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Semelhante a dysphagia.pptx
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dysphagia.pptx
- 1. DYSPHAGIA
- 2. STAGES OF SWALLOWING A. VOLUNTARY I. ORAL PREPARATORY: Prepares food for swallowing and includes mastication a. Lip closure, tensions from labial and buccal musculature (CN VII) b. Rotary jaw motion (CN VII) c. Lateral tongue rolling (CN XII) d. Anterior bulging of soft palate seals oral cavity and widens nasal airway (CN IX and X) II. ORAL: Food moves from oral cavity to pharynx • a. Posterior propulsion of food by tongue along hard palate (CN XII) • b. Triggers pharyngeal swallow by glossopharyngeal nerve (CN IX)Delayed trigger by SLN at laryngeal inlet • c. Prolonged with age and increased velocity
- 3. B. INVOLUNTARY I. PHARYNGEAL • a. Soft-palate elevation allowing velopharyngeal closure, preventing nasopharyngeal regurgitation (CN XI and XII) • b. Base of tongue retraction allowing for subsequent bolus propulsion • c. Hyolaryngeal elevation allowing for airway protection and closure (CN XI and XII) • d. Pharyngeal constrictor muscle contraction (CN IX) • e. Cricopharyngeal relaxation/pharyngoesophageal segment opening (CN X) Cricopharyngeus muscle is under tonic contracted to prevent air ingestion with inhalation and reflux from esophagus II. ESOPHAGEAL a. Peristalsis • Upper one-third of mixed voluntary muscles • Lower two-thirds involuntary STAGES OF SWALLOWING CONT.,
- 4. DEFINITION • Dysphagia is defined as having difficulty in swallowing which may affect any part of the swallowing pathway from the mouth to the stomach. • Approximately half of the dysphagia patients are seen in ENT clinics.
- 5. HISTORY AND EXAMINATION • Patients complain that foods or liquids are no longer being swallowed easily and there is a sensation of food sticking. • Clinician must try to distinguish oropharyngeal from oesophageal dysphagia
- 6. OROPHARYNGEAL VS.OESOPHAGEAL DYSPHAGIA • In Oropharyngeal dysphagia, there is difficulty in preparing and transporting the food bolus through the oral cavity as well as initiating the swallow. This may be associated with aspiration or nasopharyngeal regurgitation. • In Oesophageal dysphagia, patients complain of food sticking in their lower throat, neck, retro-sternal discomfort or epigastrium.
- 9. CAUSES: CONGENITAL • Choanal Atresia • Cleft lip and palate • Unilateral vocal cord paralysis • Laryngeal cleft • Tracheo-oesphageal fistula • Oesophageal atresia • Vascular rings
- 10. ACQUIRED: TRAUMATIC • Accidental and iatrogenic • Blunt trauma, penetrating injuries and compression effects • Direct damage and injury to cranial nerves • Head injury
- 11. ACQUIRED: INFECTIONS • Acute pharyngitis, tonsillitis, quinsy • Glandular fever • Acute supraglottitis • Herpetic, fungal and CMV mucosal lesions • Candidiasis • Tuberculosis • Submandibular, parapharyngeal and retropharyngeal abscesses
- 12. ACQUIRED: INFLAMMATORY • GERD with or without stricture formation • Patterson Brown-Kelly syndrome • Autoimmune disorders like scleroderma, Sjogrens disease, rheumatoid arthritis
- 13. ACQUIRED: OESOPHAGEAL MOTILITY DISORDERS • Achlasia • Diffuse oesophageal spasm • Nutcracker oesophagus
- 14. ACQUIRED: NEOPLASTIC • Benign and malignant tumors of oral cavity, pharynx and oesophagus • Nasopharyngeal Carcinoma • Skull base tumors • Leukemia and lymphomas • Enlarged mediastinal lymph nodes
- 15. ACQUIRED: NEUROLOGICAL • CVA (Stroke) • Isolated recurrent laryngeal nerve palsy • Parkinson's disease • Myasthenia gravis • Multiple sclerosis • Motor- neuron disease
- 16. ACQUIRED: DRUG INDUCED • Drugs causing oesophagitis • Swallowing tablets with insufficient water or just before going to bed can cause oesophagitis • Oesophagus at the level of aortic arch most vulnerable to contact by acid producing drugs (with pH less than 3) such as tetracyclines, doxycycline, vitamin C and ferrous sulphate
- 17. Acquired: Drug Induced (2) • Broad-spectrum antibiotics and chemotherapeutic agents may cause secondary viral ulceration or fungal infections • Stevens-Johnson syndrome is a more serious complications of antibiotic therapy with an acute erosive pharyngitis/ oesophagitis as well as delayed oesophageal strictures • Inhibitory drug side effects by anticholinergics, tricyclic antidepressants and calcium channel blockers
- 18. ACQUIRED: DRUG INDUCED (3) • Excitatory side effects of drugs like cisapride and metaclopramide. • Dysphagia can be a complication of drugs like antihypertensives, ACE Inhibitors, anticholinergics, antiemetics, antihistamines, diuretics, and opiates by causing xerostomia
- 19. MISCELLANEOUS • Presbydysphagia • Foreign bodies • Caustic strictures • Pharyngeal pouch • Patients with tracheostomy
- 20. Age: Possible causes • Children : Foreign body or congenital malformation • Middle aged patients: Reflux oesophagitis, hiatus hernia, anaemia, achlasia, globus syndrome. • Elderly patients: Malignancy, stricture formation from longstanding reflux, pharyngeal pouch, motility disorders associated with aging and neurological disorders.
