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121DysphagiaJeffrey B. Palmer, MD, and Koichiro Matsuo, DDS, PhD

DEFINITIONDysphagia generally refers to any difficulty with swallowing including occult or asymptomatic impairments. It is a common problem, affecting one third to one half of all stroke patients1 and about one sixth of elderly individuals.2 It is frequent in head and neck cancer, traumatic brain injury, degenerative disorders of the nervous system, gastroesophageal reflux disease, and inflammatory muscle disease (Table 121-1). Dysphagia is classified according to the location of the problem as oropharyngeal (localized to the oral cavity of pharynx, not just the oropharynx) or esophageal. It may also be classified as mechanical (due to a structural lesion of the foodway) or functional (caused by a physiologic abnormality of foodway function).3Sudden onset is suggestive of stroke. Concomitant limb weakness suggests a neurologic or neuromuscular disorder. Medication-induced dysphagia is commonly over-looked. Medications that impair level of consciousness (such as sedatives and tranquilizers), have anticholinegic effects (tricyclics, propantheline), or can damage mucous membranes (nonsteroidal anti-inflammatory drugs, aspirin, quinidine) may also cause dysphagia. 4

SYMPTOMSThe most common symptoms of dysphagia are coughing or choking during eating5 and the sensation of food sticking in the throat or chest.3 Some of the many symptoms and signs of dysphagia are listed in the Table 121-2. A history of drooling, significant weight loss, or recurrent pneumonia suggests that the dysphagia is severe. The history is most useful for identification of esophageal dysphagia; the complaint of food sticking in the chest is usually associated with an esophageal disorder. In contrast, the complaint of food sticking in the throat has little localizing value and is often caused by an esophageal disorder. Coughing and choking during swallowing suggest an oropharyngeal origin and may be elicited by aspiration (penetration of material through the vocal folds and into the trachea). However, some patients have impaired cough reflexes, resulting in silent aspiration (without cough). 5,6 Silent aspiration occurs in 28% to 94%, depending on the population of patients. 6-8 Patients with neurologic disorder have a higher incidence of silent aspiration. Pain on swallowing (odynophagia) may occur transiently in pharyngitis, but persistent pain is unusual and is suggestive neoplasia. Heart burn is a nonspecific complaint that is usually not associated with swallowing but occurs after meals. Heart burn may occur in gastroesophageal reflux disease, but a more specific symptom of gastroesophageal reflux disease is regurgitation of sour or bitter-tasting material into the throat after eating.

PHYSICAL EXAMINATIONAn examination of the oral cavity and neck may identify structural abnormalities, weakness, or sensory deficits. The finding of dysarthria (abnormal articulation of speech) or dysphonia (abnormal voice quality) is often associated with oropharyngeal dysphagia. However, the examination is primarily useful for finding evidence of underlying neurologic, neuromuscular, or connective tissue disease. The examination should always include trial swallows of water.9-11 During the swallow, there should be prompt elevation of the hyoid bone and larynx. Changes in voice quality or spontaneous coughing after swallowing suggest pharyngeal dysfunction. The history and physical examination are limited in their ability to detect and to characterize dysphagia, so instrumental studies are usually necessary.Neurologic examination is important in the evaluation of dysphagic individuals because neurologic disorders commonly cause dysphagia. Disorders of either upper or lower motor neuron may produce dysphagia. The findings of atrophy or fasciculations of the tounge or palate suggest lower motor neuron dysfunction of the brainstem motor nuclei. In contrast to the prevailing wisdom, the gag reflex is not strongly predictive of the ability to swallow. It may be absent in normal individuals and normal in individuals with severe dysphagia and aspiration.TABLE 121-1 Selected Causes of Oral and Pharyngeal DysphagiaNeurologic Disorders and StrokeStructural LesionsConnective Tissue Diseases

Cerebral InfarctionBrainstem InfarctionIntracranial HemorrhageParkinson DiseaseMultiple SclerosisAmyotrophic Lateral Sclerosis (ALS)PoliomyelitisMiasthenia GravisDementiasThyromegalyCervical HyperostosisCongenital WebZenker DiverticulumCaustic IngestionNeoplasmPost-ablative SurgeryRadiation FibrosisPolymyositisMuscular DystrophyPsychiatric DisordersPsychogenic Dysphagia

TABLE 121-2 Symptoms and Signs of DysphagiaOral or Pharyngeal DysphagiaCoughing or choking with swallowingDifficulty with initiation of swallowingFood sticking in the throatDroolingUnexplained weight lossChange in dietary habitsRecurrent pneumoniaChange in voice of speechNasal regurgitationDehydration

Esophageal DysphagiaSensation of food sticking in the chest or throatOral or pharyngeal regurgitationDroolingUnexplained weight lossChange in dietary habitsReccurent pneumoniaDehydration

FUNCTIONAL LIMITATIONSThese depend on the nature and severity of the dysphagia. Many individuals modify their diets to eliminate foods that are difficult to swallow. Some require inordinate amounts of time to consume a meal. In severe cases, tube feeding is necessary. These alterations in the ability to eat a meal may have profound effect on psychological and social function.14 Interaction with family and friends often centers on mealtime-family dinners, going out for a drink or for dinner, coming over for a snack or for dessert. Difficulty in eating a meal may disrupt relationships and result in social isolation. Some patients may require supervision during meals or feel unsafe when they eat alone, causing further disruption of social and vocational function.

