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

2. 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

3. 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

4. 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

5. 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

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

7. 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

8. 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

9. Work-Up
Detailed History PE
Radiography
Esophagoscopy
Special tests

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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

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

24. 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

25. 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

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

27. 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)

28. 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

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

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

31. Tertiary contractions
Transient motor phenomenon
Nonpropulsive

32. 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

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

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

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

36. 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

37. Diverticulum
Small pouch
Retains contrast during barium swallow

38. 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

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

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

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

42. Stricture
Lower third of esophagus
Due to long-standing reflux

43. Stricture
Stricture at GE junction
Secondary to reflux esophagitis

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

45. 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)

46. 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

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

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

49. Esophageal web
Deep web in anterior wall

50. 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