Literature Reading

BRONCHOESOPHAGOLOGY

MANAGEMENT OF DYSPHAGIA

Supervisor : dr. Ongka Muhammad Saifuddin, SpTHT-KL(K)

Presentant: Ichsan Juliansyah Juanda

Dept. of Otorhinolaryngology Head & Neck

Surgery
Medicine Faculty of Padjadjaran University-Hasan
1
Sadikin Hospital
 INTRODUCTION

Dysphagia is a medical term defined as "difficulty

swallowing

From the Greek root: dys : difficulty or disordered, and

phagia :"to eat difficulty in the passage of solids or
liquids from the mouth to the stomach.

Dysphagia is distinguished from similar symptoms including

odynophagia, which is defined as painful swallowing, and
globus, which is the sensation of a lump in the throat.
Dysphagia Pharyngeal and Esophageal
2
 ANATOMY

The Oral Cavity

Include :
- Lips
- Buccal mucosa
- Upper and lower alveolar
ridges
- Retromolar trigone
- Anterior two-thirds of the
tongue
- Floor of the mouth
- Hard palate
3
 The Pharynx

Nasopharynx
Oropharynx
Hypopharynx

4
Valve for Deglutition
1. Lips
2. Tongue
3. Velum to back of
tongue (the
glossopalatal valve)
4. Velopharynx
5. Larynx
6. Upper esophageal
(cricopharyngeal)
sphincter

5
 The Esophagus

The esophagus is a muscular tube that

starts as the continuation of the pharynx
and ends as the cardia of the stomach

The transition from pharynx to esophagus

occurs at the lower border of the sixth
cervical vertebra

Layers of the Esophagus :

- Outer musculer
- Middle submucosa
- Inner mucosal
6
 INNERVATION

Sensory information to the swallowing center is

carried along N. V, VII, IX, X

The motor respons from the swallowing center are

carried along N. V, VII, IX, X & XII and also the
ansa cervicalis (C-1 and C-2)

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 PHYSIOLOGY

The oral stage

The pharyngeal stage

The esophageal stage

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 SWALLOWING

9
10
 Mechanisms of Oropharyngeal Dysphagia

DYSFUNCTIO MECHANISM ETIOLOGY

N
ORAL PHASE
Drooling Poor lip closure Facial muscle
weakness
Poor oral Lingual dysfunction Central lesion,
clearance Delayed swallow myopathy
initiation Afferent or central
lesion
Premature bolus Incompetent Myopathy, palatal
spill glossopalatal closure surgery
11
DYSFUNCTIO MECHANISM ETIOLOGY
N
PHARYNGEAL
PHASE

Postnasal Velopharyngeal Central, tenth CN

regurgitation incompetence myopathy

Laryngeal Reduced laryngeal Suprahyoid muscle

penetration/aspiratio elevation dysfunction
n Incomplete epiglottal Suprahyoid muscle
closure dysfunction tumor
Impaired closure vocal Medullary or tenth CN
cord lesion
Impaired pharyngeal Central lesion,
clearance myopathy

Absent or delayed Central lesion

Impaired pharyngeal pharyngeal response
12 Central lesion,
propulsion Impaired tongue base myopathy
 O Differential Diagnosis
R
O
N Diseases of the central Diseases of the peripheral
E
P
U
nervous system nervous system
H R - Cerebrovascular accident - Peripheral neuropathy
A O - Parkinson diseases - Motor end plate dysfunction
R M - Brain stem tumors - Myasthenia gravis
Y U
- Degenerative diseases - Myopathies
S
N C - Amyotrophic lateral sclerosis - Polymyositis
G U - Muscular dysthropy
- Multiple sclerosis
E L
A - Huntingtons diseases
A
L - Poliomyelitis
R
- Syphilis
D
O
Y B - Tumors
S S O
- Poor denitition
- Inflammatory masses
P T - Oral ulcers
- Trauma / surgical resection T
H R
- Xerostomia
U - Zenkers diverticulum H
A
C E - Long-term
G T - Extrinsic structural lesions
I R penicillamine use
I - Anterior mediastinal masses
A V S
E - Cervical spondylosis/ Osteophytes
Yamada T, ed. Textbook of gastroenterology. 2d ed.
Philadelpia: Lippincott William & Wilkins,
13 WGO Practice Guideline Dysphagia 2007995.
 Differential Diagnosis
Reproduced with permission from Castell DO.
E N - Achalasia Approach to the patients with dysphagia.