DIAGNOSTIC TESTINGBecause the mechanics of swallowing are largely invisible to the naked eye, diagnostic studies are commonly needed. The sine qua non for diagnosis of oropharyngeal swallowing disorders is the videoflourographic swallowing study (VFSS).15 In this test, the patients eats and drinks a variety of solids and liquids combined with barium while images are recorded with videoflourography (radiographic video taping). The VFSS is usually performed jointly by a physician (physiatrist or radiologist) and a speech-language pathologist. A unique benefit of the VFSS is that therapeutic techniques (such as modification of food consistency, body position, or respiration) can be tested and their effects on swallowing observed during the study. A routine barium swallow study is frequently sufficient if the problem is clearly esophageal.If a VFSS cannot be performed because of the physical limitation of the patient, the fiberoptic endoscopic evaluation of swallowing is useful to visualize the anatomy of the pharynx and larynx and vocal fold function during eating with no x-ray exposure.16 It is also highly sensitive for detection of aspiration8; but it does not visualize essential aspects of swallowing, such as the oral and esophageal stage of swallowing including opening of the upper esophageal sphincter, elevation of the larynx, and contraction of the pharynx.In case of esophageal dysphagia, esophagoscopy is frequently necessary to detect mucosal lesion or masses. Biopsy is indicated when mucosal abnormalities are detected. Manometry is useful for detection and characterization of motor disorders of the esophagus. Electromyography is indicated when neuromuscular disease is suspected and is useful for detection of lower motor neuron dysfunction of the larynx and pharynx.

TREATMENTInitialThe treatment of dysphagia depends on its causes and mechanism. Common treatments are listed in Table 121-3. Whenever possible, initial treatment should be directed at the underlying disease process; for example, levodopa for Parkinson disease, or steroids for polymyositis. Esophageal dysphagia necessitates evaluation and treatment by a gastroenterologist. When no therapy exist for the underlying disease or the therapy is ineffective or contraindicated, rehabilitative strategies are appropriate. Patients and their family members are encouraged to learn the Heimlich manuever; this is important because airway obstruction is potentially fatal.Differential Diagnosis

Myocardial ischemia

Globus sensation

Heartburn due to gastroesophageal reflux disease

Indirect aspiration (aspiration of refluxed gastric content)

RehabilitationMany patients benefit from a structured swallowing therapy provided by a speech-language pathologist, including instruction and supervision about diet, compensatory manuevers, and exercise.17 The goals of therapy are to reduce aspiration, to improve the ability to eat and drink, and to optimize nutritional status. Therapy is individualized according to the patients specific anatomic and structural abnormalities and the initial responses to treatment trials observed at the bedside or during the VFSS.18 Table 121-3 Principal Treatments of Selected Disorders Affecting SwallowingProblemsPrincipal Treatments

Amvotrophic lateral sclerosisDietary modificationCompensatory manueversCounceling and advance directives

Carcinoma of esophagusEsophagectomy

Gastroesophageal reflux diseaseDietary modificationNo eating at bedtimePharmacologic therapySmoking cessation

Parkinson disease, polimyositis, myasternia gravisPharmacologic treatment of underlying disease (dietary modification, compensatory manuevers, and dysphagia therapy only if neccesary).

Esophageal stricture or webDilatation

Stroke multiple sclerosisDietary modificationCompensatory manueversDysphagia therapy