- 21. History • Onset. • Duration • Progression • Severity of symptoms • Types of food intake that causes problems • Alleviating factors
- 22. Associated Symptoms • Regurgitation • Pain on swallowing • Hoarseness of voice • Otalgia • Coughing after eating • Frequent chest infections
- 24. CLINICAL EXAMINATION • Complete Head and neck examination – Inspection of oral cavity – Dentition – Oropharynx – IDL – Nasolaryngoscopy – Cranial nerve examination ( tongue, gag and cough reflex, hoarseness, vocal cord mobility) – Neck for lymph nodes, neck masses, thyroid enlargement, loss of laryngeal crepitus and integrity of laryngeal cartilages.
- 25. SPECIAL INVESTIGATIONS • Blood tests to exclude anaemia (? Cause or effect) • ESR or C-Reactive Protein raised in malignancy or chronic inflammatory process • LFT, RFT along with S. Calcium when nutrition is impaired or metastasis is suspected • Thyroid function tests if dysphagia is caused by goiter or malignancy of thyroid
- 26. SPECIAL INVESTIGATIONS • Barium swallow • Chest radiograph • CT scan examination of neck, chest and abdomen. • MRI is indicated when there are neurological causes such as multiple sclerosis, cerebral tx, nasopharyngeal ca. • Rigid endoscopy • Flexible endoscopy • Manometry • Other Investigations. Bronchoscopy (for bronchial carcinoma), cardiac catheterization (for vascular anomalies),thyroid scan (for malignant thyroid) may be required, depending on the case.
- 27. RADIOLOGY • Plain x-ray neck & chest – for foreign bodies DENTURES PIN
- 30. BARIUM SWALLOW Stricture – caustic injury Slidin g Irregular filling defect – carcinoma
- 31. (RIGHT) DYSPHAGIA LUSORIA. This very rare cause of dysphagia is due to an aberrant right subclavian artery coursing posterior to the esophagus, causing a spiral filling defect.
- 32. CINE-RADIOGRAPHY • Dynamic assessment • Radiographic visualisation of food bolus movement from oral cavity to hypophyrnx
- 33. ENDOSCOPY • Rigid • Flexible • Diagnostic • Visual • biopsy • Therapeutic • foreign bodies removal • Stentings • Dilations
- 36. MANOMETERY • Indications: - Achalasia cardia - diffuse esophageal spasm - Nutcracker esophagus - hypertensive esophageal sphincter • Types: Stationary Manometery High Resolution manometery
- 38. 24-HOUR AMBULATORY PH MONITORING • The most direct method of measuring increased REFLUX (esophageal exposure to gastric juice ) is by an indwelling pH electrode, or more recently via a radio- telemetric pH monitoring capsule that can be clipped to the esophageal mucosa.
