Dysphagia
นพ.โกสิ นทร์ ชัยชำนำญ
Ent
Objectives
Normal physiology
 Dysphagia
 Definition
 Cause and classification
 History taking,physical examination
and investigation
 Disease

Normal physiology

4 stage
 Oral preparatory stage
 Oral stage
 Pharyngeal stage
 Esophageal stage
Normal physiology
Oral preparatory stage

Prepare food for swallow
 Mechanism of action
 1.lip closure to hold food in mouth anteriorly
 2.tension in labial&buccal musculature to close
Ant&Lat sulci
 3.rotatory motion of jaw for chewing
 4.lateral rolling motion of tongue position food on
teeth during mastication – most important
 5.bulging forward of soft palate to seal oral cavity
posterior and widen nasal airway
Oral preparatory stage
1.Muscle of facial expression (VII) –oral sphincter
Orbicularis
oris
– sphincter of lip
– compress
lip@flatten cheek
Buccinator
Oral preparatory stage
2.Muscle of mastication (V) – jaw movement
pterygoid –
open@grinding
Lateral
Masseter
jaw
– close
–
open@A/P move
Temporalis
pterygoid –
close@grinding
Medial
Oral
preparatory
stage
y
3.Tongue muscle
– down
soft palate@up BOT
Palatoglossus(X)
Genioglossus(XII)
elevate BOT
–
Hyoglossus(XII)
depress
--
Oral
preparatory
stage
er
Time : depend on type of food
Normal physiology
Oral stage
 Move food from front oral cavity
to pharynx
 Mechanism of action
○ 1.Upward&backward by midline& Lat
margin of tongue – most important
○ 2.Backward by tension in
buccal musculature
○ 3.trigger swallowing reflex
(locate at anterior pillar)
Oral stage
swallow
buccal musculature
 tongue

 Styloglossus
Hyoglossus
muscle
muscle
Oral stage
swallow
trigger zone at
anterior pillar
Oral
stage
ri
swallow
trigger swallowing reflex
sensory impulse at CN IX
Oral stage
swallow
Tractus solitarius nucleus/
Solitary tract nucleus
trigger swalling reflex
sensory impulse at CN IX
(& Sup. Laryngeal nerve)
Oral stage
swallow
nucleus ambiguus
nucleus ambiguus to
motor neuron of CN X at
pharynx
Oral stage
swallow
nucleus ambiguus
nucleus ambiguus to
motor neuron of CN X at
pharynx
Oral
stage
er
Time : take 1 second
Pharyngeal stage


Move food from pharynx to esophagus
Mechanism of action
 1.velopharyngeal closure
(prevent backflow of material up nose)
 2.tongue base retraction
(propel bolus through pharynx)
 3.pharynx contraction
(clear redisue through pharynx)
 4.larynx elevate and closure
(airway protection)
 5.cricopharyngeal opening
(allow bolus to pass into esophagus)
t
Pharyngeal stage
swallow

1.tongue
 Styloglossus
Hyoglossus
muscle
muscle
Pharyngeal stage
swallow

2.Levator @ Tensor palatini
Tensor
palatini
 Levator
palatini
Pharyngeal stage
swallow

3.pharyngeal constrictor muscle
Superior
Middle
Inferior
Pharyngeal stage
swallow

4.aryepiglottic fold/true vocal fold
/false vocal fold
AEF
FVF/TVF
Pharyngeal
stage
er
Time : take less than 1 second
(not vary with age and gender)
Esophageal stage


Close UES
Body of esophagus
 Outer -> longitudinal ,Inner -> circular

Peristalsis
 primary peristalsis :
○ upper 1/3 striated & transitional zone
○ mix voluntary & involuntary
 secondary peristalsis :
○ lower 2/3 smooth
○ Involuntary

Open LES
Esophageal
stage
er
Time : take 8 to 20 seconds
(depend on food influence by
peristalsis&gravity)
Dysphagia
History
Onset & Site
 Cough or choke or food coming back
through your nose
 Liquid or solid or both
 Liquid and solid  motility disorder
 Solid progress to liquid  benign or
malignant stricture
 Progression

Dysphagia
History
Other symptoms
 Loss of appetite,weight loss ,N/V
regurgitation,heart burn,weakness,
hematemesis,pain
 Medical problems
 DM, HT, cancer
 Hx. Of surgery

Dysphagia
History
Hx. Of radiation
 Medications
 In children
 Feeding
 Growth
 Development

Dysphagia
Physical examination
Complete examination
 Head and neck
 Mass
 Thyroid
 Lymph node
 Salivary gland
 Oral mucosa

 Gag
reflex, Cough reflex
Dysphagia
Investigation

Procedure to evaluate -- major
 1.Fluoroscopy
 2.Endoscopy
 3.Manometry
 4.Ultrasonography
Dysphagia
Fluoroscopy

Barium swallow
 conventional barium swallow
 modified barium swallow
Dysphagia
Fluoroscopy

Modified barium swallow
 Gold standard
 Examine oral cavity & pharyngeal
swallowing
 Ba(1/3 teaspoon per swallow) & vary
food consistency
 Seated upright in normal eating position
Dysphagia
Fluoroscopy

Modified barium swallow
 View in lat. plane with
fluoroscope tube
 Focus on lips & C7th
Dysphagia
Fluoroscopy

Modified barium swallow
 Purpose restore oral intake as quickly
○ 1.define oral&pharyngeal disorder during
swallow
○ 2.identify aspiration of any food consistency
○ 3.assess speed of swallow to determine
adequate nutrition
○ 4.assess effect of Tx eg.postural change
,heightened sensory input ,Tx procedure
(swallowing maneuvers)
Dysphagia
Fluoroscopy

convention barium swallow




Examine anatomy & motility esophagus
Ba(a cup of barium)(250 cc)swallow repeatedly
Lies in supine position
View in anteroposterior plane
Dysphagia
Fluoroscopy
Dysphagia
Achalasia(failure to relax) (bird's beak
appearance)
A:Contrast
penetrate laryngeal vestibule
within boundary of vocal cord
B:aspirate tracheobronchial tree
Dysphagia
Endoscope
 Via transnasal placement of flexible fiberoptic
scope
 Can not examine oral stage & during swallow
 May be identified residual
food in pharynx after
swallow
Dysphagia
Manometry


Used examine esophageal peristalsis & function
of UES & LES
Swallow soft tube contain 3 pressure sensor
 First register --- UES
 Second register – body of esophagus
 Third register – pressure in LES

No information on aspirate or function in oral
cavity or larynx
Dysphagia
Ultrasonography


Used assess anatomy & physiology of tongue
during swallowing (oral stage )
Can not examine pharynx or larynx because of
skeletal interference
Dysphagia
Other investigate
Plain film : film lateral neck(soft tissue
technique) -- FB,Infection
 CT/MRI
 24 hrs.pH monitoring วัดภาวะกรดด่ างในหลอดอาหาร คน
ปกติจะมี pH<4 ที่เหนือกล้ามเนื้อหูรดู ล่าง 5 cm ไม่เกิน 1 hr./วัน

Dysphagia
Other investigate
 Scintigraphy
 Nuclear medicine test
 Swallow several selected bolus of radioactive
material
 Gamma camera detect amount radiation
passing
 Oropharyngeal anatomy not visible
 Aspiration – two trial material swallows
○ One to esophagus
○ Another to airway
The end…