A fundamental principle of rehabilitation is that the best therapy for any activity is the activity itself; swallowing is generally the best therapy for swallowing disorders, so the rehabilitation evaluation is directed at identification of circumstances for safe and effective swallowing for each individual patient.Diet modification is a common treatment of dysphagia.19,20 Patients vary in ability to swallow thin and thick liquids, and that determination is usually best made by VFSS. A patient can usually receive adequate oral hydration with either thin (e.g., water or apple juice) or thick liquids (e.g., apricot nectar, tomato juice). Rarely, a patient may be limited to pudding consistency if thin and thick liquids are freely aspirated. Most patients with significant dysphagia are unable to safely eat meats or similarly though foods and require a mechanical soft diet. A pureed diet is recommended for patients who exhibit oral preparatory phase difficulties, pocket food in the buccal recesses (between the teeth and the cheek), or have significant pharyngeal retention with chewed solid foods. Maintenance of oral feeding often requires compensatory techniques to reduce aspiration or to improve pharyngeal clearance. A variety of behavioral techniques are used , including modifications of posture, head position (Fig. 121-1),21-22 and respiration, 23 as well as specific swallow manuevers.24-26 Execise therapy for dysphagia is indicated when the problem is related to weakness of the muscles of swalowing.27 The choice of exercises must be individualized according to the physiologic assessment. The full range of exercises is beyond the scope of this chapter, but several example illustrate the principles. Tongue weakness can be treated with lingual resistance exercise.28 Strengthening of the anterior suprahyoid muscles is useful when the upper esophageal sphincter opens poorly. Flexing the neck against gravity while lying supine can strengthen these muscles (Fig. 121-2).29,30 Vocal fold adduction exercises may be useful in cases of aspiration due to weakness of these muscles. These exercises are done on a daily basis whenever possible.

ProceduresVFSS functions as both a diagnostic and a therapeutic procedures for dysphagia, especially otopharyngeal dysphagia, because it can be used to test the effectiveness of modifying food consistency and other compensatory techniques.31 Endoscopy with dilatation of the esophagus is often indicated in cases of partial esophageal obstruction due to stricture or web. Dilatation is also appropriate in stenosis of the upper esophageal sphincter. Endoscopy can also be used for biofeedback, especially to demonstrate movements of the larynx during swallowing manuevers. Electromyography is also used for biofeedback. Activities of the infrahyoid and suprahyoid muscles are recorded with surface electrodes during swallowing therapy. Biofeedback itself is not a dysphagia therapy but can be a useful adjunct to therapy. Surface electrical stimulation on the submental or anterior cervical muscles is a controversial new treatment of dysphagia. There is little evidence for its safety and efficacy.32-34

SurgerySurgery is rarely indicated in the care of patients with oral pharyngeal dysphagia. The most common procedure for pharyngeal dysphagia is cricopharyngeal myotomy, during which the upper esophageal sphincter is disrupted to reduce the resistance of the pharyngeal outflow tract. However, the effectiveness of myotomy is highly controversial.35 Esophagectomy may be necessary in case of esophageal cancer or obstructive strictures. Feeding gastrotomy (usually percutaneous endoscopic gastrotomy) is indicated when the severity of the dysphagia makes it impossible for adequate alimentation or hydration to be obtained orally, although intravenous hydration or nasogastric tube feeding may be sufficient on a time-limited basis.36 Orogastric tube feedings have been used successfully by patients who have absent gag reflexes and can tolerate intermitten oral catheterization.

POTENTIAL DISEASE COMPLICATIONSevere dysphagia may result in aspiration pneumonia, airway obstruction, bronchiectasis, dehydration, or starvation37 and is potentially fatal. Severe dysphagia often causes social isolation because of the inability to consume a meal in the usual manner. This may lead to depression, sometimes severe. Suicide has been reported.

POTENTIAL TREATMENT COMPLICATIONSThe VFSS is safe and well tolerated. Prescription of a modified diet often means the substition of thick for thin liquids. Some patients find these unpalatable and reduce fluid intake to the point of dehydration and malnutrition. Failure to reevaluate patients in a timely manner may lead to unnecessary prolongation of dietary restrictions, increasing the risk of malnutrition and adverse psychological effects of dysphagia. Dilatation of the esophagus or sphincters may result in perforation, but this complication is uncommon. Percutaneous endoscopic gastrostomy may have direct or indirect sequelae. Direct sequelae, such as pain, infection, and obstruction of the feeding tube, are common. Percutaneous endoscopic gastrotomy tube feeding may promote aspiration pneumonia in individuals with severe gastroesophageal reflux disease.

