DYSPHAGIA

Dr Navin Shukla
Associate professor
Department of E.N.T&H.N.S.
 CONTENTs
• Definition
• Swallowing mechanism
• Clinical presentation
• Grading of dysphagia
• Etiology
• Investigations
• Management
 DYSPHAGIA
As typically defined, dysphagia is a
condition in which disruption of the
swallowing process interferes with a
patient’s ability to eat. It can result in
aspiration pneumonia, malnutrition,
dehydration, weight loss, and airway
obstruction.
 DYSPHAGIA
• The word dysphagia is derived from the Greek
phagia (to eat) and dys (with difficulty).
• Eating becomes unenjoyful.
• It refers to the sensation of food being
obstructed in the food passage anywhere
from the mouth to the stomach.
• The basic impairment behind dysphagia are
1)neurological
2)mechanical / obstructive
 SWALLOW MECHANISM
• The act of swallowing requires the passage for food and drink from the
mouth into the stomach.
• From mouth to hypopharynx covers 1/3rd of passage (distance) while
2/3rd is covered by the esophagus .

• The swallowing center in brain stem is located in the floor of fourth

ventricle and adjacent regions of medulla. From here it is connected
to cerebral cortex, vomiting and respiratory centre.
• All these areas works in coordinated manner to provides voluntary as
well the involuantary control of swallowing.

• An adult swallow approximately 580 times daily and the act goes on
unconsciously .
• Swallowing phase
– Oro-Pharyngeal phase( voluntary phase)

– Esophageal phase( involuntary phase)

OROPHYRANGEAL PHASE
 ELEVATION OF POSTERIOR MOVEMENT ELEVATION OF SOFT
TOUNGE OF TOUNGE PALATE

ELEVATION OF HYOID ELEVATION OF LARYNX TILTING OF EPIGLOTTIS

 Esophageal Phase
• Food bolus is propelled through the esophagus
by an involuntary wave of contraction mediated
by the enteric nervous system.
• Pressure gradient speeds the movement of food
from the hypopharynx into the esophagus when
the cricopharyngeus muscle relaxes.
• The primary peristaltic contraction which is
initiated by a swallowing , moves down the
esophagus at the rate of 2 to 4 cm/s and reaches
the distal esophagus about 9 seconds .
• This duration varies from 8 to 20 seconds
 Clinical presentation
• Pain and difficulty in swallowing.
• Sensation of food being stuck into throat or chest.
• Coughing or gagging while swallowing.
• Nasal regurgitation
• Dysarthria
• Nasal speech because of associated muscle
weaknesses
• Frequent burning sensation in chest.
• Having food or stomach acid back up into the throat.
• Unexpectedly losing weight.
FUNCTIONAL GRADES OF DYSPHAGIA

There are 6 grades of dysphagia

• GRADE 1 : Complains of dysphagia but still

eating normally
• GRADE 2 : Requires liquid with Meals
• GRADE 3 : able to take semisolid ,but unable
to take any solids
• GRADE 4 : able to swallow liquids only
• GRADE 5 : unable to swallow liquid, but able
to swallow saliva
• GRADE 6 : unable to swallow saliva also
 Etiology
Dyspahgia has been classified broadly into
two types on the basis of site.

Oropharyngeal Esophageal
OROPHARYNGEAL VS.OESOPHAGEAL
DYSPHAGIA
 In Oropharyngeal dysphagia, there is difficulty in
preparing and transporting the food bolus through the
oral cavity as well as initiating the swallow. This may be
associated with aspiration or nasopharyngeal
regurgitation.
 In Oesophageal dysphagia, patients complain of food
sticking in their lower throat, neck, retro-sternal
discomfort or epigastrium.
 Abnormalities Causing
Oropharyngeal Dysphagia
• Inability to initiate the act of swallowing.

Etiology
(1) Neuromuscular Diseases
• Central nervous system (CNS)
• Cerebral vascular accident involving the brain stem.
• Parkinson disease
• Wilson disease
• Multiple sclerosis
• Brain stem tumor
• Peripheral nervous system
• poliomyelitis
• Peripheral neuropathies (e.g. diphtheria, tetanus rabies, diabetes mellitus)
• Motor end plate
• Myasthenia gravis
 CONTINUED ........................

• Muscle
• Oculopharyngeal muscular dystrophy
• Primary myositis
• Metabolic myopathy (e.g., glycogen storage disease, lipid storage
disease)
(2) mechanical or obstructive Lesions
1) Inflammatory
• Pharyngitis
• Abscess ( peri-tonsillar , paraphryngeal/retrophryngeal )
• Tuberculosis
• Syphilis
2) Neoplastic
3)Plummer-Vinson syndrome
4)Extrinsic compression
• Thyromegaly( hashimoto’s thyroiditis)
• cervical osteophytes
• Lymphadenopathy
 CONTINUED.........................

