DYSPHAGIA

DYSPHAGIADYSPHAGIA

dr. Ery Oliviantodr. Ery OliviantoChild Health Department Child Health Department Faculty of Medicine Airlangga Faculty of Medicine Airlangga University / University / dr Soetomo General Hospitaldr Soetomo General Hospital

IntroductionIntroduction

Dysphagia typically refers to difficulty Dysphagia typically refers to difficulty in eating as a result of disruption in the in eating as a result of disruption in the swallowing process swallowing process

Dysphagia Dysphagia risk of aspiration risk of aspiration pneumonia, malnutrition, dehydration, pneumonia, malnutrition, dehydration, weight loss, and airway obstruction. weight loss, and airway obstruction.

A number of etiologies have been A number of etiologies have been attributed to dysphagia in populations attributed to dysphagia in populations with neurologic and nonneurologic with neurologic and nonneurologic conditions conditions

introductionintroduction

Dysphagia may affect the oral, Dysphagia may affect the oral, pharyngeal, or esophageal phases of pharyngeal, or esophageal phases of swallowing. swallowing.

Thorough history taking and careful Thorough history taking and careful physical examination are important in the physical examination are important in the diagnosis and treatment diagnosis and treatment

The bedside physical should include The bedside physical should include examination of the neck, mouth, examination of the neck, mouth, oropharynx, and larynx. A neurologic oropharynx, and larynx. A neurologic examination also should be performed.examination also should be performed.

Certain factors make dysphagia in Certain factors make dysphagia in children unique. Successful oral children unique. Successful oral feeding and growth in infants and feeding and growth in infants and children depend not only on children depend not only on functional deglutition but also on a functional deglutition but also on a broad range of neurodevelopmental broad range of neurodevelopmental skills involving sensory systems, skills involving sensory systems, cognition, communication, and gross cognition, communication, and gross and fine motor behaviors and fine motor behaviors

introductionintroduction

Normal swallowing Normal swallowing physiologyphysiology Food or liquid bolus is transported from the Food or liquid bolus is transported from the

mouth through the pharynx and esophagus mouth through the pharynx and esophagus into the stomach.into the stomach.

Normal deglutition is a smooth coordinated Normal deglutition is a smooth coordinated process that involves a complex series of process that involves a complex series of voluntary and involuntary neuromuscular voluntary and involuntary neuromuscular contractions,contractions,

and typically is divided into distinct phases: and typically is divided into distinct phases: (1) oral, (2) pharyngeal, and (3) (1) oral, (2) pharyngeal, and (3) esophageal. esophageal.

Oral phaseOral phase

the oral preparatory phase the oral preparatory phase the oral propulsive phase the oral propulsive phase contractions of the tongue and striated contractions of the tongue and striated

muscles of masticationmuscles of mastication (coordinated (coordinated fashion) mix the food bolus with saliva fashion) mix the food bolus with saliva and propel it into the oropharynx and propel it into the oropharynx involuntary swallowing reflex. involuntary swallowing reflex.

Lasts about 1 second. Lasts about 1 second.

Pharyngeal phasePharyngeal phase

A rapid sequence of overlapping events. A rapid sequence of overlapping events. The soft palate rises. The hyoid bone and The soft palate rises. The hyoid bone and

larynx move upward and forward. The larynx move upward and forward. The vocal folds move to the midline, and the vocal folds move to the midline, and the epiglottis folds backward to protect the epiglottis folds backward to protect the airway. The tongue pushes backward and airway. The tongue pushes backward and downward into the pharynx to propel the downward into the pharynx to propel the bolus down. The tongue is assisted by bolus down. The tongue is assisted by the pharyngeal walls, which move inward the pharyngeal walls, which move inward with a progressive wave of contraction with a progressive wave of contraction from top to bottom. from top to bottom.

Pharyngeal phasePharyngeal phase

The upper esophageal sphincter The upper esophageal sphincter relaxes during the pharyngeal phase relaxes during the pharyngeal phase and is pulled open by the forward and is pulled open by the forward movement of the hyoid bone and movement of the hyoid bone and larynx. This sphincter closes after larynx. This sphincter closes after passage of the food, and the passage of the food, and the pharyngeal structures then return to pharyngeal structures then return to reference position. reference position.

