharyngeal,and Esophageal.

Swallowing takes about 8-10 seconds Before swallowing begins, Oral Preparation of the bolus must

occur.

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Physiology of Swallowing:

Oral Phase Pharyngeal Phase

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Physiology of Swallowing

Pharyngeal and Esophageal Phase:

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Evaluation of Dysphagia

History

Review of Systems Physical Exam

Imaging Studies

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History

Duration dietary changes, weight loss

Odynophagia

Solids or Liquids Level of sensation of dysphagia

Past surgery to head and neck, trauma,ingestion of caustic substances

Associated symptoms such as with GERD,voice changes, nasal leakage, otalgia

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Review of Systems:

Ask about common systemic processesassociated with dysphagia:

Tobacco/Alcohol

Medications antihistamines, anticholinergics,antidepressants, antihypertensives

Osteoarthritis

Systemic neuromuscular disordersAuto-Immune disorders

Psychiatric state

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Physical Exam:

General: body habitus, mental status,drooling, wheezing, dyspnea, voice quality

Cranial nerves Inspection of the tongue and palate for

strength/symmetry

Laryngeal Examination: pooled secretions,vocal fold movement, interaretynoid area

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Imaging Studies

Should be chosen to suit the patientssymptoms and to confirm a finding.

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Plain Film

Uses:Suspected infectious cause of dysphagia with gross

displacement of structures.

Advantages Disadvantages

cheap Radiation

Fast Poor anatomic detail

No assessment of swallow

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Plain Film

(Epiglottitis)

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Barium Esophagram

Uses: structural disorders, e.g. dysphagiafor solid foods. Can use air contrast.

Advantages Disadvantages

Good anatomic detail Radiation

Logistics in bedridden pts.

Cannot detect dynamicdisorders.

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Air Contrast Barium Esophagram

Normal Fungal Plaques

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Manometry

Uses: disorders in which intraluminalpressures must be measured (achalasia,

esophageal spasm, etc.)

Advantages Disadvantages

It is the only test of pressure

wave physiology

Cannot diagnose visible

lesions

Unpleasant for patient

Techincally demanding

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Manometry

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Bolus Scintigraphy

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Ultrasound

Uses: Portable tool for dynamic studies,especially in children

Advantages: Disadvantages:

No radiation Not widely available

Portable Poor anatomic detail

Normal Food can be used

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Ultrasound

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Modified Barium Swallow

Uses excellent to evaluate dynamic (e.g.neuromuscular, aspiration) swallow

disorders.

Advantages Disadvantages

Gives good anatomic detail Radiation

Evaluates all phases ofswallowing

Does not directly testsensitivity

Logistics

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Fiberoptic Endoscopic

Evaluation of Swallowing Uses as a mobile tool that can be used in

training patients via biofeedbackAdvantages Disadvantages

Portable Blind spot

Allows assessment of sensation Cannot evaluatecricopharyngeus directly

Cheap Cannot eval. esophagus

Can be used for pt teaching

No radiation

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Fiberoptic Endoscopic

Evaluation of Swallowing

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Disorders that Cause Dysphagia

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Foreign Bodies

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Tracheostomy

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Cricopharyngeal Achalasia

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Cricopharyngeal Achalasia

Cricopharyngeal Myotomy:

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Zenkers Diverticulum

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Cervical Spine Disease

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Esophageal Webs and Rings

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Strictures / Caustic Ingestion

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Diffuse Esophageal Spasm

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Aging

Dysphagia is present in 2% > 65

Poor dentition

Loss of tongue connective tissue Increased pharyngeal transit time

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Case Review

50 year old man presents with 6 monthhistory of progressive dysphagia.

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Case Report

His dysphagia is worse for solid foods. Additionally he notes that he hears gurgling

noises when he swallows, and occasionallychokes on his food.

When he chokes, he often ends upvomitting his food back up.

He has lost about 6 lbs over the past 6

months. He drinks socially but gave up tobacco

x10yrs

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Case Report

Physical exam reveals a thin whitegentleman in no apparent distress.

Neck exam reveals nothing unusual.

Indirect Laryngoscopy is difficult becauseof frothy secretions in his hypopharynx and

piriform sinus.

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