5) Disorders of the Upper Esophageal Sphincter (UES)

It is related to the abnormal UES relaxation or opening

• Incomplete relaxation
cricopharyngeal achalasia
oculopharyngeal muscular dystrophy
• Inadequate opening
cricopharyngeal bar
Zenker diverticulum
• Delayed relaxation
familial dysautonomia
 Esophageal Dysphagia

Patients usually complains of feeling of food getting stuck several

seconds after swalloing and will point towards the suprasternal
notch or behind the sternum.

ETIOLOGY
1) Neuromuscular (Motility) Disorders
• Most common
– Achalasia
– Diffuse esophageal spasm
• Other motility abnormalities
– Nutcracker esophagus
– Hypertensive lower esophageal sphincter
– motility disorders secondary to
Scleroderma
collagen disorders
Chagas disease
 CONTINUED ........
(2) Mechanical or obstructive
i) Esophagitis:dysphagia is due to mucuosal edema or benign
stricture
• Gastroesophageal reflux disease (GERD)
• Infectious esophagitis HIV , H. pylori, Herpes, Candidiasis
• Medication-induced esophagitis NSAIDs , quinidine,
potassium, vitamins (B. complex), Iron sulphate
• Radiation treatment
• Caustic injury
ii) Disorders of wall
Esophageal stricture
Zenker diverticulum
Epiphrenic diverticula
CONTINUED............

(iii) Disease causing external compression

Hiatus hernia ( mainly paraesophageal hernia )
Cervical osteophytes
Mediastinal growth
Vascular ring (dysphagis lusoria)
(iv)Luminal obstruction:
Foreign bodies
Esophageal webs
Schatzki rings
Carcinoma esophagus
 Associated symptoms and possible etiologies

Condition Diagnosis to consider

Difficulty in initiating swallow Oropharyngeal dysphagia
Food sticks after swallow in chest Esophageal dysphagia
Progressive dysphagia Neuro muscular dysphagia, carcinoma
Sudden dysphagia Foreign body, esophagitis
Intermittent dysphagia Rings and webs, Diffuse esophageal spasm,
Nutcracker esophagus
Cough: Early in swallow Neuromuscular dysphagia
Late in swallow Obstructive dysphagia
Weight loss: In elder patient Carcinoma
With regurgitation Achalasia
Pain after swallowing Esophagitis
Dysphagia related to: solid foods only Obstructive dysphagia
Solid and liquid both Neuromuscular dysphagia

Regurgitation of old food and halitosis Zenkers diverticulum

Dysphagia relieved with repeated swallow Achalasia
 Evaluation of dysphagia
• History
• Clinical examination
• Blood investigations Hb % , TC ,DC ,serum iron
• Radiology – plain x-ray , barium meal , CECT thorax / Neck
• Upper GI endoscopy
• laryngoscopy
• Manometery
• 24 hr pH monitoring
• Endoscopic ultrasound
• Histopathology
 THE HISTORY
 The history can also be used to help
differentiate structural from functional (i.e.,
motility disorders) causes of dysphagia.
 Dysphagia that is episodic and occurs with
both liquids and solids from the outset (Equal
dysphagia) suggests a motor disorder,
whereas when the dysphagia is initially for
solids, and then progresses with time to
semisolids and liquids, one should suspect a
structural cause (e.g., stricture).
 If such a progression is rapid and associated
with significant weight loss, a malignant
stricture is suspected
HISTORY
 Onset.

 Duration

 Progression

 Severity of symptoms
Types of food intake that causes
problems
 Alleviating factors
ASSOCIATED SYMPTOMS
 Regurgitation

 Pain on swallowing
 Hoarseness of voice

 Otalgia

 Coughing after eating

 Frequent chest infections

Dyspha
gia
AGE: POSSIBLE CAUSES
 Children : Foreign body or congenital malformation
 Middle aged patients: Reflux oesophagitis, hiatus
hernia, anaemia, achlasia, globus syndrome.
 Elderly patients: Malignancy, stricture formation from
longstanding reflux, pharyngeal pouch, motility disorders
associated with aging and neurological disorders.
SYMPTOM ONSET AND
PROGRESSION
 Sudden onset of symptoms may result from a stroke
(OPD) or food impaction (OD).
 Intermittent non progressive or slowly progressive
dysphagia suggests a benign cause, such as a motility
disorder or a stable peptic esophageal stricture.
 A history of prolonged heartburn may suggest peptic
esophageal stricture, neoplasm, or esophageal ring.
EXACERBATING AND RELIEVING FACTORS
 Greater difficulty swallowing liquids than solids (OPD)
 Precipitation or worsening of dysphagia with
consumption of very cold liquids or ice cream (ED)
 Dysphagia that progresses from solid to semisolid
food or liquid in a brief period of time suggests
esophageal stricture related to tumor.
PHARYNGEAL DYSPHAGIA INCLUDE
THE FOLLOWING:

