DYSPHAGIA
DYSPHAGIA: Difficulty in swallowing
ANATOMY OF OESOPHAGUS
• Fibromuscular tube about 25cm long in an adult
• Extending from lower end of pharynx (C6) to cardiac end of stomach
(T11)
• Areas of narrowing or constriction
• 1. pharyngoesophageal junction: 15cm from upper incisor
• 2. arch of aorta and 3. Lt main bronchus: T4: 25cm from upper incisor
• 4. pierces diaphragm (T10): 40cm from incisor
RELEVANT ANATOMY OF THE
OESOPHAGUS
DYSPHAGIA
ANATOMY contd
• Muscles : Upper 1/3 striated muscles: Middle 1/3 striated and smooth
, lower 1/3 smooth
• PHYSIOLOGY OF SWALLOWING
• 1. oral or buccal phase
• 2. pharyngeal phase
• 3. oropharyngeal phase
DYSPHAGIA
AETIOLOGY
• Pre-oesophageal (disturbance in oral and pharyngeal phase)
• Oesophageal (disturbance in oesophageal phase)
PREOESOPHAGEAL CAUSES
1. ORAL PHASE
a. Mastication: Trismus, mandibular fracture, jaw tumour, TMJ disorder
b. Disturbance in lubrication: xerostomia (Mikulicz dx, Sjogren’s
syndrome)
DYSPHAGIA – Pre-oesophageal
causes
d. Mobility of the tongue: paralysis of tongue, painful ulcers, tumours
of the tongue, lingual abscess, total glossectomy
e. Defects of Palate: Cleft palate, oronasal fistula
f. Lesions of buccal cavity & floor of mouth: Stomatitis, ulcerative
lesions, Ludwig angina
PHARYNGEAL PHASE
• A. Obstructive lesions: Tumours of tonsils, soft palate, base of tongue,
supraglottic larynx or obstructive hypertrophic tonsils
DYSPHAGIA
d . Inflammatory conditions: acute tonsillitis, quinsy, retro- &
parapharyngeal abscess, acute epiglottitis, laryngeal oedema
c. Spasmodic conditions: Tetanus, rabies
d. Paralytic conditions: of soft palate (diphtheria, bulbar palsy, CVA:
they cause regurgitation into the nose), Paralysis of Larynx, lesions of
the vagus and superior laryngeal nerve (they cause aspiration of food
into the larynx)
DYSPHAGIA
OESOPHAGEAL CAUSES
1. Lumen: atresia, FB, Stricture, benign and malignant tumours
2. Wall:
-Acute and chronic oesophagitis
-Motility disorders
Hypomotility: achalasia, scleroderma, amyotrophic lateral sclerosis
Hypermotility: cricopharyngeal spasm, diffuse oesophageal spasm
DYSPHAGIA – oesophageal
causes
3. Outside the wall
• Hypopharyngeal diverticulum
• Hiatus hernia
• Cervical osteophytes
• Thyroid diseases: enlargement, tumours, Hashimoto thyroiditis
• Mediastinal: tumours, lymph node enlargement, aortic aneurysm,
cardiac enlargement
• Vascular ring (dysphagia lusoria)
DYSPHAGIA
INVESTIGATIONS
History
• Onset: sudden – FB
• Progressive – Malignancy
• Intermittent – spasms
• More to liquid: paralytic
• More to solid, then to liquid – malignancy
• Intolerance to acid food or fruits juice – ulcerative lesions
DYSPHAGIA - INVESTIGATIONS
• Associated symptoms:
• Regurgitation & heart burn – hiatus hernia
• Regurgitation of undigested food while lying down, with cough at
night – hypopharyngeal diverticulum
• Aspiration into lungs – laryngeal paralysis
• Aspiration into the nose; palatal paralysis
DYSPHAGIA - Investigation
CLINICAL EXAM
• Exam of oral cavity, oropharynx – exclude pre-oesophageal causes
• Exam of neck, chest, nervous system and cranial nerves
BLOOD EXAM
• Haemogram: Plumer-Vinson syndrome, nutritional status
RADIOGRAPHY
• CXR: cardiovascular, pulmonary and mediastinal diseases
DYSPHAGIA - Investigations
• Lateral view of neck: cervical osteophytes, soft tissue lesions of
postcricoid or retropharyngeal space.
• Barium swallow: malignancy, cardiac achalasia, stricture,
diverticulum, hiatus hernia, or oesophageal spasm
• MANOMETRIC & PH System
• OESOPHAGOSCOPY (fexible or rigid); visualize mucosa, take biopsy,
oesophagoscopy
DYSPHAGIA -Investigation
OTHER INVESTIGATIONS
• Bronchoscopy, cardiac catheterization, thyroid scan etc
• TREATMENT: depends on the cause