References1. Martino R, Foley N, Bhogal S, et al. Dysphagia after stroke: incidence, diagnosis, and pulmonary complications. Stroke 2005; 36: 2756-2763.2. Achem SR, Devault KR. Dysphagia in aging. J Clin Gastroenterol 2005; 39: 357-371.3. Palmer JB, Drennan JC, Baba M. Evaluation and treatment of swalowing impairments.Am Fam Physician 2000; 61: 2453-2462.4. Buchholz DW. Oropharyngeal dysphagia due to iatrogenic neurological dysfunction. Dysphagia 1995; 10: 248-254.5. Smith Hammond CA, Goldstein LB. Cough and aspiration of food and liquids due to oral-pharyngeal dysphagia: ACCP evidence-based clinical practice guidelines. Chest 2006; 129: 154S-168S.6. Smith CH, Logemann JA, Colangelo LA, et al. Incidence and patient characteristics associated with silent aspiration in the acute care setting [see comments]. Dysphagia 1999; 14: 1-7.7. Arvedson J, Rogers B, Buck G, et al. Silent aspiration prominent in children with dysphagia. Int J Pediatr Otorhinolaryngol 1994; 28: 173-181.8. Leder SB, Sasaki CT, Burrell MI. Fibreoptic endoscopic evaluation of dysphagia to identify silent aspiration. Dysphagia 1998; 13: 19-21.9. dePippo KL, Holas MA, Reding MJ. Validation of the 3-oz water swallow test for aspiration following stroke [see comments]. Arch Neurol 1992; 49: 1259-1261.10. Tohara H, Saitoh E, Mays KA, et al. Three tests for predicting aspiration without videofluorography. Dysphagia 2003; 18: 126-134.11. Wu MC, Chang YC, Wang TG, et al. Evaluating swallowing dysfunction using a 100-ml water swallowing test. Dysphagia 2004; 19:43-47.12. Palmer JB. Evaluation of swallowing disorders. In Grabois M, ed. Physical Medicine and Rehabilitation: The Complete Approach. Malden, Mass, Blackwell Science, 1999:277-290.13. Leder SB. Gag reflex and dysphagia. Head Neck 1996; 18: 138-141.14. Kumlien S, Axelsson K. Stroke patients in nursing homes: eating, feeding, nutrition and related care. J Clin Nurs 2002; 11: 498-509.15. Palmer JB, Kuhlemeier KV, Tippett DC, et al. A protocol for the videofluorographic swallowing study. Dysphagia 1993; 8:209-214.16. Langmore SE. Endoscopic Evaluation and Treatment of Swallowing Disorders. New York, Thieme, 2001.17. Carnaby G, Hankey GJ, Pizzi J. Behavioural intervention for dysphagia in acute stroke: a randomised controlled trial. Lancet Neurol 2006; 5:31-37.18. Ott DJ, Hodge RG, Pikna LA, et al. Modified barium swallow; clinical and radiographic correlation and relation to feeding recommendations. Dysphagia 1996; 11: 187-190.19. Bisch EM, Logemann JA, Rademaker AW, et al. Pharyngeal effects of bolus volume, viscosity, and temperature in patients with dysphagia resulting from neurologic impairment and in normal subjects. J Speech Hear Res 1994; 37: 1041-1059.20. McCallum SL. The National Dysphagia Diet: implementation at regional rehabilitation center and hospital system. J Am Diet Assoc 2003; 103:381-38421. Welch MV, Logemann JA, Rademaker AW, et al. Changes in pharyngeal dimensions effected by chin tuck. Arch Phys Med Rehabil 1993;74: 178-181.22. Ohmae Y, Ogura M, Kitahara S, et al. Effects of head rotation on pharyngeal function during normal swallow. Ann Otol Rhinol Laryngol 1998;107:344-348.23. Bullow M, Olsson R, Erkberg O. Videomanometric analysis of supraglottic swallow, effortful swallow, and chin tuck in patients with pharyngeal dysfunction. Dysphagia 2001;16:190-19524. Hind JA, Nicosia MA, Roecker EB, et al. Comparison of effortful and noneffortful swallows in healthy middle-aed and older aduls. Arch Phys Med Rehabil 2001;82:1661-1665.25. Ding R, Larson CR, Longemann JA, et al. Surface electromyographic and electroglottographic studies in normal subjects under two swallow condition; normal and during the Mendelsohn maneuver. Dysphagia 2002;17:1-12.26. Longemann JA. Behavioral management for oropharyngeal dysphagia. Folia Phoniatr Logop 1999;51:199-21227. Longemann JA. The role of exercise programs for dysphagia patients. Dysphagia 2005:20:139-14028. Robbins J, Gangnon RE. Theis Sm, et al. The effects of lingual exercise on swallowing in older adults. J Am Geriatri Soc 2005;53:1483-148929. ShakerR, Kern M, Bardan E, et al. Augmentation of deglutitive upper esophageal sphincter opening in elderly by exercise. Am J Physiol 1997;272:G 1518-152230. Shaker R, Easterling C, Kern M, et al. rehabilitation of swallowing by exercise in tube-fed patients with pharyngeal dysphagia secondary to abnormal UES opening. Gastroenterology 2002;122:1314-132131. Palmer JB, Carden EA. The role of radiology in rehabilitation of swallowing. In Jones B, ed. Normal and Abnormal Swallowing: Imaging in Diagnosis and Theraphy, 2nd ed. New York, SpringerVelag, 2003:261-27332. Freed ML, freed L, Chatburn RL, et al. Electrical stimulation for swallowing disorders caused by stroke. Respire Care 2001;46:466-474.33. Ludlow CL, Humbert I, Saxon K, et al. Effects of surface electrical stimulation both at rest and during swallowing in chronic pharyngeal dysphagia. Dysphagia 2006;21:1-10.34. Suiter Dm, Leder SB, ruark JL. Efects of neuromuscular electrical stimulation on submental muscle activity. Dysphagia 2006;21:56-6035. Jacobs JR, Logemann J, Pajak TF, et al. Failure of cricopharyngeal myotomy to improve dysphagia following head and neck cancer surgery. Arch Otolaryngol Head and Neck Surg 1999;125:942-94636. Dennis MS, Lewis SC, warlow C. Effect of timing and method of enteral tube feeding for dysphagic stroke patients (FOOD): a multicenter randomized controlled trial. Lancet 2005;365:764-772.37. Finestone HM, Greene-Finestone LS, Wilson ES, et al. Malnutrition in stroke patients on the rehabilitation service and at follow up: prevalence and predictors. Arch Phys Med Rehabil 1995;76:310-316.121DisfagiaJeffrey B. Palmer, MD, and Koichiro Matsuo, DDS, PhD