 Coughing or choking with swallowing

 Difficulty initiating swallowing

 Food sticking in the throat

 Sialorrhea

 Unexplained weight loss

 Change in dietary habits

 Recurrent pneumonia

 Change in voice or speech (wet voice)

 Nasal regurgitation
ESOPHAGEAL DYSPHAGIA INCLUDE
THE FOLLOWING:

 Sensation of food sticking in the chest or throat

 Change in dietary habits

 Recurrent pneumonia [1]

 Symptoms of gastroesophageal reflux disease

(GERD), including heartburn, belching, sour
regurgitation, and water brash
Other associated factors/symptoms of dysphagia
include the following:
 General weakness

 Mental status changes

KEY POINTS
 Age suggests most likely cause of dysphagia
 Globus pharyngeus rarely associated with any serious
disease
 Dysphagia of short duration in elderly patient who smoke
or drink and which progress from solids to liquids is a
classic case of malignancy
 Referred otalgia with dysphagia is a sinister symptom
and poor prognostic sign
 CLINICAL EXAMINATION
 Complete Head and neck examination
 Inspection of oral cavity
 Dentition
 Oropharynx
 IDL
 Nasolaryngoscopy
 Cranial nerve examination ( tongue, gag and
cough reflex, hoarseness, vocal cord mobility)
 Neck for lymph nodes, neck masses, thyroid
enlargement, loss of laryngeal crepitus and
integrity of laryngeal cartilages.
PHYSICAL EXAMINATION
• General factors such as body habitus, drooling, and
mental status should be noted.
• Voice quality (e.g. a wet sounding voice suggesting
pooling of secretions), Wheezing or labored breathing,
and any cranial nerve weakness should be noted.
• Gurgling noise in the neck or crepitus in the neck
may indicate the presence of Zenker’s diverticulum.
• Inspection or palpation of the tongue and
tongue strength may unmask fibrillation or
fasciculation of one or both sides.
• The oropharynx should be inspected for
palatal elevation and posterior pharyngeal
wall motion on phonation
Investigations for Dysphagia:
Inflammatory (epiglottitis, Retro-Pharyngeal
Plain Films abscess), radio-opaque foreign bodies.

Barium Indicated in patients in whom structural disorders

Esophagram are suspected (e.g. dysphagia to solid foods)

Manometry Rarely used except in cases where elevated

intraluminal pressures must be followed (e.g.
achalasia).

Bolus Indicated to follow improvement in a patient with

Scintigraphy h/O aspiration or to follow esophageal emptying
in achalasia.

Video "Gold standard", study the anatomy and

fluoroscopic
examination or
physiology of the oral, pharyngeal, and
modified esophageal stages of deglutition.
barium
swallow
 Radiology
• Plain x-ray neck & chest – for foreign bodies

PIN

DENTURES
 Barium swallow

Mid esophageal Zenkers

Epiphrenic
diverticulam diverticulam diverticulam
 Barium Swallow

Bird beak Sigmoid

sign – esophagus Nut Cracker
Achalasia Achalasis Esophagus
 Barium Swallow

Stricture – Irregular filling defect

Sliding –
caustic injury
Hernia carcinoma Esophagus
 Cine-radiography
• Dynamic assessment
• Radiographic visualisation of food bolus movement from oral cavity to
hypophyrnx
 Endoscopy
• Rigid
• Flexible

• Diagnostic
visual
biopsy
• Therapeutic
foreign bodies
removal
Stentings
Dilations
Barret’s Esophagitis Schzkati ring

Esophagitis Esophagial diverticulam

 Paraesophageal hernia
Foreign body – bone
retro flexion view

Corrosive stricture Carcinoma Esophagus

 Manometery
• Indications
- Achalasia cardia
- diffuse esophageal spasm
- Nutcracker esophagus
- hypertensive esophageal sphincter
Types
• Stationary Manometery
• High Resolution manometery
 Manometery

Normal peristalsis Achalasia

Nutcracker esophagus Diffuse esophageal spasm

 24-Hour Ambulatory pH Monitoring

• The most direct method of measuring

increased REFLUX (esophageal exposure
to gastric juice ) is by an indwelling pH
electrode, or more recently via a radio-
telemetric pH monitoring capsule that
can be clipped to the esophageal mucosa.
 Endoscopic ultrasound
Used for dysphagia due to
carcinoma esophagus
for T , N staging

