Dysphagia

Question 1

define dysphagia and the two types

Answer 1

difficulty swallowing

oropharyngeal vs esophageal

Question 2

define oropharyngeal dysphagia

Answer 2

problems with transferrence of food bolus from the oropharynx to the upper esophagus (disease involving the pharynx, upper esophagus or upper esophageal sphincter)

Question 3

define esophageal dysphagia

Answer 3

impairment of the food bolus through the body of the esophagus (problems with lower esophagus, lower esophageal sphincter or cardia)

Question 4

causes of oropharyngeal dysphagia

Answer 4

1. neurologic disorders
   - -brainstem CVA, mass lesion
   - -pseudobulbar palsy
   - -ALS
   - -MS
   - -poliomyelitis
   - -myasthenia gravis
2. muscular disorders
   - -myopathies
   - -polymyositis
   - -hypothyroidism
3. motility disorders
   - -UES dysfunction
4. structural defects
   - -zenkers diverticulum
   - -malignancy
   - -surgery
   - -radiation of oropharynx

Question 5

causes of esophageal dysphagia

Answer 5

1. mechanical disruption
   - -schatzki’s ring
   - -esophageal stricture
   - -esophageal cancer
2. motility disorder
   - -achalasia
   - -diffuse esophageal spasm
   - -scleroderma

Question 6

what are the three phases of oropharyngeal portion of swallowing

Answer 6

oral preparatory

pharyngeal

esophageal

Question 7

what do you need for the oral preparatory phase

Answer 7

proper mastication
adequate salivary production
intact mucosa
neuromuscular coordination

Question 8

what types of diseases interfere with the oral preparatory phase of swallowing

Answer 8

poor dentition

decreased salivary flow (sjogrens, meds)

parkinsons

mucositis

apthous ulcers

oral herpes

anything affecting CNs V, VII, XII

Question 9

what nerves control the pharygeal peristalsis required for the pharyngeal phase of swallowing

Answer 9

CN V, X, XI, XII

Question 10

what signs suggest the problem is with the esophageal phase of swallowing

Answer 10

coughing, choking, regurgitation through nose as soon as swallowing initiated

liquids more difficult to swallow than solids

associated dysphonia and dysarthria

neuro signs pointing to CVA, MG, ALS, MS

associated heartburn or odynophagia

patients often point to their cervical region to ID this problem

Question 11

in problems with the esophageal phase of swallowing, which is more difficult to swallow, liquids or solids?

Answer 11

liquids

Question 12

what signs suggest esophageal (vs oropharyngeal) dysphagia

Answer 12

symptoms occur several second after initiating swallowing

patients often extend arms and neck to reposition themselves properly

often point towards suprasternal notch or behind sternum as the area causing their symptoms

Question 13

what suggests a mechanical lesion causing the esophageal dysphasia

Answer 13

recurrent and progressively worsens so that fluids may become involved (initially usualyl just solids)

if over 50 and progressive think cancer

if intermittent and not progressive think schatskis ring

Question 14

patient has esophageal dysphasia that is intermittent and not progressive, liquids better than solids

Answer 14

think schatskis ring

Question 15

patient has esophageal dysphasia that is associated with heartburn and progressive

Answer 15

think peptic stricture

Question 16

patient has esophageal dysphasia that is progressive, patient is over 50

Answer 16

think esophageal cancer

Question 17

what signs suggest a motility disorder is behind esophageal dysphasia

Answer 17

fluids and solids are equally hard to swalloe

unpredictable

episodic

progresses slowly or not at all

Question 18

patient has esophageal dysphasia, both solids and liquids are affected and it is progressive

Answer 18

think achalasia (scleroderma)

Question 19

patient has esophageal dysphasia, associated with chest pain and not progressive

Answer 19

think diffuse esophageal spasm

Question 20

patient has esophageal dysphasia, chronic heartburn and raynaud’s phenomenon

Answer 20

think scleroderma

Question 21

what questions to ask to elicit dysphagia history

Answer 21

1. problems initiating swallowing (oropharyngeal) vs food getting stuck a few seconds after swallowing (esophageal)
2. is there coughing or choking or is food coming back through your nose?
3. liquids, solids or both?
4. how long have you had the problem? have the symptoms progressed or stayed the same, or are they intermittent?
5. can you point to where the food/liquid is getting stuck?
6. other symptoms, B symptoms, loss of appetite, weight loss, N/V, regurgitation, heartburn, hematemesis, chest pain?
7. PMHx
8. previous surgery on larynx, esophagus, stomach, c spine?
9. alcohol, iron deficiency, smoking?

Question 22

what to ask specifically on PMHx for dysphagia

Answer 22

previous dysphagia
GERD
scleroderma
cancer
radiation
diabetes
sjogrens
AIDs
stroke
myasthesia gravis
ALS
parkinsons
MS

Question 23

what should you look for specifically on exam for dysphagia

Answer 23

cranial nerves V, VII, X, XII

examine oral cavity, head and neck, supreclavicular region looking for lymph nodes, masses, facial mucle weakness, poor dentition, thyroid enlargement

generalized neuro exam looking for CVA, MS, ALS, MG

hypothyroidism exam

signs of scleroderma

abdo exam

Question 24

what constitutes a hypothyroidism exam

Answer 24

dry skin
brady
delayed return of deep tendon reflexes
thinning hair
slow speech
hoarseness
thickening of tongue
facial puffiness
hard pitting edema

Question 25

what are signs of scleroderma

Answer 25

raynaud’s
dermatological pigmentation changes
skin thickening

Question 26

investigations for dysphagia

Answer 26

swallowing study i.e barium swallow

upper endoscopy
videoesophagography
esophageal manometry
embulatory esophageal pH monitoring

Question 27

treatment of dysphagia

Answer 27

treat underlying cause

mechanical obstructions may need surgery but some, like strictures, can be dilated with a bougie tube

causes associated wtih reflux can be treated with an H2 blocker, PPI or cisapride

swallowing rehab after stroke, head or neck trauma, surgery or degenerative neurological disease