DEFINISISecara umum disfagia merujuk pada suatu kondisi kesulitan menelan, termasuk gangguan yang bersifat asimptomatik atau tanpa gejala. Disfagia merupakan masalah umum yang dijumpai pada sepertiga sampai setengah dari pasien stroke dan seperenam pada manula. Kondisi ini juga sering dijumpai pada keganasan kepala dan leher, cedera otak, penyakit degeneratif sistem saraf, penyakit refluk gastro esofagus dan penyakit inflamasi otot (Tabel 121-1). Berdasarkan letak kelainannya, disfagia digolongkan menjadi dua yaitu orofaring (termasuk oral/mulut dan faring, tidak hanya orofaring) atau esofagus. Disfagia juga dapat diklasifikasikan sebagai kelainan mekanik (karena lesi struktural pada jalur makanan) atau fungsional (karena ganguang fisiologi dari jalur makanan).Bila terjadi secara mendadak, kemungkinan merupakan stroke. Bila disertai dengan kelemahan anggota tubuh kemungkinan merupakan gangguan neurologi atau neuromuskular. Disfagia yang diinduksi oleh penggunaan obat sering terabaikan. Obat-obatan yang menggangu kesadaran (seperti sedatif dan obat penenang), obat dengan efek antikolinergik (trisiklik, propanteline) atau obat-obatan yang merusak membran mukosa (anti inflamasi non steroid, aspirin, quinidin) juga dapat menginduksi disfagia.

GEJALAGejala yang paling umum dari disfagia adalah batuk atau tersedak saat makan serta perasaan adanya makanan yang melekat di ke tenggorokan atau dada. Beberapa gejala dan tanda disfagia dapat dilihat pada tabel 121-2. Riwayat pengeluaran air liur berlebihan, penurunan berat badan yang drastis, atau pneumonia berulang menunjukkan kondisi disfagia yang berat. Riwayat pasien sangat penting untuk mengidentifikasi disfagia esophagus; keluhan seperti rasa makanan melekat di dada biasanya berhubungan dengan kelainan esophagus. Bertentangan dengan hal tesebut, keluhan rasa makanan melekat di tenggorokan hampir tidak berarti dan hal ini biasanya berhubungan dengan kelainan esophagus. Batuk dan tersedak saat menelan menunjukkan asal gangguan yang berada pada orofaring dan dapat menyebabkan apirasi (masuknya material ke pita suara dan trakea). Beberapa pasien mempunya refleks batuk yang buruk yang akan menyebabkan terjadinya aspirasi (tanpa batuk). Aspirasi yang tanpa diketahui (silent aspiration) terjadi pada 28%-94% tergantung populasi pasien. Pasien dengan ganguan neurologi mempunyai angka kejadian yang lebih tinggi untuk silent aspiration. Nyeri saat menelan (odinofagia) dapat terjadi pada pasien dengan faringitis, tetapi bila nyeri menelan yang menetap meskipun hal ini jarang terjadi, mengindikasikan adanya keganasan. Heart burn merupakan keluhan yang tidak khas, hal ini biasanya tidak berhubungan dengan proses menelan, tetapi biasanya terjadi setelah makan. Heart burn merupakan gejala dari penyakit refluk gastro-esofagus, tetapi gejala khas pada penyakit refluk gastro-esofagus adalah regurgitasi material asam dan pahit di tengorokan setelah makan.