S E In: Yamada T, ed. Textbook of gastroenterology. 2d ed.

Philadelpia: Lippincott William & Wilkins, 1995.
U - Spastic motor disorders :
O R
P O Diffuse esophageal spasm
H M
A U
S
Hypertensive LES
G C
E U
A L - Scleroderma
A
L R

Intrinsic structural lesions Extrinsic structural lesions

O - Tumors - Vascular compression
D B - Strictures - Enlarge aorta or left atrium
Y S
- Peptic - Aberrant vessels
S T
- Radiation induced
P R - Mediastinal masses
U - Chemical induced
H - Lymphadenopathy
C - Medication induced
A - Lower esophageal rings - Substernal thyroid
T
G I (Schatzkis rings)
V - Esophageal webs
I
14 - Foreign bodies
A E
 COMPLICATION

a decrease in the efficacy of deglutition

leading to malnutrition
and dehydration

a decrease in deglutition safety,leading to

tracheobronchial aspiration
which results in aspiration pneumonia and can
lead to death.
15
 EVALUATION OF DYSPHAGIA

16
 History

Duration dietary changes, weight loss

Odynophagia
Solids or Liquids
Level of sensation of dysphagia
Past surgery to head and neck, trauma, ingestion
of caustic substances
Associated symptoms such as with GERD, voice
changes, nasal leakage, otalgia
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 Physical Exam

General: body habitus, mental status, drooling,

wheezing, dyspnea, voice quality
Cranial nerves
Inspection of the tongue and palate for
strength/symmetry
Laryngeal Examination: pooled secretions, vocal
fold movement, interaretynoid area

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 Imaging Studies

Should be chosen to suit the patients

symptoms and to confirm a finding

19
 Plain Film

Uses: Suspected infectious cause of dysphagia with

gross displacement
of structures.
ADVANTAGES DISADVANTAGES
Cheap Radiation
Fast Poor anatomic detail
No assessment of
swallow
(Epiglottitis)
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 Barium Esophagogram

Uses: structural disorders, e.g. dysphagia for solid

foods. Can use air
contrast.
ADVANTAGES DISADVANTAGES
Good anatomic Radiation
detail
Cannot detect
dynamic disorders.

Normal Fungal Plaques

21
 Manometry

Uses: disorders in which intraluminal pressures must

be measured
(achalasia, esophageal spasm, etc.)
ADVANTAGES DISADVANTAGES
It is the only test Cannot diagnose
of pressure wave visible lesions
physiology
Unpleasant for patient

22
 Bolus Scintigraphy

Uses: follow improvement in a patient with history of

aspiration, patient with achalasia.
ADVANTAGES DISADVANTAGES

Less radiation No anatomic details

Quantitative count Single bolus, not different

of particles consist. used

23
 Ultrasound

Uses: Portable tool for dynamic studies, especially

in children
ADVANTAGES DISADVANTAGES

No radiation Poor anatomic detail

Portable

Normal Food can be

used
24
 Videofluoroscopy

Videofluoroscopic procedure
Also known as modified barium swallow
A radiographic study of a persons swallowing
mechanism that is recorded on videotape
Uses excellent to evaluate dynamic (e.g.
neuromuscular, aspiration) swallow disorders
(Logeman)

25
 Videofluoroscopy

ADVANTAGES DISADVANTAGES

Gives good anatomic Radiation

detail
Evaluates all phases of Does not directly test
swallowing sensitivity
Logistics

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 Fiberoptic Endoscopic Evaluation of
Swallowing

Objective evaluation of swallowing

process :
> Best with visualitation
> Silent aspiration
> Dysphagia in patients : oral and
pharynx
phase

