Dr.Ümit Akyüz Yeditepe University Department of Gastroenterology Dysphagia Dr.Ümit Akyüz Yeditepe University Department of Gastroenterology

Swallowing Mechanism is complex Involves the actions of 26 muscles and 5 cranial nerves CN V -- both sensory and motor fibers; important in chewing CN VII -- both sensory and motor fibers; important for sensation of oropharynx & taste to anterior 2/3 of tongue CN IX -- both sensory and motor fibers; important for taste to posterior tongue, sensory and motor functions of the pharynx CN X -- both sensory and motor fibers; important for taste to oropharynx, and sensation and motor function to larynx and laryngopharynx; important for airway protection CN XII -- motor fibers that primarily innervate the tongue A normal adult swallows unconsciously 600 times in a 24-hour period

Esophageal Anatomy Upper one-third is composed of skeletal muscle Distal two-thirds is smooth muscle NO SEROSA Outer longitudinal, inner circular muscle layer Myenteric plexus of Auerbach, parasympathetic ganglion cells, interspersed among the muscle layers Submucosa – blood vessels/lymphatics, myenteric plexus of Meissner (parasympathetic ganglion cells) Mucosa – stratified squamous epithelium

Swallowing Stage 1 Oral Food ingested, prepared (mastication) and modified (lubrication) Voluntary control Frequently results from weakness – lips, tongue, cheeks Unable to organize food into well formed bolus and move posteriorly Xerostomia – difficulty breaking down solids

Swallowing Stage 2 Pharyngeal Prevented from entering nasopharynx, larynx rises, retroflexion of epiglottis and vocal fold closure, synchronized contraction of middle and inferior constrictors, and synchronized relaxation of the cricopharyngeal muscle Involuntary Timing – neurologic – epiglottis doesn’t protect larynx - leads to cough/aspiration Weakness – neurologic injury/cancer – residual food after swallow – can lead to aspiration

Swallowing Stage 3 Esophageal Begins with crico-pharyngeal relaxation Involuntary Most common Sensation of food sticking at base of throat/chest Peristalsis, tumor, stricture

Differential Diagnosis Neuromuscular disorder Esophageal spasm Pseudobulbar palsy CVA Multiple Sclerosis Myasthenia Gravis Dermatomyositis Muscular Dystrophy Inflammatory lesions Thrush (Candida) Tonsillitis (PTA vs. lingual tonsillitis) Abscesses (retro-, para-) Systemic causes Scleroderma Plummer-Vinson syndrome

Differential Diagnosis (continued) Extrinsic lesions Thyroid mass Dysphagia lusoria Aortic aneurysm Intrinsic lesions Zenker’s diverticulum Benign tumors (leiomyoma) Carcinoma (SCCA, Adeno) Strictures Achalasia Esophageal webs Schatzki’s ring

Work-Up Detailed History PE Radiography Esophagoscopy Special tests

History Temporal pattern < 4 seconds after initiation usually can be localized to the OC, pharynx or CP regions > 4 seconds most are due to pathology in the esophagus Weight loss increases the likelihood of a significant organic process Strictures may occur from chemical ingestion or traumatic injuries

History Voice changes Globus hystericus Consider reflux, vocal cord paralysis (s/p CVA or from tumor involvement) or presbylaryngeus Globus hystericus Pressure, fullness, or a lump in the throat, not related to meals Old myth of overweight, depressed, obsessive, menopausal females Actually often associated with real GERD/LPR

Physical Examination Complete head and neck exam Look for signs of chronic illness or recent weight loss “wet” voice failure to clear the HP of retained secretions Palpable crepitus or gurgling noises in the neck Possible Zenker's diverticulum or other pouch Drooling

Fluoroscopy Standard barium swallow uses thin barium, is a quick view, and is not satisfactory for most swallowing disorders MBS is the definitive study for evaluation of the swallowing mechanism Uses both thick and thin barium consistencies and simulated foods

MBS Dynamic recordings using air-contrast exams both in the upright and recumbent positions Assess pharyngeal anatomy and motility Most have a speech pathologist present Superior to FEES for evaluating the oral phase and aspiration

FEES (Fiberoptic endoscopic evaluation) Directly viewing liquid or food bolus via scope Positioned high in oropharynx Observation of vocal and arytenoid movements Elevation of larynx and tongue base Management of residuals Pooling and aspiration can be noted

FEESST (Functional endoscopic evaluation of swallowing with sensory testing ) FEEST objective evaluation of laryngeal sensory function uses an air pulse stimulus to determine laryngopharyngeal sensory discrimination thresholds on mucosa of SLN distribution Sensory decrease and consequent decreased reflexes may lead to aspiration

Esophagoscopy Flexible (in office) vs. rigid Foreign body, biopsy of lesions, evaluation of stenosis Patients with persistent neck pain, odynophagia or those with tumors found in the preliminary workup require a rigid examination (DL/E) Esophagus should be biopsied in all patients suspected of having esophagitis, a neuromuscular disorder, or a collagen vascular disease

Special Tests pH probe - monitors over a 24 hour period Acid infusion tests infuses a dilute HCL solution into the esophagus checks reproducibility of symptoms Manometry – essential if dysfunction of the cricopharyngeus, esophagus or LES identified on swallow study Quality laboratory Interpreted by an experienced gastroenterologist

Esophageal Manometry Patient is awake and alert 4.5mm catheter via the nose secured at 50cm 8-lumen catheter with 8 orifices Multiple ports simultaneously take measurements in mmHg UES, LES, and at 2cm intervals above the LES

Manometry Senses the activity of the muscles Identifies subtle failures of pressure generation or hyperfunctioning of the sphincters Helps accurately diagnose the site of dysfunction

