Dysphagia吞咽障碍

DYSPHAGIA,Wendy Funk, M.D.University of Connecticut Health CenterJanuary 7, 2005,Definition?,Inability to swallowRegurgitationPainful swallowingCoughing/chokingFood “sticks”GlobusFeels “tight”,Importance,Approximately 50% of nursing home residents suffer from some form dysphagiaPatients are often concerned about the possibility of cancerIt is essential that the physician demonstrates serious interest in the patients complaints to rule out a malignant or CNS process,Swallowing,Mechanism is complexInvolves the actions of 26 muscles and 5 cranial nervesCN V - both sensory and motor fibers; important in chewing CN VII - both sensory and motor fibers; important for sensation of oropharynx important for airway protection CN XII - motor fibers that primarily innervate the tongueA normal adult swallows unconsciously 600 times in a 24-hour period,Esophageal Anatomy,Upper one-third is composed of skeletal muscleDistal two-thirds is smooth muscleNO SEROSAOuter longitudinal, inner circular muscle layerMyenteric plexus of Auerbach, parasympathetic ganglion cells, interspersed among the muscle layersSubmucosa blood vessels/lymphatics, myenteric plexus of Meissner (parasympathetic ganglion cells)Mucosa stratified squamous epithelium,Review,The outermost collection, lying between the inner circular and outer longitudinal smooth-muscle layers of the gut, is called the myenteric (or Auerbachs) plexus. Neurons of this plexus regulate the peristaltic waves, consisting of polarized muscular activity, that move digestive products from oral to anal openings. In addition, myenteric neurons control local muscular contractions that are responsible for stationary mixing and churning. The innermost group of neurons is called the submucosal (or Meissners) plexus. This group regulates the configuration of the luminal surface, controls glandular secretions, alters electrolyte and water transport, and regulates local blood flow,Swallowing Stage 1,OralFood ingested, prepared (mastication) and modified (lubrication)Voluntary controlFrequently results from weakness lips, tongue, cheeksUnable to organize food into well formed bolus and move posteriorlyXerostomia difficulty breaking down solids,Swallowing Stage 2,PharyngealPrevented from entering nasopharynx, larynx rises, retroflexion of epiglottis and vocal fold closure, synchronized contraction of middle and inferior constrictors, and synchronized relaxation of the cricopharyngeal muscleInvoluntary,Timing neurologic epiglottis doesnt protect larynx - leads to cough/aspirationWeakness neurologic injury/cancer residual food after swallow can lead to aspiration,Swallowing Stage 3,Esophageal Begins with crico-pharyngeal relaxationInvoluntaryMost commonSensation of food sticking at base of throat/chest Peristalsis, tumor, stricture,Physiology,Detailed account Gates p. 478-485,Differential Diagnosis,Inflammatory lesionsThrush (Candida)Tonsillitis (PTA vs. lingual tonsillitis)Abscesses (retro-, para-)Systemic causesSclerodermaPlummer-Vinson syndrome,Neuromuscular disorderEsophageal spasmPseudobulbar palsyCVAMultiple SclerosisMyasthenia GravisDermatomyositisMuscular Dystrophy,Differential Diagnosis(continued),Extrinsic lesionsThyroid massDysphagia lusoriaAortic aneurysm,Intrinsic lesionsZenkers diverticulumBenign tumors (leiomyoma)Carcinoma (SCCA, Adeno)StricturesAchalasiaEsophageal websSchatzkis ring,Work-Up,Detailed HistoryPERadiographyEsophagoscopySpecial tests,History,While eating or between meals?Difficulty with solids/liquids is a serious complaint usually caused by an obstructive or neuromuscular disorder,History,Temporal pattern 4 seconds most are due to pathology in the esophagusWeight loss increases the likelihood of a significant organic processStrictures may occur from chemical ingestion or traumatic injuries,History,Voice changes Consider reflux, vocal cord paralysis (s/p CVA or from tumor involvement) or presbylaryngeusGlobus hystericusPressure, fullness, or a lump in the throat, not related to mealsOld myth of overweight, depressed, obsessive, menopausal femalesActually often associated with real GERD/LPR,History,MedsDrug-induced dysphagia Affects smooth muscle function or production of xerostomiaROSPMHPSH,Physical Examination,Complete head and neck examLook for signs of chronic illness or recent weight loss“wet” voice