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