1. DysphagiaDysphagia นพ. โกสินทร์ ชัยชำนาญ Ent

2.  Normal physiology  Dysphagia Definition Cause and classification History taking,physical examination and investigation Disease Objectives

3.  4 stage Oral preparatory stage Oral stage Pharyngeal stage Esophageal stage Normal physiology

4. Oral preparatory stage  Prepare food for swallow  Mechanism of action  1.lip closure to hold food in mouth anteriorly  2.tension in labial&buccal musculature to close Ant&Lat sulci  3.rotatory motion of jaw for chewing  4.lateral rolling motion of tongue position food on teeth during mastication – most important  5.bulging forward of soft palate to seal oral cavity posterior and widen nasal airway

5. Oral preparatory stage 1.Muscle of facial expression (VII) –oral sphincter  Buccinator – compress lip@flatten cheek  Orbicularis oris – sphincter of lip

6. 2.Muscle of mastication (V) – jaw movement Oral preparatory stage  Masseter – close jaw  Temporalis – open@A/P move  Medial pterygoid – close@grinding  Lateral pterygoid – open@grinding

7. y 3.Tongue muscle Oral preparatory stage  Palatoglossus(X) – down soft palate@up BOT  Genioglossus(XII) – elevate BOT  Hyoglossus(XII) -- depress

8. er Time : depend on type of food Oral preparatory stage

9. Move food from front oral cavity to pharynx Mechanism of action ○ 1.Upward&backward by midline& Lat margin of tongue – most important ○ 2.Backward by tension in buccal musculature ○ 3.trigger swallowing reflex (locate at anterior pillar) Normal physiology Oral stage

10.  buccal musculature buccal musculature  tongue Oral stage swallow  Styloglossus muscle  Hyoglossus muscle

11. Oral stage swallow trigger zone at anterior pillar

12. ri Oral stage swallow trigger swallowing reflex sensory impulse at CN IX CN IX

13. Oral stage swallow trigger swalling reflex sensory impulse at CN IX (& Sup. Laryngeal nerve) Tractus solitarius nucleus/ Solitary tract nucleus

14. Oral stage swallow nucleus ambiguus to motor neuron of CN X at pharynx nucleus ambiguus CN X

15. Oral stage swallow nucleus ambiguus to motor neuron of CN X at pharynx nucleus ambiguus

16. er Time : take 1 second Oral stage

17.  Move food from pharynx to esophagus  Mechanism of action 1.velopharyngeal closure (prevent backflow of material up nose) 2.tongue base retraction (propel bolus through pharynx)tongue base retraction 3.pharynx contraction (clear redisue through pharynx) 4.larynx elevate and closure (airway protection) 5.cricopharyngeal opening (allow bolus to pass into esophagus) Pharyngeal stage

18. t

20.  1.tongue Pharyngeal stage swallow  Styloglossus muscle  Hyoglossus muscle

21.  2.Levator @ Tensor palatini Pharyngeal stage swallow  Levator palatini  Tensor palatini

22.  3.pharyngeal constrictor muscle Pharyngeal stage swallow  Superior  Inferior  Middle

23.  4.aryepiglottic fold/true vocal fold /false vocal fold Pharyngeal stage swallow  AEF  FVF/TVF

24. er Time : take less than 1 second (not vary with age and gender) Pharyngeal stage

25.  Close UES  Body of esophagus Outer -> longitudinal,Inner -> circular  Peristalsis primary peristalsis : ○ upper 1/3 striated & transitional zone ○ mix voluntary & involuntary secondary peristalsis : ○ lower 2/3 smooth ○ Involuntary  Open LES Esophageal stage

26. er Time : take 8 to 20 seconds (depend on food influence by peristalsis&gravity) Esophageal stage

27.  Onset & Site  Cough or choke or food coming back through your nose  Liquid or solid or both Liquid and solid  motility disorder Solid progress to liquid  benign or malignant stricture  Progression History Dysphagia

28.  Other symptoms Loss of appetite,weight loss,N/V regurgitation,heart burn,weakness, hematemesis,pain  Medical problems DM, HT, cancer  Hx. Of surgery History Dysphagia

29.  Hx. Of radiation  Medications  In children Feeding Growth Development History Dysphagia

30.  Complete examination  Head and neck Mass Thyroid Lymph node Salivary gland Oral mucosa  Gag reflex, Cough reflex Physical examination Dysphagia

31.  Procedure to evaluate -- major 1.Fluoroscopy 2.Endoscopy 3.Manometry 4.Ultrasonography Investigation Dysphagia

32.  Barium swallow conventional barium swallow modified barium swallow Fluoroscopy Dysphagia

33.  Modified barium swallow Gold standard Examine oral cavity & pharyngeal swallowing Ba(1/3 teaspoon per swallow) & vary food consistency Seated upright in normal eating position Fluoroscopy Dysphagia

34.  Modified barium swallow View in lat. plane with fluoroscope tube Focus on lips & C7 th Fluoroscopy Dysphagia

35.  Modified barium swallow Purpose restore oral intake as quickly ○ 1.define oral&pharyngeal disorder during swallow ○ 2.identify aspiration of any food consistency ○ 3.assess speed of swallow to determine adequate nutrition ○ 4.assess effect of Tx eg.postural change,heightened sensory input,Tx procedure (swallowing maneuvers) Fluoroscopy Dysphagia

36.  convention barium swallow Examine anatomy & motility esophagus Ba(a cup of barium)(250 cc)swallow repeatedly Lies in supine position View in anteroposterior plane Fluoroscopy Dysphagia

37. Dysphagia

38. Dysphagia  A:Contrast penetrate laryngeal vestibule within boundary of vocal cord  B:aspirate tracheobronchial tree  Achalasia (failure to relax) ( bird's beak appearance)

39. Via transnasal placement of flexible fiberoptic scope Can not examine oral stage & during swallow May be identified residual food in pharynx after swallow Endoscope Dysphagia

40.  Used examine esophageal peristalsis & function of UES & LES  Swallow soft tube contain 3 pressure sensor First register --- UES Second register – body of esophagus Third register – pressure in LES  No information on aspirate or function in oral cavity or larynx Manometry Dysphagia

45.  Used assess anatomy & physiology of tongue during swallowing (oral stage )  Can not examine pharynx or larynx because of skeletal interference Ultrasonography Dysphagia

46.  Plain film : film lateral neck(soft tissue technique) -- FB,Infection  CT/MRI  24 hrs.pH monitoring วัดภาวะกรดด่างใน หลอดอาหาร คนปกติจะมี pH<4 ที่เหนือ กล้ามเนื้อหูรูดล่าง 5 cm ไม่เกิน 1 hr./ วัน Other investigate Dysphagia

47.  Scintigraphy Nuclear medicine test Swallow several selected bolus of radioactive material Gamma camera detect amount radiation passing Oropharyngeal anatomy not visible Aspiration – two trial material swallows ○ One to esophagus ○ Another to airway Other investigate Dysphagia

49. The end…