PEMERIKSAAN FISIKMelalui pemeriksaan rongga mulut dan leher, dapat dilakukan identifikasi kelainan struktural, kelemahan, atau defisit sensorik. Disartria (abnormalitas artikulasi) atau disfonia (abnormalitas kualitas suara) sering memiliki hubungan dengan disfagia orofaring. Bagaimanapun juga, pemeriksaan menjadi sangat penting untuk mengetahui penyebab kelainan seperti ganggaun neurologi, neuromuskular, atau penyakit jaringan ikat. Pemeriksaan harus mencakup percobaan menelan air. Pada saat menelan, harus dilakukan elevasi tulang hyoid dan laring secara tepat. Perubahan kualitas suara atau batuk spontan menunjukkan disfungsi faring. Anamnesis dan pemeriksaan fisik memiliki keterbatasan dalam mendeteksi dan menggambarkan disfagia, oleh karena itu diperlukan studi instrumental. Pemeriksaan neurologi penting dilakukan dalam mengevaluasi individu dengan disfagia karena kelainan neurologi menjadi penyebab disfagia yang cukup sering. Kelainan pada UMN dan LMN menyebabkan disfagia. Adanya atrofi dan fasikulasi lidah atau palatum menunjukkan disfungsi LMN nukleus motorik batang otak. Berlawanan dengan hal tersebut, refleks gag tidak cukup kuat untuk memprediksi individu dengan ketidakmampuan menelan. Refleks ini mungkin tidak ditemukan pada individu normal dan ditemukan normal pada individu dengan disfagia berat dan aspirasi.

Tabel 121-1 Beberapa Penyebab Disfagia Oral dan FaringKelainan Neurologis dan StrokeLesi StrukturalPenyakit Jaringan Ikat

Infark SerebriInfark Batang OtakPerdarahan IntrakranialPenyakit ParkinsonMultiple SclerosisAmyotrophic Lateral Sclerosis (ALS)PoliomyelitisMiasthenia GravisDemensiaTiromegaliHiperostosis servikalCongenital WebDivertikulum ZenkerIngesti KaustikNeoplasmaBedah Post-ablativeFibrosis RadiasiPolimiositisDistropi MuskularPenyakit PsikiarikDisfagia Psikogenik

Tabel 121-2 Gejala dan Tanda DisfagiaDisfagia Oral dan FaringBatuk dan tersedak saat menelanKesulitan saat memulai menelanRasa makanan melekat ditenggorokanPengeluaran air liur yang berlebihanKehilangan berat badan yang tidak dapat dijelaskanPerubahan pola makan Pneumonia berulangPerubahan suaraRegurgitasi hidungDehidrasi

Disfagia EsofagusRasa makanan melekat di tenggorokanRegurgitasi Oral atau FaringPengeluaran air liur yang berlebihanKehilangan berat badan yang tidak dapat dijelaskanPerubahan pola makan Pneumonia berulangDehidrasi

KETERBATASAN FUNGSIONALKeterbatasan fungsional pada individu dengan disfagia tergantung pada tingkat keparah disfagia seseorang. Bayak individu yang melakukan modifikasi makan untuk menghindari makanan yang sulit ditelan. Beberapa orang membutuhkan waktu yang lama untuk makan. Pada beberapa kasus, dibutukan selang makan. Ketidakmampuan dalam makan ini akan berefek pada kondisi psikologis dan sosial. Interkasi antara keluarga dan teman biasanya terjadi disaat waktu makan malam keluarga, bersantai untuk minum atau makan malam, menikmati makanan ringan atau makanan penutup. Kesulitan makan dapat menyebabkan terganggunya hubungan ini dan mengakibatkan terjadinya isolasi sosial. Beberapa pasien mungkin membutuhkan pegawasan saat makan atau merasa tidak nyaman saat makan sendirian, yang mengakibatkan gangguan fungsi sosial.

TES DIAGNOSTIK Mekanisme menelan tidak dapat dilihat secara kasat mata, oleh karena itu dibutuhkan studi diagnosis. Videoflourographic swallowing studi (VFSS) sangat diperlukan untuk diagnosis kelainan menelan pada lokasi orofaring. Dalam tes ini, pasien diinstruksikan untuk makan dan minum beberapa jenis sediaan padat dan cair yang telah dikombinasikan dengan barium, sementara gambar akan direkam menggunakan videoflourographic (perekam video radiografi). VSFF biasanya dilakukan oleh dokter dan ahli kelainan bahasa dan bicara. Manfaat dari VFSS adalah teknik terapeutik (seperti modifikasi konsistensi makanan, posisi tubuh, atau respirasi) dapat di uji dan efeknya dalam proses menelan dapat diobservasi selagi pemeriksaan. Pemeriksaan barium rutin sering kali sudah cukup jika kelainannya jelas berada pada esofagus.Jika VFSS tidak dapat dilakukan karena keterbatasan fisik pasien, evaluasi menggunakan endoskopi serat optik akan berguna untuk melihat anatomi faring dan laring dan fungsi pita suara saat makan tanpa menggunakan sinar x. ini juga sensitif untuk mendeteksi aspirasi, namun tidak dapat memvisualisasikan aspek penting dalam proses menelan seperti oral (mulut) dan proses menelan di esofagus, atau kejadian penting dari proses menelan di faring termasuk pembukaan spingter esofagus atas, peninggian laring, dan kontraksi faring.Pada kasus disfagia esophagus, esofagoskopi sering kali dibutuhkan untuk mendeteksi lesi pada membran mukosa atau masa. Biopsi diindikasikan bila ditemukan abnormalitas mukosa. Manometri berguna untuk mendeteksi dan menggambarkan kelainan motorik pada esofagus. Elektromiografi diindikasikan bila curiga kelainan pada neuromuskular dan berguna untuk mendeteksi disfungsi LMN dari laring dan faring.