Manometry CP = UES has a normal resting tone, which is increased during inspiration and relaxed during bolus passage LES has a normal resting tone with relaxation coincident with bolus arrival Esophageal antegrade peristalsis may be disrupted due to spasm, aperistalsis or other dyskinetic contractions May be asymptomatic, although inflammation and muscular spasm are often recognized by sensations of substernal pressure or discomfort

Differential Diagnosis Neuromuscular disorder Esophageal spasm Pseudobulbar palsy CVA Multiple Sclerosis Myasthenia Gravis Dermatomyositis Muscular Dystrophy Inflammatory lesions Thrush (Candida) Tonsillitis (PTA vs. lingual tonsillitis) Abscesses (retro-, para-) Systemic causes Scleroderma Plummer-Vinson syndrome

Candidiasis Multiple ulcerations and nodularity over a long segment Most common in immuno-compromised patients

Differential Diagnosis Neuromuscular disorder Esophageal spasm Pseudobulbar palsy CVA Multiple Sclerosis Myasthenia Gravis Dermatomyositis Muscular Dystrophy Inflammatory lesions Thrush (Candida) Tonsillitis (PTA vs. lingual tonsillitis) Abscesses (retro-, para-) Systemic causes Scleroderma Plummer-Vinson syndrome

Scleroderma Chronic, degenerative, autoimmune disorder that leads to the over-production of collagen in the body's connective tissue Decreased motility Chronic reflux due to incompetent LES Stricture of the distal esophagus

Plummer-Vinson Syndrome Iron-deficiency anemia Upper esophageal web Hypothyroidism Glossitis &/or cheilitis Gastritis Dysphagia (even without presence of a web)

Plummer-Vinson Syndrome 90% women Predominantly in northern hemisphere/ Scandinavian descent Rx: iron replacement alone may reverse some of the pathologic changes; dilation of web Increased incidence of postcricoid SCCA (15% in one prospective study)

Differential Diagnosis Neuromuscular disorder Esophageal spasm Pseudobulbar palsy CVA Multiple Sclerosis Myasthenia Gravis Dermatomyositis Muscular Dystrophy Inflammatory lesions Thrush (Candida) Tonsillitis (PTA vs. lingual tonsillitis) Abscesses (retro-, para-) Systemic causes Scleroderma Plummer-Vinson syndrome

Functional/Motor Disorders Spasm Corkscrew esophagus Neuromuscular disorders Diabetes, alcoholism, ALS Presbyesophagus Associated with age Incoordination of sphincter function Reduced peristalsis Frequent tertiary contractions

Diffuse Esophageal Spasm Numerous nonpropulsive contractions “corkscrew/ rosary bead” esophagus DES requires normal peristalsis interspersed with 30% + periods of nonpropulsive motor activity

Tertiary contractions Transient motor phenomenon Nonpropulsive

Differential Diagnosis (continued) Extrinsic lesions Thyroid mass Dysphagia lusoria Aortic aneurysm Intrinsic lesions Zenker’s diverticulum Benign tumors (leiomyoma) Carcinoma (SCCA, Adeno) Strictures Achalasia Esophageal webs Schatzki’s ring

Anatomic compression locations Cricoid Thyroid Aorta Left mainstem bronchus Diaphragm Cervical spine may impinge, esp. in the elderly

Chest compression due to… Large nodes Mediastinal tumors Enlargement of the heart Aneurysms Massive enlargement of the liver

Dysphagia lusoria Very rare cause Due to an aberrant right subclavian artery coursing posterior to esophagus Causes a spiral filling defect

Differential Diagnosis (continued) Extrinsic lesions Thyroid mass Dysphagia lusoria Aortic aneurysm Intrinsic lesions Zenker’s diverticulum Benign tumors (leiomyoma) Carcinoma (SCCA, Adeno) Strictures Achalasia Esophageal webs Schatzki’s ring

Diverticulum Small pouch Retains contrast during barium swallow

Leiomyoma Submucosal mass Arise from circular or longitudinal smooth muscle Solitary lesions, multiple seen 3-4% of the time Round filling defect Splitting of barium around tumor Esophagus appears widened on AP view

Carcinoma (SCCA, Adeno) Associated with EtOH/Tobacco Predisposing factors Lye stricture Plummer-Vinson syndrome Esophagitis/Barrett’s Esophagus

Cancer of the mid-esophagus Shelf at the upper and lower extent Extensive irregularities in the tumor mass

Cancer of the mid-esophagus “apple-core” filling defect

Stricture Lower third of esophagus Due to long-standing reflux

Stricture Stricture at GE junction Secondary to reflux esophagitis

Stricture High-grade Partial obstruction of distal esophagus Dilated proximally Retained barium above stricture

Reflux Hypertrophy of the cricopharyngeal muscle is commonly seen in patients with long-standing reflux Narrows the lumen and causes solid-food dysphagia Zenker's diverticulum may form from the area of muscle thinning just superior to the CP muscle Typically retains fluid/food particles (often medications/pills)

Achalasia Failure of the LES to relax normally Esophageal dilation Aperistalsis Primary idiopathic degeneration of the ganglion cells of Auerbach’s plexus Secondary - caused by other conditions i.e. Distal esophageal carcinoma, Chagas’ disease, postvagotomy syndrome, CVA, DM

Achalasia Grossly dilated esophagus Contains food and liquid debris Distal part of the esophagus is extremely narrow

Achalasia LES is narrowed Esophagus is dilated to 6-7 cm wide Air-fluid level

Esophageal web Deep web in anterior wall

Sequelae of Irradiation Acute/subacute effects of mucositis such as pain, soreness Oropharyngeal motility disorders Radiation damage to the CP muscular portion of the sphincter Paresis of the pharyngeal constrictor muscles