DYSPHAGIA

Anatomy

Anatomy of oropharynx

Anterior boundary:
Palatoglossus muscle (fauces)
Circumvallate papillae
Superior boundary:
Soft palate
Posterior boundary:
Superior and middle
pharyngeal constrictor muscle
Inferior boundary:
Based of tougue

uperior pharyngeal constrictor muscle

Palatoglossus muscle

Anatomy of hypopharynx

Oropharyn
x

Posterior pharyngeal wall

Hypopharynx
Piriform recess

Anatomy of oropharynx
Neural control is motor nuclei of CN V, VII,
IX, X and XII
Structures involved:
a) Lips
b) Dentition and muscle of mastications
c) Tongue
d) Palate
e) Salivary glands
f) Pharyngeal muscles

Mechanism of Swallowing
4 phases:
1)Oral preparatory
2)Oral
3)Pharyngeal
4)Esophageal

Oral Preparatory Phase

- Involves lips, tongue, mandible, dentition,
soft palate, muscles of the buccal cavity
- Grind and position the food
- Transfer phase- tongue arranges the bolus,
move it posteriorly to chew
- Reduction phase- food is chewed, ground
and mixed with saliva to form bolus.

Oral Phase
-

Food bolus is transported via the action of

the tongue, palate and teeth
- Bolus is positioned posteriorly on the tongue
- Lips and buccal muscles contract to built
pressure and reduce the volume of the oral
cavity
- Posterior tongue depressed, middle and
anterior tongue elevate, propulsion of bolus
into the oropharynx

Pharyngeal Phase
- Involuntary phase
- Bolus reaches the anterior tonsillar pillars
- Initiates automatic pharyngeal muscle
contraction
Soft palate pulled upward to seal
nasopharynx
Larynx pulled upward and anteriorly
Epiglottis swing backward over the
laryngeal inlet
Relaxation of the upper esophageal

Esophageal Phase
- Peristalsis or
sequential
contraction of the
esophagus and
relaxation of the
lower sphincter
- Propels food into
stomach

DEFINITION
Dysphagia is difficulty in swallowing,
which may be associated with
ingestion of solids or liquids or both.

AETIOLOGY
1) Pre-esophageal
a) Oral phase
b) Pharyngeal phase
2) Esophageal
a) Lumen
b) Wall
c) Outside the wall

Pre-esophageal (Oral phase)

1) Disturbance in
mastication
-Trismus, fracture of mandible,
TMJ problem

2) Disturbance in
lubrication
-Xerostomia

3) Disturbance in mobility
of tongue
-Painful ulcer, tongue
tumors, tongue paralysis

4) Defects of palate
-Cleft palate, oronasal
fistula

5) Lesions of buccal
cavity and floor of
mouth
-Ulcerative lesion,
Ludwigs angina

Xerostomia
Dry mouth due to lack of saliva
Difficulty in eating, speaking,
halitosis and caries
Causes: Diabetes, Parkinson's
disease and Sjogren's syndrome,
radiotherapy, medications

Sjgren's syndrome /Mikulicz disease -systemic

autoimmune disease in which immune cells attack
and destroy the exocrine glands that produce
tears and saliva

Ulceration
Commonly in the form of
apthous ulcer
Painful and self limiting in
about 10 days
Well-demarcated edge
with a white slough base
Usually few mm in
diameter
It can be more larger,
more painful and
persistent major
aphthous

Ludwigs angina
Cellulitis, usually of odontogenic origin
Causes : mostly Streptococcal bacteria
Bilaterally involving the submaxillary,
sublingual, and submental spaces
Painful swelling floor of the mouth,
elevation of the tongue, dysphonia,
dysphagia, malaise, fever, stridor or
difficulty in breathing.

Ludwigs angina

Pre-esophageal (Pharyngeal phase))

1) Obstructive lesions of pharynx
- Tumours of tonsil, soft palate, pharynx, base of
tongue, supraglottic larynx

2) Inflammatory conditions
-acute tonsillitis, acute epiglottitis, retro or parapharyngeal abscess

3) Spasmodic conditions
-tetanus, rabies
4) Paralytic condition
-paralysis of soft palate due to diphteria, bulbar
palsy

Neoplasms
Cause distortion,
obstruction, reduced
motility, or
neuromuscular and
sensory dysfunction of
the upper aerodigestive
tract
Neoplasm at floor of
mouth, tongue, buccal
mucosa restrict mobility
of the tongue
Impair oral preparatory
phase

Neoplasms
Tumor of pharynx interfere with
peristalsis/ laryngeal elevation and
cause mechanical obstruction
Invade or destroy larynxincompetent laryngeal sphincter or
sensory denervation- aspiration

MANAGEMENT
HISTORY
PHYSICAL EXAMINATION
INVESTIGATION
TREATMENT

HISTORY
Detailed history is very important to
know :
The anatomic site of problem
oesophageal/oropharyngeal
The causes structural/motility

History
Sudden onset
Foreign bodies
Impaction of food on a preexisting stricture or
malignancy
Neurological disorder
Progressive
Malignancy
Intermittent
Spasm or spasmodic episodes over an organic
lesion
More to liquids
Paralytic lesion

 More to solid and even progressing even

to liquids
Malignancy or stricture
Intolerance to acid food or fruit juices
Ulcerative lesion
Associated symptoms
- regurgitation and heart burn (hiatus
hernia,GORD)
- aspiration into lungs (laryngeal paralysis)
- aspiration into the nose (palatal paralysis)
-any changes in the voice/ dysarthria
(restricted tongue movement)

Predictive symptoms of
oropharyngeal dysfunction
Four symptoms that have high specificity for
oropharyngeal dysfunction:
1)delayed or absent oropharyngeal swallow initiation;
2)deglutitive postnasal regurgitation or regress of fluid
through the nose during swallowing
3)deglutitive cough indicative of aspiration
4)the need to swallow repetitively to achieve satisfactory
clearance of swallowed material from the hypopharynx.