- 40. ENDOSCOPIC ULTRASOUND tumor confined to the esophageal wall an advanced esophageal carcinoma penetrating through all layers Used for dysphagia due to carcinoma esophagus for staging Biopsycan also be taken
- 41. FUNCTIONAL ENDOSCOPIC EXAMINATION OF SWALLOWING (FEES) a) Visualization of pharynx before and after swallow b) Uses different consistencies with or without food coloring c) Good for detection of penetration, aspiration, pooling, retained secretions, effectiveness of cough d) Examination Start with pharyngeal squeeze (high-pitched strained phonation in rising crescendo). • Start with water/ice chips and progress to puree then crackers • Pre-swallow Secretion level: assess amount and location of secretion prior to swallow • Can indicate patients who are at high risk for aspiration due to open glottis during bolus formation and transit
- 42. • Post swallow Assess whether food contents have penetrated larynx or if the patient aspirated the contents. • Location of residue (velleculae, pharyngeal wall, pyriform). • Can be used in conjunction with compensatory maneuvers to test for benefit. • Limitation is that one cannot visualize oral phase, events during swallow or upper esophageal sphincter function
- 44. KEY POINTS • Age suggests most likely cause of dysphagia • Globus pharyngeus rarely associated with any serious disease • Dysphagia of short duration in elderly patient who smoke or drink and which progress from solids to liquids is a classic case of malignancy • Referred otalgia with dysphagia is a sinister symptom and poor prognostic sign
- 45. KEY POINTS (2) • Neurological causes of dysphagia mostly affect orpharyngeal phase • Ingested foreign bodies tend to lodge at sites of constriction • Barium study is contraindicated in patients with suspected perforation of oesophagus
- 47. ZENKERS DIVERTICULUM • Esophageal diverticula, or outpouchings of the lumen, include pharyngoesophageal (Zenker) diverticulum, midesophageal diverticulum, and epiphrenic diverticulum. • Zenker diverticulum is the most commonly encountered esophageal diverticulum and is the most likely to be symptomatic. • The outpouching occurs between the inferior pharyngeal constrictor muscle and the cricopharyngeus, in an area called Killian dehiscence. • This pulsion diverticulum likely results from cricopharyngeal dysfunction. • ZD is more prone to herniate to the Left.
- 49. PRESENTATION SYMPTOMS: • Progressive Dysphagia(.>90%) • Regurgitation Of Food Even Hours After A Meal, • Unprovoked Aspiration • Noisy Deglutition (Borborygmi) • Belching, • Hypopharyngeal Mucous Collection, • Halitosis, • Choking • Coughing, • Hoarseness, • Globus Pharyngeus, • Weight Loss, • Recurrent Respiratory Infections SIGNS: • mucous pooling in the hypopharynx that initially clears with swallowing then recurs, • Emaciation • Dehydration • Boyce sign—a swelling in the neck that gurgles on palpation
- 50. PATHOPHYSIOLOGY • Ludlow in Bristol, England, gave the first anatomic description of a pulsion diverticulum of the hypopharynx in 1769. • Bell who proposed in 1816 that incoordination of the inferior constrictor muscle against a closed cricopharyngeal muscle resulted in this type of outpouching at regions of inherent weakness. • The congenital theory describes an unusually weak or large Killian triangle from birth that with time herniates with normal pharyngeal contraction • Patterson first proposed cricopharyngeal achalasia as an etiology for ZD in 1919. • Spasm or persistently elevated resting tone of the cricopharyngeus secondary to reflux could cause ZD, although others refuted a direct causal association. • Lerut in 1988 proposed a structural abnormality of the cricopharyngeal muscle itself. • Cook et al in 1992 suggested partial, incomplete opening of the cricopharyngeal muscle because of fibroadipose tissue replacement as an etiology. • Six years later, Walters et al.proposed that ZD might be a manifestation of central or peripheral neurologic disease.
- 51. MANAGEMENT TRANSCERVICAL APPROACH. • A transverse incision along the neck crease at the level of the cricoid cartilage is the preferred approach. Alternatively, the incision can be made along the anterior border of the sternocleidomastoid (SCM) muscle from the level of the hyoid bone to the clavicle. • Subplatysmal flaps are then raised, • Lateral retraction of the SCM muscle. • The fascial attachments along the anterior border are divided. • The strap muscles may be retracted anteromedially, but for better exposure, the anterior belly of the omohyoid muscle may be divided inferiorly, • As blunt dissection is carried out to expose the posterior aspect of the pharynx, larynx, and esophagus, the recurrent laryngeal nerve is identified. and protected before the thyroid vessels are ligated and divided.
