Dysphagia
Define dysphagia?
Dysphagia is a subjective sensation of difficulty in swallowing either solids or liquids or both.
Discuss the phases of normal swallowing?
Normal swallowing is divided into three phases: oral, pharyngeal and oesophageal.
Oral phase
- Food enters oral cavity
- Mastication and bolus formation.
- Tongue elevates and propels bolus to pharynx.
Pharyngeal phase
- Soft palate elevates to seal nasopharynx
- Larynx and hyoid bone move anteriorly and upwards
- True vocal folds adduct
- False vocal cord adduct
- Epiglottis moves posteriorly and downwards
- Respiration stops
- Pharyngeal wave
- Upper oesophageal sphincter relaxes
- Upper oesophageal sphincter opens
Oesophageal phase
- Bolus passes to oesophagus
- Oesophagus contracts sequentially
- Lower oesophageal sphincter relaxes
- Bolus reaches stomach
Discuss the types of dysphagia?
Dysphagia can be either oropharyngeal or oesophageal:
Oropharyngeal dysphagia (or transfer dysphagia) – this is due to impairment of the oral or pharyngeal phase of swallowing. It commonly occurs in neurological diseases like CVA, Parkinson’s disease, MS, MND, Myasthenia, Alzheimer’s disease etc.
Oesophageal dysphagia arises from oesophageal cause like benign stricture, malignant stricture, motility disorders, eosinophilic oesophagitis and extrinsic compression.
In some patients no cause can be identified; these patients have been categorized as having functional dysphagia. Patients should be reassured. If the symptoms are severe, treatment with a calcium channel blocker or antidepressant can be considered
Discuss transfer dysphagia?
Transfer dysphagia characteristics:
- Postnasal regurgitation
- Coughing or choking during swallowing
- Dysphonia
- Patient’s point toward the neck when asked to identify the site of their symptoms
Video fluoroscopy- is the gold standard for analysing the swallowing physiology. It takes about 10 minutes and is painless. The patient swallows solids and liquids mixed with barium while radiographic images are displayed on a monitor and videotaped. It demonstrates anatomic structures, identifies aspiration and allows assessment of compensatory strategies. It is however difficult to be applied to fragile and immobile patients.
Fibreoptic Endoscopic Swallowing Study (FESS)
It is done with a fibreoptic laryngoscope that passes transnasally into the pharynx and observes swallowing. It can be done at the bedside. Food mixed with blue dye is used to evaluate swallowing, identify pooling of material in the hypopharynx and upper oesophageal sphincter and aspiration. The main disadvantage of FEESS is its limited ability to detect aspiration or assess the oral or oesophageal phase of swallowing.
Discuss the evaluation of dysphagia?
- Difficulty in initiating swallow (rather than dysphagia a few seconds after swallowing), nasal regurgitation, coughing or choking etc suggest transfer dysphagia
- Dysphagia to solids or liquids or both ((Liquids only suggests a motility disorder; solids progressing to liquids suggests a benign or malignant stricture).
- Is dysphagia intermittent, stable or progressive (progressive dysphagia suggests malignancy. Intermittent dysphagia may be due to a ring or Eosinophilic oesophagitis)
- Further enquiry like heartburn, weight loss, previous radiotherapy, systemic diseases like scleroderma etc will further narrow down the differential diagnosis
Discuss oesophageal web and rings?
Oesophageal web is a thin mucosal fold that protrudes into the lumen. It commonly occurs in the postcricoid area. Oesophageal ring (Schatzki) is a thin mucosal structure at the GO junction. They cause intermittent dysphagia
Discuss the investigations for oesophageal dysphagia?
Barium swallow- may be more sensitive and safer if
Proximal oesophageal lesion is suspected (radiotherapy, Zenkers diverticulum etc)
Complex stricture is suspected (h/o caustic ingestion or radiotherapy)
Achalasia is suspected
Upper GI endoscopy- in other patients direct OGD is a better option
24 hr pH study and manometry as indicated.
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