DYSPHAGIA
Dr. Juveria Majeed,MS ENT
CLINICAL ANATOMY
Introduction• Deglutition – is a process, whereby a bolus,
liquid or solid is transferred from the buccal cavity to the stomach.
• 3 phases: - Oral - Pharyngeal - Oesophageal
Stages of Swallowing• Oral phase: voluntary• Pharyngeal phase:
involuntary reflex• Esophageal phase:
Peristalsis – Primary wave- initiated by impulses from swallowing center.
Sec. waves are initiated by a bolus in the esophagus.Tertiary contractions- nonpropulsive, irregular.
Dysphagia• Defined as a sensation of sticking or obstruction of the
passage of the food in the mouth, pharynx or the oesophagus.
• Dysphagia should be distinguished from:
Odynophagia- painful swallowing
Aphagia – Absolute dysphagia
Phagophagia – Fear or refusal to swallow
Globus Hystericus – Sensation of lump in the throat.
Aetiology of Dysphagia
Pre-oesophage
alCauses
Oral Phase PharyngealPhase
Oesophageal
Causes
Pre-oesophageal causes• Oral Phase: Normally
food must be masticated, lubricated with saliva and converted into a bolus. Then its pushed by tongue against hard palate into pharynx. Any disturbance in this sequences will cause dysphagia.
Oral causesDisturbance in mastication
Trismus, #mandible, Tumors of upper or lower jaw, disorders of TM joint.
Disturbance in lubrication
Xerostomia foll. RT, Mickulicz disease
Disturbance in mobility of tongue
Paralysis of tongue, painful ulcers, tumors of tongue,, lingual abscess
Defects of palate Cleft palate, oronasal fistula
Lesions of buccal cavity and floor of mouth
Stomatitis, ulcerative lesions, ludwigs angina
Pharyngeal Phase
• For a normal swallow, food should enter the pharynx and then be directed towards the oesophageal opening. All unwanted connections into the nasopharynx, larynx and oral cavity should be cut off.
Pharyngeal phase causes leading to dysphagia
Obstructive lesions of pharynx
Tumors of tonsil, soft palate, base of tongue, supraglottic larynx, or even obstructive hypertrophied tonsils
Inflammatory Conditions
Ac.tonsillitis, peritonsillar abscess, retro or parapharyngeal abscess, ac.epiglottitis, edema larynx.
Spasmodic conditions
Tetanus, rabies
Paralytic conditions
Paralysis of soft palate due to diphteria, bulbar palsy, CVA.They cause regurgitation into nose.Lesions of vagus and b/l SLN leading to aspiration.
Oesophageal Causes
•Atresia, FB, Strictures, Benign and Malignant tumorsLesions in
the lumen of oesophagus
•Ac. Or Ch. oesophagitis•Motility disorders- hypomotility
(achalasia,scleroderma)•Hypermotility disorders-cricopharyngeal
spasm, diffuse oesophageal spasm.
Lesions on the wall of
oesophagus
•Hypopharyngeal diverticulum•Hiatus Hernia•Cervical osteophytes•Thyroid lesions, eg enlargement, tumors,
hashimotos thyroiditis.•Mediastinal lesions eg. Tumors, LN
enlargement, aortic aneurysm, cardiac enlargement.
•Vascular rings- Dysphagia Lusoria.
Lesions outside the
wall of oesophagus
HOW TO EVALUATE A CASE OF DYSPHAGIA???
History
Clinical Examination
Radiography
Blood
Examinatio
n
Manometric and pH
studies
Oesophagoscop
y
Other
investigations
HISTORY• Sudden or gradual onset?• Progressive?• Intermittent?• More to liquids?• More to solids, progressing to
liquids?• Intolerance to acid foods?• Associated symptoms-
regurgitation and heart burn, cough on lying supine, aspiration into lungs.
Clinical Examination:Examination of oral cavity oropharynx, hypopharynx larynx to exclude pre
oesophageal causes of dysphagia.Examination of neck, chest and
nervous system.
Radiography• Xray chest• Xray Neck lateral view• Barium swallow
FB OesophagusOesophageal Stricture
BARIUM SWALLOWAchalasia Cardia Ca. Oesophagus
Blood Investigations:Hemogram – Plummer vinsons
syndrome
Manometric and pH studies:
These studies help in motility disorders, gastro-oesophageal reflux and to find whether oesophageal spasms are spontaneous or acid induced.
OesophagoscopyIt gives direct
examination of oesophageal mucosa and permits biopsy specimens.
Flexible fibre optic or rigid scopes.
Oesophageal webs and rings
Other investigations• Bronchoscopy (for bronchial
carcinoma)• Cardiac catheterisation (for vascular
anomalies• Thyroid scan (for malignant thyroid)
NEOPLASMS OF OESOPHAGUS
Benign Neoplasms• Rare compared to malignant ones.• Leiomyomas – most common (2/3rds
of all benign neoplasms)• Dysphagia • Treatment is enucleation of the
tumors by thoracotomy.• Other rare tumors- mucosal polyps,
lipomas, fibromas and hemangiomas.
Carcinoma OesophagusIncidence: • High in China, Japan, USSR and south
Africa.• In India, it constitutes 3.6% of all
body cancers
Aetiology:Smoking and Alcohol
consumptionDietary habits.Pre-existing pathological
lesions such as strictures, cardiac achlasia, diverticula and hiatus hernia.
Barrets oesophagus
Barrett’s Oesophagus
Pathology• SCC is the most
common (93%).• Adenocarcinoma
(3%) is also seen, but in the lower esophagus, and maybe an upward extension of the gastric ca.
Spread of Carcinoma
• Direct• Lymphatic• Blood borne
Clinical Features• Substernal discomfort• Progressive dysphagia and
emaciation• Vomitings• Back Pain • Aspiration problem
DIAGNOSIS• Barium swallow• Oesophagoscopy• Bronchoscopy• CT• MRI• PET- CT
Barium swallow
CT Scan
PET Scan
• Early stages- Endoscopic mucosal resection(EMR) , Surgery.
• Surgery is the preferred method of treatment for cancer of lower 2/3rd.
• Affected segment with wide margin along with the fundus of the stomach can be removed followed by primary reconstruction.
• Surgery of upper 2/3rd is difficult due to great vessels and involvement of mediastinal nodes.
• Radiotherapy is the treatment of choice.
In advanced lesions, only palliation is possible. An alternative food channel can be provided by:
• A by pass operation• Oesophageal intubation with Celestin or
Mousseau Barbin or a similar tube.• Permanent gastrostomy or a feeding
jejunostomy• Laser surgery: Oesophageal growth is burnt
with Nd:YAG lase to provide a food channel.
Surgery followed by reconstruction
RADIOTHERAPY
• SCC of oesophagus are radiosensitive .
• Radiotherapy to a dose of 6000cGy is employed for ca. esophagus.
CHEMOTHERAPY
• CT is used only as a palliative measure in the locally advanced or disseminated disease. Commonly in combination with RT.
• Mtx, Bleomycin,5FU, Cisplatin have been used in SCC.
COMBINED MODALITY TREATMENT• Is the best modality for advanced
oesophageal ca.• Improves five-year survival rate.• Surgery + CT• Surgery + RT• CT+RT• Radiochemotherapy+ Surgery• Prognosis: Five-year survival rate not
more than 5-10%
THANK YOU