TATALAKSANAInisialPengobatan disfagia bergantung pada penyebab dan mekanismenya. Berbagai pengobatan yang umum dilakukan terlampir pada Tabel 121-3. Bila memungkinkan, pengobatan awal seharusnya diarahkan pada proses penyakit yang mendasari, misalnya levodopa untuk penyakit Parkinson, atau steroid untuk polimiositis. Disfagia esofagus membutuhkan evaluasi dan pengobatan oleh seorang gastroenterologis. Ketika tidak ada terapi yang tersedia berdasarkan penyakit yang mendasari atau terapi tidak efektif atau dikontraindikasikan, maka pendekatan rehabilitatif adalah pilihan yang tepat. Pasien dan anggota keluarganya didorong untuk mempelajari manuver Heimlich; hal ini penting karena obstruksi jalan napas berpotensi menimbulkan kematian.

Diagnosis Banding

Iskemia miokardium

Sensasi globus

Heartburn dikarenakan penyakit refluks gastroesofagus

Aspirasi tidak langsung (aspirasi refluks isi lambung)

RehabilitasiBanyak pasien mendapatkan manfaat dari terapi menelan terstruktur yang diberikan oleh ahli patologi bahasa-wicara, termasuk instruksi dan pengawasan mengenai makanan, manuver kompensasi, dan latihan.17 Tujuan dari terapi tersebut adalah untuk mengurangi aspirasi, meningkatkan kemampuan makan dan minum, dan mengoptimalkan status nutrisi. Terapi tersebut diterapkan individual berdasarkan pada anatomi spesifik pasien dan kelainan-kelainan struktural dan respon awal terhadap uji coba pengobatan selama perawatan di tempat tidur atau VFSS.18 Prinsip dasar rehabilitasi adalah bahwa terapi terbaik untuk setiap aktifitas adalah aktifitas itu sendiri; menelan secara umum merupakan terapi terbaik untuk gangguan menelan, sehingga evaluasi rehabilitasi diarahkan pada identifikasi keadaan untuk menelan aman dan efektif pada setiap pasien.Tabel 121-3 Prinsip Pengobatan Gangguan yang Berhubungan Proses Menelan GangguanPrinsip Pengobatan

Sklerosis lateral amiotropik

Modifikasi makananManuver kompensasiKonseling dan arahan

Karsinoma esofagusEsofagektomi

Penyakit refluks esofagusModifikasi makananTidak makan menjelang waktu tidurTerapi farmakologisBerhenti merokok

Penyakit Parkinson, polimiositis, miasternia gravisPengobatan farmakologis berdasarkan penyakit yang mendasari (modifikasi makanan, manuver kompensasi, dan terapi disfagia bila diperlukan).

Striktur esofagus Dilatasi

Sklerosis multipel strokeModifikasi makananManuver kompensasiTerapi disfagia

Modifikasi makanan adalah pengobatan umum disfagia.19,20 Para pasien bervariasi dalam kemampuan menelan cairan encer dan kental, dan penentuan tersebut biasanya dilakukan sangat baik dengan VFSS. Seorang pasien biasanya dapat menerima hidrasi oral adekuat baik dengan cairan encer (misal, air atau jus apel) atau kental (misal, nektar aprikot, jus tomat). Walaupun jarang, seorang pasien mungkin terkendala pada konsistensi pudding apabila cairan encer dan kental diambil. Kebanyakan pasien dengan disfagia yang berarti tidak mampu makan daging atau makanan keras yang serupa dengan aman dan membutuhkan makanan yang lunak. Diet bubur direkomendasikan untuk pasien yang memperlihatkan kesulitan-kesulitan pada tahap persiapan oral, makanan tersisa dalam kantung bukal (antara gigi dan pipi), atau tersangkutnya makanan yang telah dikunyah pada rongga faring. Pemeliharaan dari pemberian makan secara oral sering membutuhkan teknik kompensasi untuk mengurangi aspirasi atau untuk meningkatkan pembersihan rongga faring. Berbagai teknik perilaku digunakan, termasuk modifikasi sikap tubuh, posisi kepala (Fig.121-1),21-22 dan pernapasan,23 serta manuver menelan tertentu.24-26Terapi latihan untuk disfagia diindikasikan ketika gangguan yang terkait dengan kelemahan otot-otot menelan.27 Pilihan latihan harus individual berdasarkan pada penilaian fisiologis. Berbagai bentuk latihan tidak dijelaskan pada bab ini, tetapi beberapa contoh mengilustrasikan prinsip-prinsip tersebut. Kelemahan lidah dapat diterapi dengan latihan daya tahan lidah.26 Penguatan otot-otot suprahioid anterior berguna ketika sfingter esofagus atas sulit membuka. Memfleksikan leher melawan gravitasi saat berbaring terlentang dapat menguatkan otot-otot tersebut (Fig.121-2).29,30 Latihan aduksi pita suara mungkin berguna pada kasus aspirasi dikarenakan kelemahan otot-otot tersebut. Latihan ini dilakukan setiap hari apabila memungkinkan.