- 52. • Once the diverticulum is identified and freed from the surrounding tissues down to its base attachment to the esophagus, • a long cricopharyngeal myotomy is performed. • The pouch itself can then be excised, inverted, or suspended by a suturing or stapling technique. • For small diverticula (1 to 2 cm), a cricopharyngeal myotomy alone may be sufficient. • Possible significant complications from external procedures fistula formation, recurrent laryngeal nerve paralysis, pneumomediastinum, mediastinitis, esophageal stricture
- 53. ENDOSCOPIC STAPLE DIVERTICULOTOMY • Endoscopic techniques involve visualization of the ZD through a modified laryngoscope with division of the common wall between the diverticulum and esophagus using electrocautery, CO2 laser, ultrasonic shears, or staples. • A bivalved endoscope is inserted with one blade into the cervical esophagus and the other into the diverticulum). • The endoscope is suspended. • Visualization is achieved with a 0-degree rigid endoscope. The diverticulum pouch is carefully examined, and if any lesions are noted, biopsy specimens are obtained for frozen section diagnosis. • The “bar” between the pouch and the esophagus, whichc onsists of the cricopharyngeus muscle, is stabilized by grasping it with alligator forceps or by using a stitch placed with an endoscopic stitching device. • The Endo-GIA stapler is then used to divide the party wallbetween the esophagus and diverticulum, with several rows of staples being deposited on each side in the process.
- 56. • Patients resume an oral diet within 24 hours. • Compared with external approaches, endoscopic techniques result in a shorter, if any, inpatient stay; shorter anesthesia times, which is important in the elderly or the medically infirm; and more rapid convalescence. • Furthermore, in patients whose diverticula have recurred after primary external or endoscopic approaches, ESD may be performed without any increase in technical difficulty or morbidity
- 57. RECURRENCE • Incomplete division of the cricopharyngeal muscle and restenosis of the common wall diverticulostomy from scarring. • Reflux • Intraoperative measures to decrease the chance of recurrence and complications include the use of retraction sutures to help position the common wall and allow the stapler to be placed for maximal sectioning and the removal of any loose staples or retained sutures immediately after the common wall is divided to prevent mucosal edge irritation and subsequent restenosis. • Revision ESD may not be the best option for patients with a very small recurrent pouch (1 to 2 cm or less) who have had previous external diverticulectomy. • ESD RX OF CHOICE FOR BOTHN INITIAL PRESENTATION AND RECURRENCES
- 58. MOTILITY DISORDERS • These conditions include: – Achlasia – Scleroderma – Diffuse Esophageal Spasm – Nutcracker Esophagus • Up to 30% pts with diagnosis of MI will be found to have an esophageal cause of pain and motility disorders account for over 50% of these patients. • Mainstay of investigation is manometry , endoscopy, barium studies
- 59. Achlasia • Failure of relaxation of LES during swallowing due to degeneration of myenteric plexus. • Presentation long standing dysphagia and regurgitation • Barium swallow: Dilated esophagus with a smooth tapering stricture at its lower end • Esophageal manometry: Synchronous contractions and failure to relax • 24 Hour pH measurement: Confirms reflux
- 60. Achlasia-Treatment • Sequential dilatation of Lower Oesophageal Sphincter with intraluminal balloons under fluoroscopic control • Balloon myotomy is safe, effective in 3/4th cases and can be repeated • Surgical myotomy (Open/laparoscopic) reserved for failed balloon failures • Failed myotomy can be treated with balloon dilatation
- 61. DES & Nutcracker Esophagus • Characterized by severe chest pain and dysphagia • Primarily involvement of lower 1/3, muscle hypertrophy and high pressure contractions • Symptoms intermittent so ambulatory manometry is required • Treat with calcium channel blockers or balloon dilatation • Results disappointing
- 62. TREATMENT • Life style modification • Drug therapy • Therapeutic endoscopy • Dilation • Stentings • Chemo-radiation • Surgery
- 63. LIFE STYLE MODIFICATION • These include – avoidance of precipitating foods(fatty foods,alcohol, caffeine) – Oral hygine – avoidance of recumbency postprandially – elevation of the head of the bed – smoking cessation – weight reduction.
- 64. • Inflammatory lesion Antibiotic s Antifunga l Incision & Drainage – for abscess Neuromuscular dysphagia Maintenanceof oral hygine Chew well Semisolid /liquid diet Eat small meals more
- 65. Drug therapy for esophageal dysphagia • H2 Blocker • Antacids • PPI • Metaclopromide/ Domperidon • Nitrates • Calcium channel Blockers • sildenafil • Botox injection • Steroids • Vinegar, lemon, orange juice - Alkali ingestion • Milk, egg white, Antacid - Acid ingestion Reflux esophagitis Motility disorders Caustic injuries
- 66. Dilation • Upto 40- 60 F ( Hydrostatic / pneumatic ) • Indications -Strictures, Schatki rings Achalasia Anastomotic stenosis , Pneumatic Dilator