If one or more of these four symptoms are present

then the cause of dysphagia is probably
oropharyngeal, either structural or neuromyogenic

PHYSICAL EXAMINATION
Full ENT examination is mandatory
but special attention is directed to
the
Oral cavity
Pharynx
Larynx

Palpation of any local lesion and the

neck is essential

INVESTIGATION
FBC-anaemia may represent a dietary deficiency
secondary to the dysphagia
Radiography chest X-ray, barium swallow study,
lateral view neck
Manometry
Oesophageal pH monitoring
Oesophago-gastro-duodenoscopy (OGD)
Fibreoptic Endoscopic Evaluation of Swallowing
(FEES).
Others bronchoscopy, cardiac catetherisation
and thyroid scan

Chest X-ray
To exclude cardiovascular disease,
pulmonary disease and
mediastinal disease

Lateral view neck

To exclude cervical osteophytes
and any soft tissue lesion of postcricoid/retropharyngeal space

Barium swallow study

Gold standard
Outlines the hypopharynx,
oesophagus and stomach
Suspected obstructive lesion and
oesophageal motility disorder

 Zenker Diverticulum or
Pharyngoesophageal
Diverticulum
It is a outpouching of the
mucosa of the posterior
pharyngeal wall through
Killian's triangle(also
known as Laimer's
triangle, and the KillianLaimer triangle)an area
of weakness between
the two parts of the
inferior pharyngeal
constrictor - the
thyropharyngeus and
the cricopharyngeus - at
their posterior margin

 Barium swallow
showing tight
stricture of cervical
oesophagus with
proximal dilatation

Oesophageal Manometry
Measures the motility and function of
the oesophagus and oesophageal
sphincter
A tube is usually inserted through the
nose and passed into the
oesophagus
The pressure of the sphincter muscle
is recorded and the contraction
waves of swallowing are recorded

Oesophageal pH monitoring
Measures how often and how long stomach acid is
entering the oesophagus
A small thin tube is introduced through the nose mouth
and into the stomach, which is then drawn back up into
the esophagus
The tube is attached to a monitor which records the level
of acidity in the esophagus
The patient records symptoms and activity while the tube
is left in place for the next 24 hours
The information from the monitor is compared to the
diary the patient provides
This test is helpful in determining the amount of stomach
acid entering the esophagus

Fibreoptic Endoscopic Evaluation of

Swallowing (FEES).
Is a procedure which
uses endoscopy to
evaluate the
pharyngeal stage of
swallowing and
diagnose dysphagia.
The endoscope
passes trans-nasally
into the pharynx so
the swallow can be
viewed on a monitor

Other investigations
Rigid upper GI endoscopy
Bronchoscopy
For bronchial carcinoma

Cardiac catetherisation
For vascular anomalies

Thyroid scan
For malignant thyroid

TREATMENT
Non surgical
Surgical

Non-surgical
Diet modification (modifications to the
consistency of foods)
vary from thin liquids, to thick liquids, to soft
foods, and to mixed textures
Sample classification of dysphagia diet by
NDDNational
Pureed
(homogenous,
very cohesive, puddingDysphagia
Diet(NDD):
Level 1

like, requiring very little chewing ability)

NDD
Level 2

Mechanical Altered (cohesive, moist, semisolid

foods, requiring some chewing)

NDD
Level 3

Advanced (soft foods that require more

chewing ability)

Regular

All foods allowed

 Swallow theraphy (reduce the risk of

aspiration)
Modified head positions and swallowing
techniques to reduce the size and
duration
airway
openings
during
the
Chin tuck of The
patient
holdshis/her
chin down,
swallowing increasing
processthe epiglottic angles, and pushes
the anterior laryngeal wall backward, thereby

decreasing the airway diameter.

Reduce the speed of bolus passage when
airwaay protection is delayed during oral and
pharyngeal phase of deglutiton.
Head tilt

To the stronger side, used when there is

weakness on one side of the oral cavity and
pharyngeal wall , this causes the bolus to go
down the stronger side.

Head
rotation

To the damaged or weaker side , used when

there isparalysisorparesison one side of the
pharyngeal wall; this causes the bolus to go
down the stronger side.

Chin tuck

Head
rotation

Head tilt

 Exercises
focus on range of motion and strengthening muscles in
the jaw, cheek, lips, tongue, soft palate and vocal cords
for effective swallowing
Sample exercise:

Lip exercises

Facilitate the patients ability to prevent food

or liquid from leaking out of the oral cavity

Tongue exercises

To facilitate manipulation of the bolus and its

propulsion through the oral cavity or to
facilitate retraction of the tongue base

Jaw exercises

Help to facilitate the rotary movements of

mastication

Respiratory exercises

To improve respiratory strength

Vocal cord adduction

exercises

Promote strengthening of weak vocal cords

Head-lift exercises

Increase anterior movement of the

hyolaryngeal complex and opening of the
upper oesophageal sphincter

Tongue-holding
maneuvers

Facilitate compensatory anterior movement

of the posterior pharyngeal wall

 Nutritional supply
Nasogastric tube feeding
Oroesophageal tube feeding
Oral supplement such as oral liquid supplement

Hydration
Offering patient preferred liquids or food with high
fluid content
I/V fluids or water boluses given via a feeding tube

Surgical
Usually recommended as the last
resort
Cricopharygeal Myotomy
Tracheostomy
Medialization Laryngoplasty