ProsedurVFSS berfungsi sebagai prosedur diagnostik dan terapeutik pada disfagia, khususnya disfagia orofaring, karena prosedur ini dapat digunakan untuk menguji efektivitas modifikasi konsistensi makanan dan teknik kompensasi lainnya.31 Endoskopi dengan dilatasi esofagus sering diindikasikan pada kasus obstruksi esofagus parsial dikarenakan striktur atau tertutupi. Dilatasi juga cocok pada kasus stenosis sfingter esofagus atas. Dilatasi juga dapat digunakan untuk biofeedback, khususnya menunjukkan pergerakan laring selama manuver menelan. Elektromiografi juga digunakan untuk biofeedback. Aktifitas otot-otot suprahioid dan infrahioid dicatat dengan elektrode selama terapi menelan. Biofeedback sendiri bukan suatu terapi disfagia tetapi dapat menjadi tambahan yang berguna untuk terapi. Stimulasi elektrik pada otot-otot servikal anterior dan submental merupakan suatu pengobatan baru yang masih kontroversial untuk disfagia. Namun, masih sedikit bukti yang ada untuk keamanan dan keberhasilannya.

PembedahanPembedahan jarang diindikasikan pada perawatan pasien dengan disfagia oral atau faring. Prosedur yang paling umum untuk disfagia faring adalah krikofaringomiotomi, dimana sfingter esofagus atas dikacaukan untuk menurunkan tahanan saluran keluar rongga faring. Bagaimanapun, efektifitas miotomi masih sangat kontroversial.35 Esofagektomi mungkin diperlukan pada kasus kanker esofagus atau striktur obstruktif. Gastrostomi sebagai cara pemberian makan (biasanya gastrostomi endoskopi perkutaneus) diindikasikan ketika keparahan disfagia tidak memungkinkan untuk masuknya asupan makanan secara adekuat atau hidrasi cairan dicapai secara oral, walaupun hidrasi intravena atau pemberian makan melalui selang nasogastrik mungkin mencukupi dalam batas waktu tertentu.36 Pemberian makan melalui selang orogastrik telah digunakan dengan baik pada pasien yang kehilangan refleks muntah dan tahan terhadap kateterisasi oral.

POTENSI KOMPLIKASI PENYAKITDisfagia berat mungkin menyebabkan pneumonia aspirasi,obstruksi jalan napas, bronkiektasis, dehidrasi, atau kelaparan37 dan berpotensi menimbulkan kematian. Disfagia berat sering menyebabkan isolasi sosial dikarenakan ketidakmampuan untuk mengkonsumsi makanan sesuai tata cara biasanya. Hal ini mungkin menyebabkan timbulnya depresi, yang terkadang menjadi berat. Kasus bunuh diri juga telah dilaporkan.

POTENSI KOMPLIKASI PENGOBATANVFSS dinilai aman dan ditoleransi dengan baik. Rekomendasi tentang modifikasi pola makan berarti mengganti makanan yang kental menjadi cair. Beberapa pasien merasakan pengobatan ini tidak menyenangkan dan mengurangi asupan cairan berujung pada dehidrasi dan malnutrisi. Kegagalan untuk mengevaluasi kembali pasien-pasien pada waktu yang tepat mungkin menyebabkan perpanjangan yang tidak perlu dari restriksi makanan, meningkatnya risiko malnutrisi dan efek psikologis yang merugikan dari disfagia. Dilatasi esofagus atau sfingter mungkin menyebabkan perforasi, tetapi komplikasi ini tidak umum terjadi. Gastrostomi endoskopi perkutaneus mungkin menimbulkan sequele baik secara langsung maupun tidak langsung. Sequele langsung, seperti nyeri, infeksi, dan obstruksi saluran makan, umum terjadi pada pasien. Gastrostomi endoskopi perkutaneus saluran makan mungkin mendorong terjadinya pneumonia aspirasi pada individu dengan penyakit refluks gastroesofagus berat.

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