 Biopsy can also be taken

tumor confined to the an advanced esophageal carcinoma

esophageal wall penetrating through all layers
 HISTOLOGY

Barret’s esophagitis Squamous cell carcinoma Adenocarcinoma

 TREATMENT
 The goals of dysphagia treatment are to maintain adequate
nutritional intake for the patient and to maximize airway
protection.
 Disorders of oral and pharyngeal swallowing are usually
amenable to rehabilitation, including dietary modification and
training in swallowing techniques and maneuvers.
In adults
 Direct techniques include modifications of food consistency;

 indirect techniques include stimulation of the oropharyngeal

structures and the adoption of behavioral techniques,
 TREATMENT
• Life style modification
• Drug therapy
• Therapeutic endoscopy
• Dilation
• Stentings
• Chemo-radiation
• Surgery
 LIFE STYLE MODIFICATION
• These include
– avoidance of precipitating foods(fatty foods,
alcohol, caffeine)
– Oral hygine
– avoidance of recumbency postprandially
– elevation of the head of the bed
– smoking cessation
– weight reduction.
• Inflammatory lesion
Antibiotics
Antifungal
Incision & Drainage – for abscess
Neuromuscular dysphagia
Maintenance of oral hygine
Chew well
Semisolid /liquid diet
Eat small meals more frequently
Thermal tactile stimulation
For grade 4-6 dysphagia – cricomyotomy
 Drug therapy for esophageal dysphagia
• H2 Blocker
• Antacids
Reflux esophagitis
• PPI
• Metaclopromide/ Domperidon

• Nitrates
• Calcium channel Blockers
Motility disorders
• sildenafil
• Botox injection

• Steroids
• Vinegar, lemon, orange juice - Alkali ingestion Caustic injuries
• Milk, egg white, Antacid - Acid ingestion
 Therapeutic Endoscopy
• Foreign body / food bolus extraction

Food bolus extracted endoscopically

Graspers
 Dilation
• Upto 40- 60 F ( Hydrostatic / pneumatic )
• Indications -Strictures,
Schatki rings
Achalasia
Anastomotic stenosis , Pneumatic Dilator
 Stents
• Self expanding metal stents
• Indication –
grade 4 -6 dysphagia in ca esophagus ( not resectable ) Non-covered stents

 Types - covered , uncovered stents

 Complication - stent blockage , stent migration , erosion
 Blockage can be removed by coring using laser or cryo
ablation

Stent delivery system Stent in situ

 Chemo-radiation
• Indications
Grade 1-3 dysphagia in case of ca
esophagus ( neo adjuvent )
Grade 4-6 dysphagia in case of ca
esophagus ( palliative )
Cisplatin+5FU + 60Gy radiation over 8 weeks
 Surgery
• Diverticulotomy/diverticulopexy + myotomy -
esophagial diverticulum
• Myotomy –
motility disorders
neuronal dysphagia
• Fundoplication –
reflux esophagitis
• Hernia repair (crural repair) -
Hiatus hernia
• Esophageal resection and reconstruction
Malignancy
long standing Achalasia
caustic injuries
Zenker’s diverticulum repair
• Open Cricomyotomy +
diverticulopexy/diverticulectomy

• Dohlam’s procedure
trans oral approach

Dohlam’s procedure
 Motility disorder
• Long esophageal myotomy
Indications
Diffuse esophageal spasm
Nutcracker esophagus
Scleroderma
Epiphrenic diverticulum
• Heller’s myotomy ( modified )
indications
Achalasia
chagas disease
These myotomy are done in
conjunction with partial
fundoplication – Dor , Toupet ,
Nissen
 Reflux esophagitis
• Fundoplication
indications
failure of medical treatment
structurally defective LES ( lower esophageal
spintcher )
stricture
Barrets esophagitis
in conjunction with myotomy or hiatus
hernia repair

Types :
Nissen’s fundoplication
Dor fundoplication
Toupet fundoplication
Besely fundoplication
 Esophageal resection
• Indications
Carcinoma esophagus ( with two /three field
lymphadenectomy )
long standing achalasia
Extensive corosive injury
• Surgical Approach
 Open – Trans-hiatal (Orringer)
Laprotomy + Trans thoracic (Ivor-lewis )
Three phase (Mc Keown)
 Laproscopic
Laproscopic Ivor lewis procedure
Laproscopic Tran-hiatal
 VATS (video assited transthoracic surgery)
 Robotic
 Ivor- lewis operation

Trans-Hiatal approach

Mc Keown three phase –

post op patient
 Reconstruction
stomach
colon
jejenuum ( pedicle / free )

Gastroesophageal
Anastomosis at
Orthotropic site