Diagnosis therapi How to swallow

safely
27
 FEES

28 Langmore SE. Endoscopic evaluation and treatment of swallowing disorders.

Thieme. 2000
 Secretio Spillage
n

Residue Penetration-Aspiration

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 Indication of FEES

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 Fiberoptic Endoscopic Evaluation of
Swallowing

ADVANTAGE DISADVANTAGE

To detect abnormality of swallowing

mechanism and evidence of aspiration
To perform evaluation for using NGT Blind spot
To provide on line visual feedback Can evaluate neither cricopharyngeus
To assess the effects of various nor esophagus directly
strategies, i.e head turning, breath
holding repeatedly

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 THERAPY

32
 Non Operative

1. Healing disease stroke

2. Modification of diet bolus volume and speed of
feeding, food viscosity/texture (speech language
pathologist and nutritionist)
3. Therapeutic intervention
Sensory- Motor integration procedure
Posturaltechniquestofacilitateswallowing
Swallow maneuvers : supraglottic swallow, super-
supraglotic swallow, efforthful swallow, and Mendelsohn
maneuver.
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 National Dysphagia Diet (NDD)

The National Dysphagia Diet (NDD), published in

2002 by the American Dietetic Association, aims
to establish standard terminology and practice
applications of dietary texture modification in
dysphagia management

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 National Dysphagia Diet

Four levels of the NDD

Dysphagia Pureed
Very cohesive, pudding-like, does not require chewing
Dysphagia Mechanically Altered
Semisolid foods, requiring chewing ability
Dysphagia Advanced
Soft-solid foods that require more chewing
Regular
All foods allowed

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 DESCRIPTION RATIONALE

Pudding-like, no coarse For people who have

texture, raw fruit or moderate to severe
Dysphagia vegetables, nuts, cannot use dysphagia
Pureed any food that requires bolus
formation, controlled
manipulation, or mastication

Dysphagia Foods that are moist, soft- Chewing ability

Mechanically textured, and easily formed required, for those with
Altered into a bolus. mild to moderate
dysphagia
-A transition to a
Dysphagia Regular texture food with regular diet
Advanced the exception of very -For individuals with
hard, sticky or crunchy foods mild
36 dysphagia
 Diet Examples of Foods to
Avoid
Dysphagia Pureed Beverages with lumps, dry
Level 1 breads and cereals, oatmeal,
ices, gelatins, cookies, cakes, fats
with chunky additives, whole
fruit, whole or ground meat,
cheese, cottage cheese, rice,
potatoes, soups with chunks,
vegetables
Dysphagia Mechanically Altered Dry breads, coarse cereals that
Level 2 may contain nuts or seeds, dry
cakes and cookies, fresh or frozen
fruits, dried fruits, dry meat,
peanut butter, soups with
chunks, fibrous vegetables, seeds
and nuts
37
Dysphagia Advanced Dry bread, coarse cereals, dry
 Thickened Liquids

Liquids :
Swallowing of liquids requires coordination and
control
Easily aspirated into the lungs
Liquids may need to be thickened for safe swallow
What are the benefits?
Delay the bolus transit through the pharynx
Extend the duration of pharyngeal peristalsis
Prolong the opening of the cricopharyngeal (upper
esophageal) sphincter
38
 DIET POSITION
Chin - Tuck Narrows the opening to the
airway
Head Rotation to the weakness
rotation pharyngeal side, channels bolus to
strong side
Head Tilt Tilt to the stronger side direct the
bolus away from the side of
weakness
Side Lying May reduce hypopharyngeal
pooling for selected patients

39
 Postural Techniques Succesful in Eliminating
Aspiration
Disorder Observed Posture Applied
Inefficient oral transit Head back
Delay in triggering the pharyngeal Chin down
swallow
Reduced posterior motion of Chin down
tongue base
Reduced laryngeal closure Chin down; head rotated
to damaged side
Unilateral pharyngeal paresis Head rotated to
damaged side
Reduced pharyngeal contraction Lying down on one side
Cricopharyngeal dysfunction Head rotated
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41
 Swallow Maneuvers
Problems for Which
Swallow Maneuvers Was Rationale
Maneuvers Designed
Supraglottic Reduced or late vocal Voluntary breath hold
swallow fold closure usually closed vocal
folds before and
during swallow
(Martin et al., 1993)
Delayed pharyngeal Closes vocal folds
swallow before and during
delay
Super Reduced closure of Effortful breath hold
supraglottic airway entrance tilts
Swallow arytenoid forward,
closing airway
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entrance before and
 Problems for Which
Swallow Maneuvers Was Rationale
Maneuvers Designed