failure to clear the HP of retained secretionsPalpable crepitus or gurgling noises in the neckPossible Zenkers diverticulum or other pouchDrooling,Oropharynx,Ulcerative cancer of the right tonsilThe source might be VERY OBVIOUS during the H&N exam,PE,Absence of an upward movement of larynx with deglutitionindicates fixation due to inflammation, tumor, or paralysisNeurologic examEvaluate for other deficits or CN palsies Flexible fiberoptic laryngoscopyidentify defects in the larynx/pharynx, pooling of secretions in the hypopharynx, or mass lesions that may produce obstruction,Radiography,CXR foreign body perforation mediastinal anatomyCT Only to evaluate mass lesions in the neckMRI useful when neurologic disorders are suspectedDelineate mass lesions in the brainEvaluate degenerative processes in the brain and spinal cord,Fluoroscopy,Standard barium swallow uses thin barium, is a quick view, and is not satisfactory for most swallowing disordersMBS is the definitive study for evaluation of the swallowing mechanismUses both thick and thin barium consistencies and simulated foods,MBS,Dynamic recordings using air-contrast exams both in the upright and recumbent positionsAssess pharyngeal anatomy and motilityMost have a speech pathologist presentSuperior to FEES for evaluating the oral phase and aspiration,FEES (Fiberoptic endoscopic evaluation),Directly viewing liquid or food bolus via scopePositioned high in oropharynxObservation of vocal and arytenoid movementsElevation of larynx and tongue baseManagement of residualsPooling and aspiration can be noted,FEESST(Functional endoscopic evaluation of swallowing with sensory testing ),FEESTobjective evaluation of laryngeal sensory functionuses an air pulse stimulus to determine laryngopharyngeal sensory discrimination thresholds on mucosa of SLN distributionSensory decrease and consequent decreased reflexes may lead to aspiration,Esophagoscopy,Flexible (in office) vs. rigidForeign body, biopsy of lesions, evaluation of stenosisPatients with persistent neck pain, odynophagia or those with tumors found in the preliminary workup require a rigid examination (DL/E)Esophagus should be biopsied in all patients suspected of having esophagitis, a neuromuscular disorder, or a collagen vascular disease,Special Tests,pH probe - monitors over a 24 hour periodAcid infusion testsinfuses a dilute HCL solution into the esophagus checks reproducibility of symptomsManometry essential if dysfunction of the cricopharyngeus, esophagus or LES identified on swallow studyQuality laboratory Interpreted by an experienced gastroenterologist,Esophageal Manometry,Patient is awake and alert4.5mm catheter via the nose secured at 50cm8-lumen catheter with 8 orificesMultiple ports simultaneously take measurements in mmHgUES, LES, and at 2cm intervals above the LES,Manometry,Senses the activity of the musclesIdentifies subtle failures of pressure generation or hyperfunctioning of the sphinctersHelps accurately diagnose the site of dysfunction,Manometry,CP = UES has a normal resting tone, which is increased during inspiration and relaxed during bolus passageLES has a normal resting tone with relaxation coincident with bolus arrival Esophageal antegrade peristalsis may be disrupted due to spasm, aperistalsis or other dyskinetic contractionsMay be asymptomatic, although inflammation and muscular spasm are often recognized by sensations of substernal pressure or discomfort,Differential Diagnosis,Inflammatory lesionsThrush (Candida)Tonsillitis (PTA vs. lingual tonsillitis)Abscesses (retro-, para-)Systemic causesSclerodermaPlummer-Vinson syndrome,Neuromuscular disorderEsophageal spasmPseudobulbar palsyCVAMultiple SclerosisMyasthenia GravisDermatomyositisMuscular Dystrophy,Candidiasis,Multiple ulcerations and nodularity over a long segmentMost common in immuno-compromised patients,Differential Diagnosis,Inflammatory lesionsThrush (Candida)Tonsillitis (PTA vs. lingual tonsillitis)Abscesses (retro-, para-)Systemic causesSclerodermaPlummer-Vinson syndrome,Neuromuscular disorderEsophageal spasmPseudobulbar palsyCVAMultiple SclerosisMyasthenia GravisDermatomyositisMuscular Dystrophy,Scleroderma,Chronic, degenerative, autoimmune disorder that leads to the over-production of collagen in the bodys connective tissue Decreased motilityChronic reflux due to incompetent