Involuntary and totally reflexiveInvoluntary and totally reflexive Lasts approximately 1 second, Lasts approximately 1 second,

Esophageal phaseEsophageal phase

The bolus is propelled by The bolus is propelled by peristaltic movement.peristaltic movement.

8-20 seconds may be required 8-20 seconds may be required for contractions to drive the bolus for contractions to drive the bolus into the stomach. into the stomach.

PathophysiologyPathophysiology   In children and infants, may present with In children and infants, may present with feeding feeding

difficultiesdifficulties. . Nasal obstructionNasal obstruction : nasal masses, choanal atresia, : nasal masses, choanal atresia,

and choanal stenosis fall in this category. and choanal stenosis fall in this category. Oral lesionsOral lesions : cleft lip or palate, mucoceles, ranulas, : cleft lip or palate, mucoceles, ranulas,

and Warthin's duct stenosis may cause dysphagia. and Warthin's duct stenosis may cause dysphagia. Upper aerodigestive tract anomaliesUpper aerodigestive tract anomalies : :

laryngomalacia, vocal cord paralysis, tracheo-laryngomalacia, vocal cord paralysis, tracheo-esophageal fistula, or vascular rings of the aorta or esophageal fistula, or vascular rings of the aorta or pulmonary arteries that compress the esophagus or pulmonary arteries that compress the esophagus or trachea trachea

Tumors of the aerodigestive tractTumors of the aerodigestive tract : : hemangiomas, lymphangiomas, papillomas, hemangiomas, lymphangiomas, papillomas, leiomyomas, and neurofibromas.leiomyomas, and neurofibromas.

Signs and symptomsSigns and symptoms Oral or pharyngeal dysphagia Oral or pharyngeal dysphagia

– Coughing or choking with swallowing Coughing or choking with swallowing – Difficulty initiating swallowing Difficulty initiating swallowing – Food sticking in the throat Food sticking in the throat – Sialorrhea Sialorrhea – Unexplained weight loss Unexplained weight loss – Change in dietary habits Change in dietary habits – Recurrent pneumonia Recurrent pneumonia – Change in voice or speech (wet voice) Change in voice or speech (wet voice) – Nasal regurgitationNasal regurgitation

Esophageal dysphagia Esophageal dysphagia – Sensation of food sticking in the chest or throat Sensation of food sticking in the chest or throat – Oral or pharyngeal regurgitation Oral or pharyngeal regurgitation – Change in dietary habits Change in dietary habits – Recurrent pneumoniaRecurrent pneumonia

CausesCauses

Prematurity by itself and neurologic Prematurity by itself and neurologic impairment (eg, cerebral palsy) are impairment (eg, cerebral palsy) are common causes. Children with cerebral common causes. Children with cerebral palsy typically manage solid boluses palsy typically manage solid boluses more easily than liquid boluses and more easily than liquid boluses and small liquid boluses more easily than small liquid boluses more easily than large liquid boluses. large liquid boluses.

Congenital structural lesions (eg, Congenital structural lesions (eg, choanal atresia, cleft lip and palate, choanal atresia, cleft lip and palate, craniofacial syndromes) craniofacial syndromes)

GERD GERD Childhood achalasiaChildhood achalasia

Physical examination Physical examination

During the physical examination, look for oral-During the physical examination, look for oral-motor and laryngeal mechanisms. Testing of motor and laryngeal mechanisms. Testing of cranial nerves V and VII-XII is essential for cranial nerves V and VII-XII is essential for determining physical evidence of oropharyngeal determining physical evidence of oropharyngeal dysphagia. dysphagia.

Direct observation of lip closure, jaw closure, Direct observation of lip closure, jaw closure, chewing and mastication, tongue mobility and chewing and mastication, tongue mobility and strength, palatal and laryngeal elevation, strength, palatal and laryngeal elevation, salivation, and oral sensitivity is necessary. salivation, and oral sensitivity is necessary.