Effortful swallow Reduced posterior Effort increases posterior

movement of the tongue tongue base movement
base (Pouderoux & Kahrilas,
1995)
Mendelsohn Reduced laryngeal Laryngeal movement
maneuvers movement opens the upper
esophageal sphincter
(UES); prolonging
laryngeal elevation
prolongs UES opening
(Cook et al.,
Discoordinated swallow 1989; Jacob et al., 1989)
Normalized timing of
pharyngeal swallow
events (Lazarus,
43 Logemann, & Gibbons,
1993)
 Operative

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 PERHATI - KL

PEMERIKSAAN FISIK:
-Tanda Dehidrasi
-Tanda Malnutrisi
-Sumbatan jalan nafas
-Pneumonia Aspirasi

KELAINAN FASE ORAL:

Tanda & Gejala
-Drooling/Sialorrhea
-Residu di mulut
-Karies gigi
-Hilangnya rasa kecap
-Ggn proses mengunyah
PEMERIKSAAN FEES 3 -Ggn mendorong bolus ke
TAHAP : faring
-Preswallowing Assessment -Preswallowing Leakage
-Pem.langsung fungsi -Aspirasi cairan
menelan dgn 5
konsistensi makanan KELAINAN FASE FARING
-Terapeutik Assessment Tanda & Gejala:
-Refleks menelan gagal
PENILAIAN 5 PROSES FISIOLOGI DASAR teraktivasi
-Sensitivitas, Kebocoran sblm menelan -Refleks menelan terlambat
(spillage/preswallowing leakage), Residu, -Proteksi laring tdk adekuar
Penetrasi, Aspirasi -Choking
-Coughing
-Silent aspiration
-Refleks batuk melemah
45 LIHAT ALUR 2 -Peristaltik faring melemah
-Sfingter krikofaring gagal
 ALUR 2
MODIFIKASI DIET

-Modifikasi Makanan Padat :

bubur saring, bubur nasi,
makanan solid
-Modifikasi Makanan Cair :
thin liquid, thick liquid

POSISI KEPALA
Disfagia Fase Oral/Fase
Faring (+)

-Head Back
-Chin Down
Konsul Gizi Konsul RM -Head
Rotation
-Head Tilt
Maneuvers Menelan
TERAPI KAUSAL:
THT
Neurologi
-Supraglotik
Geriatri
-Super-
Onkologi
Supraglotik
Pediatri
-Efforthful
Swallow
-Mendelson
Pipa Nasogaster
Gastrotomi

46 Follow Up Intractable aspiration OPERASI

Setiap Bulan menetap dlm
6 bulan
 ALUR 3

KESUKARAN MAKAN
KESUKARAN MAKAN
PADAT DAN CAIR
PADAT

OBSTRUKSI MEKANIK KELAINAN

NEUROMUSKULAR

INTERMITEN PROGRESIF INTERMITEN PROGRESIF

Heart Burn Umur > 50 Heart Burn Gejala

Kronik thn Chest Pain Kronik Respirasi

Skleroder Akalasi
Sriktur Peptik Kanker
ma a
Spasme
Esofagus Difus

Striktur Esofagus
Bawah
Esofagoskopi
Esofagoskopi dan/atau Barium
Barium Esifagogram Esofagogram
47
Dan/atau
Manometri
 CONCLUSION

Dysphagia is a symptom that refers to difficulty or discomfort

during the progression of the alimentary bolus from the
mouth to the stomach.

Oropharyngeal dysphagia is a large and growing problem,

the consequence of which can be severe: malnutrition,
aspiration, choking, pneumonia, and death.

A problem that frequently demands a multidisciplinary

management approach, which may involve the radiologist,
gastroenterologist, neurologist, speech-language pathologist,
48 dietitian, otolaryngologist.
 THANK YOU

49