DYSPHAGIADYSPHAGIA

Mr Andrew Lale

Consultant ENT surgeon

Oral Preparatory PhaseOral Preparatory Phase

Break down foodBreak down foodMix with salivaMix with salivaPrevent premature escape into pharynxPrevent premature escape into pharynx

Oral PhaseOral PhaseTongue elevates ant to postTongue elevates ant to post

Tongue forms central grooveTongue forms central grooveLabial andLabial and buccalbuccal sealseal

Begins when tongue moves bolusBegins when tongue moves bolus posteriorlyposteriorly, ,

and ends when bolus passes anterior pillar ofand ends when bolus passes anterior pillar of faucesfauces

Voluntary control Voluntary control -- ( XII )( XII )

Pharyngeal PhasePharyngeal Phase

Begins when bolus passes anterior pillar or Begins when bolus passes anterior pillar or faucesfaucesEnds when bolus passes through upper oesophageal sphincter into Ends when bolus passes through upper oesophageal sphincter into oesophagusoesophagusVelum elevates and contracts, closing nasal passage, bolus propeVelum elevates and contracts, closing nasal passage, bolus propelled through pharynx, lled through pharynx, larynx closed and elevated, respiration inhibited, upper oesophalarynx closed and elevated, respiration inhibited, upper oesophageal sphincter relaxesgeal sphincter relaxes

Involuntary control Involuntary control –– ( IX, X, XII )( IX, X, XII )

OesophagealOesophageal PhasePhase

Begins when bolus enters Begins when bolus enters oesophagusoesophagusEnds when bolus passes through lower Ends when bolus passes through lower oesophageal oesophageal sphincter into stomach 8sphincter into stomach 8--20 seconds later20 seconds laterSequential peristaltic wave propels bolus Sequential peristaltic wave propels bolus Relaxation of lower Relaxation of lower oesophageal oesophageal sphinctersphincter

Involuntary control Involuntary control –– ( X )( X )

SWALLOWINGSWALLOWING

“5 minute consultation” CAUSES: Acute Neurogenic Globus pharyngeus Laryngopharyngeal reflux Strictures and narrowing Pharyngeal Pouches

CONSULTATIONCONSULTATION

True Dysphagia or feeling of a lump?Dysphagia for what?Regurgitation or Aspiration?Gastro-oesophageal reflux current or past?Change of Diet or weight loss?Odynophagia

ACUTE DYSPHAGIAACUTE DYSPHAGIA

History: FB. Previous problems.Examination: Drooling. Pain. Pyrexia.

OdynophagiaTreatment:Food bolus: Buscopan, fizzy drink, refer at

1 hourFB: Refer

Foreign bodiesForeign bodies

Strictures and narrowingStrictures and narrowing

Malignant/benignCricopharyngeal barC-spine osteophytesKyphosisPost cricoid web

Cricopharyngeal barCricopharyngeal bar

OsteophytesOsteophytes

NeurogenicNeurogenic

CVAMotor neurone diseaseMultiple SclerosisParkinson’s diseaseMyaesthena gravis

GLOBUS PHARYGEUSGLOBUS PHARYGEUS

Previously Globus HystericusWorse when NOT eating or drinkingNo true dysphagia solids/liquidsNo odynophagiaNo reguritation/aspirationVariable history. ?exclude reflux…..

Laryngopharyngeal Reflux Laryngopharyngeal Reflux (LPR)(LPR)

Reflux of gastric acid to larynx/pharynxMay be “silent”Symptoms include feeling of a lump,

odynophagia/chronic sore throat, chronic cough (especially nightime), hoarse voice and “mucous in throat”.

LPR InvestigationsLPR Investigations

Nasopharyngoscopy, red post cricoid region.

? Barium swallow?Oesophageal pH manometry

LPR treatmentLPR treatment

6 weeks PPI + Gaviscon initiallyAt review further 6 weeks treatment if

improvingGeneral laryngeal hygiene measuresIf no better, rigid pharyngo-

oesophagoscopypH manometry ?fundoplication

Pharyngeal pouchesPharyngeal pouches

HISTORYLong Hx dysphagiaRegurgitation esp at night“gurgling” swallowAspiration (recurrent pneumonia)Weight loss and change in Diet.

Pharyngeal PouchesPharyngeal Pouches

EXAMINATIONNasopharyngoscopy might show poolingUnlikely to feel anything in neckBarium swallow

Pharyngeal pouchesPharyngeal pouches

TREATMENTSurgical if fit for GA(External approach)Endoscopic stapling, low morbidity and

high success rate.

PouchesPouches

BARIUM SWALLOW.jpg

PouchesPouches

BARIUM SWALLOW.jpg

Summary :Fast track patientsSummary :Fast track patients

Young male patient Short historyOdynophagiaSmoking and AlcoholWeight lossAspiration and reguritation

Summary: Globus patientsSummary: Globus patients

Variable historyNo true dysphagiaYoung femaleNo weight lossAssociated anxiety

Summary: Pouch patientsSummary: Pouch patients

Older male/femaleREGURGITATIONGurgling swallowRecurrent chest infectionsWeight loss

ThankyouThankyou