LESStricture of the distal esophagus,Plummer-Vinson Syndrome,Iron-deficiency anemiaUpper esophageal webHypothyroidismGlossitis &/or cheilitisGastritisDysphagia (even without presence of a web),Plummer-Vinson Syndrome,90% womenPredominantly in northern hemisphere/ Scandinavian descentRx: iron replacement alone may reverse some of the pathologic changes; dilation of webIncreased incidence of postcricoid SCCA (15% in one prospective study),Differential Diagnosis,Inflammatory lesionsThrush (Candida)Tonsillitis (PTA vs. lingual tonsillitis)Abscesses (retro-, para-)Systemic causesSclerodermaPlummer-Vinson syndrome,Neuromuscular disorderEsophageal spasmPseudobulbar palsyCVAMultiple SclerosisMyasthenia GravisDermatomyositisMuscular Dystrophy,Functional/Motor Disorders,SpasmCorkscrew esophagusNeuromuscular disordersDiabetes, alcoholism, ALSPresbyesophagus Associated with ageIncoordination of sphincter functionReduced peristalsisFrequent tertiary contractions,Diffuse Esophageal Spasm,Numerous nonpropulsive contractions“corkscrew/ rosary bead” esophagusDES requires normal peristalsis interspersed with 30% + periods of nonpropulsive motor activity,Tertiary contractions,Transient motor phenomenonNonpropulsive,Differential Diagnosis(continued),Extrinsic lesionsThyroid massDysphagia lusoriaAortic aneurysm,Intrinsic lesionsZenkers diverticulumBenign tumors (leiomyoma)Carcinoma (SCCA, Adeno)StricturesAchalasiaEsophageal websSchatzkis ring,Anatomic compression locations,CricoidThyroidAortaLeft mainstem bronchusDiaphragmCervical spine may impinge, esp. in the elderly,Chest compression due to,Large nodesMediastinal tumorsEnlargement of the heartAneurysmsMassive enlargement of the liver,Dysphagia lusoria,Very rare cause Due to an aberrant right subclavian artery coursing posterior to esophagusCauses a spiral filling defect,Differential Diagnosis(continued),Extrinsic lesionsThyroid massDysphagia lusoriaAortic aneurysm,Intrinsic lesionsZenkers diverticulumBenign tumors (leiomyoma)Carcinoma (SCCA, Adeno)StricturesAchalasiaEsophageal websSchatzkis ring,Diverticulum,Small pouchRetains contrast during barium swallow,Leiomyoma,Submucosal massArise from circular or longitudinal smooth muscleSolitary lesions, multiple seen 3-4% of the timeRound filling defectSplitting of barium around tumorEsophagus appears widened on AP view,Carcinoma (SCCA, Adeno),Associated with EtOH/TobaccoPredisposing factorsLye stricturePlummer-Vinson syndromeEsophagitis/Barretts Esophagus,Cancer of the mid-esophagus,Shelf at the upper and lower extentExtensive irregularities in the tumor mass,Cancer of the mid-esophagus,“apple-core” filling defect,Stricture,Lower third of esophagusDue to long-standing reflux,Stricture,Stricture at GE junctionSecondary to reflux esophagitis,Stricture,High-gradePartial obstruction of distal esophagusDilated proximallyRetained barium above stricture,Reflux,Hypertrophy of the cricopharyngeal muscle is commonly seen in patients with long-standing refluxNarrows the lumen and causes solid-food dysphagiaZenkers diverticulum may form from the area of muscle thinning just superior to the CP muscleTypically retains fluid/food particles (often medications/pills),Achalasia,Failure of the LES to relax normallyEsophageal dilationAperistalsisPrimaryidiopathic degeneration of the ganglion cells of Auerbachs plexusSecondary - caused by other conditionsi.e. Distal esophageal carcinoma, Chagas disease, postvagotomy syndrome, CVA, DM,Achalasia,Grossly dilated esophagusContains food and liquid debrisDistal part of the esophagus is extremely narrow,Achalasia,LES is narrowedEsophagus is dilated to 6-7 cm wideAir-fluid level,Esophageal web,Deep web in anterior wall,Differential Diagnosis,OTHER,Sequelae of Irradiation,Acute/subacute effects of mucositis such as pain, sorenessOropharyngeal motility disordersRadiation damage to the CP muscular portion of the sphincterParesis of the pharyngeal constrictor muscles,Sequelae of Irradiation,Failure of the epiglottis to tilt completely down over the laryngeal inlet during swallowingAltered laryngeal/hyoid elevation contribute to reduced laryngeal vestibule closure during the swallow, resulting in aspiration,Post-laryngectomy,Pharyngeal dysmotilityCricopharyngeal dysmotilityRecurrent tumorBenign stricturePseudodiverticulum,Post-laryngectomy,Healthy neopharynxAppears as a re