Check the patient's level of alertness and Check the patient's level of alertness and cognitive status because they can impact the cognitive status because they can impact the safety of swallowing safety of swallowing

Dysphonia and dysarthria are signs of motor Dysphonia and dysarthria are signs of motor dysfunction of the structures involved in oral and dysfunction of the structures involved in oral and pharyngeal swallowing. pharyngeal swallowing.

Inspect the oral cavity and pharynx for Inspect the oral cavity and pharynx for mucosal integrity and dentition. mucosal integrity and dentition.

Examine the soft palate for position and Examine the soft palate for position and symmetry during phonation and at rest. symmetry during phonation and at rest.

The gag reflex is elicited by stroking the The gag reflex is elicited by stroking the pharyngeal mucosa with a tongue depressor. pharyngeal mucosa with a tongue depressor. Cervical auscultation becomes part of the Cervical auscultation becomes part of the clinical evaluation of dysphagic patients. clinical evaluation of dysphagic patients. Assess sound strength and clarity, timing of Assess sound strength and clarity, timing of apneic episode, and speed of swallowing. apneic episode, and speed of swallowing.

Assessing respiratory function Assessing respiratory function The final step in physical examination is The final step in physical examination is

direct observation of the act of swallowing. direct observation of the act of swallowing.

Physical examination Physical examination

Laboratory evaluationLaboratory evaluation

Obtain a Obtain a CBCCBC to screen for to screen for infectious or inflammatory infectious or inflammatory conditions.conditions.

Nutritional assessmentNutritional assessment may aid in may aid in determining serum protein and determining serum protein and albumin levels. albumin levels.

Thyroid function studiesThyroid function studies may help in may help in detecting dysphagia associated with detecting dysphagia associated with hypothyroidism or hyperthyroidism. hypothyroidism or hyperthyroidism.

Imaging studiesImaging studies

Chest radiographyChest radiography is a simple is a simple assessment for pneumonia. assessment for pneumonia.

UltrasonographyUltrasonography depicts only the region depicts only the region of the tongue posterior to the hyoid and of the tongue posterior to the hyoid and may aid in the evaluation of submucosal may aid in the evaluation of submucosal and extramural lesions of the esophagus. and extramural lesions of the esophagus.

CT and MRICT and MRI provide excellent definition of provide excellent definition of structural abnormalities, particularly structural abnormalities, particularly when used to evaluate patients with when used to evaluate patients with suspected CNS causes of dysphagia. suspected CNS causes of dysphagia.

Special studiesSpecial studies

Videofluorographic swallowing studyVideofluorographic swallowing study Fiberoptic endoscopic examination of Fiberoptic endoscopic examination of

swallowingswallowing ScintigraphyScintigraphy Reflex cough testReflex cough test Swallowing electromyographySwallowing electromyography Laryngeal EMGLaryngeal EMG ManometryManometry Esophageal pH monitoringEsophageal pH monitoring EndoscopyEndoscopy

Management of pediatric dysphagia Management of pediatric dysphagia requires a special approach. requires a special approach.

Cognitive, developmental, and Cognitive, developmental, and behavioral issues can affect the behavioral issues can affect the treatment options. treatment options.

Treatment does not necessarily imply Treatment does not necessarily imply feeding therapy. feeding therapy.

Hypoxemia can occur while a child with Hypoxemia can occur while a child with dysphagia eats, so pulse oximetry dysphagia eats, so pulse oximetry during mealtime can be useful. during mealtime can be useful.

TREATMENTTREATMENT

TREATMENTTREATMENT

Dietary modification Dietary modification – Viscosity and texture Viscosity and texture

Nutritional supplyNutritional supply HydrationHydration Oral hygiene and dental care Oral hygiene and dental care

Other techniquesOther techniques Enteral feeding methods Enteral feeding methods Nasoenteric tube feeding Nasoenteric tube feeding

(NGT)(NGT) Percutaneous endoscopic Percutaneous endoscopic

gastrostomy (PEG) gastrostomy (PEG) Oroesophageal tube feeding Oroesophageal tube feeding

TREATMENTTREATMENT