Dysphagia
Dysphagia - Inability to swallow
or difficulty in swallowing. This may manifest as a sensation of food
sticking or getting caught in the throat or as it passes to the stomach.
Odynophagia - pain with swallowing, often seen with dysphagia
- Presentation depends on the phase of Deglutition
- Oral
- drooling
- preferentially open mouth
- poor sucking
- refusal to swallow
- cough
- gaging
- choking
- respiratory distress
- aspiration
- Pharyngeal
- dysphagia during swallowing
- Esophageal
- dysphagia after swallowing
- Diagnosis can similarly be divided into phase of deglutition or
can be broken up by using a systems approach
- Oral phase
- choanal atresia / stenosis
- sinus/ nasal infections
- Cleft lip/palate
- hypopharyngeal web/stenosis
- craniofacial syndromes with micrognathia - Robin sequence
- trauma, infection, mucositis
- tonsillar and adenoid hypertrophy
- pharyngitis
- Profound Developmental delay - uncoordinated chewing
/swallowing
- skeletal muscle hypotonia, cranial nerve abnormalities
(spasticity, dystonia, paresis) Mobius syndrome, transient infantile
paralysis of the superior laryngeal nerve
- Pharyngeal phase
- Pharyngeal web
- laryngeal stenosis
- laryngopharyngeal cleft
- laryngeal web
- cricopharyngeal achalasia
- muscular hyperplasia
- cricopharyngeal incoordination
- dysphagia occurs due to failure to relax the upper esophageal
sphincter (central or cranial nerve damage)
- meds:
- nitrazepam
- benzodiazepines
- Tracheostomy
- Neuro defects:
- head trauma
- hypoxic brain injury
- CNS infection
- microcephaly
- anencephaly
- myelomeningocele
- syringomyelia
- chiari malformation, dysautonomia
- Neuromuscular
- myotonic dystrophy
- myasthenia gravis
- guillain-barre syndrome
- poliomyelitis
- spinal muscular atrophy
- polyneuritis
- dermatomyositis
- Lupus (SLE)
- scleroderma
- DM
- Thyroid
- amyloidosis
- Chagas
- Graft v Host
- Mitochondrial d/o
- paraneoplastic
- Vascular
- double aortic arch, R aortic arch w/ L ligmentum arteriosum
compresses the esophagus
- aberrant R subclavian artery (rarely causes obstruction)
- Dx with MRA
- Esophageal phase
- stricture
- caustic ingestion
- peptic esophagitis
- EoE
- epidermolysis bulosa
- trauma
- gastric rest
- pill esophagitis
- Anatomic abnormalities
- diverticulae
- TEF
- aberrant cervical thymus
- Webs
- Motility Disorders
- Achalasia - regurgitation and dysphagia for solids and
liquids
- abnormal or absent peristalsis
- loss of LES relaxation leads to functional obstruction
of distal esophagus (impaired bolus transit)
- hypertensive LES
- esophageal wall stretch stimulates nociceptors causing
dysphagia/odynophagia
- Causes:
- degenerative
- autoimmune - antibodies to auerbach plexus
- infectious - chagas
- familial
- achalasia, alacrima, adrenal insufficiency (Triple A
or Allgrove syndrome)
- Pseudoachalasia - cancer or paraneoplastic syndrome
(anti-Hu Ab)
- Diffuse or distal esophageal spasm
- simultaneous esophageal contractions
- LES relaxation is normal
- dysphagia is caused by the esophageal dilation proximal
to the transient musclar obstruction
- Treat with CCB or anticholinergics
- Nutcracker esophagus
- very strong simultaneous esophageal body contractions
- odynophagia is more prominent Sx than dysphagia
- Testing
- Videofluoroscopy (modified Barium swallow) detect
abnormalieites with swallowing, aspiration, and esophageal obstruction
- achalsia presents with tapering of distal esophagus
(Birds Beak)
- Upper endoscopy assess for mucosal disease
- esophageal manometry - motility disorders
- Tx
- relief of Sx, improvement of esophageal emptying,
prevention of megaesophagus
- options
- Dilation -intial treatment of choice -does not preclude
later myotomy
- Heller Myotomy
- peroral endoscopic myotomy (POEM) may be more
effective/safe
- Meds
- CCB
- phosphodiesterase inhibitors
- anticholinergics
- endoscopic injection of botox effective in 50-60% of pts
but may require repeat injection within 1 year and most eventually
require surgery
References:
- Venes, D., & Taber, C. W.
(2013). Taber's cyclopedic medical
dictionary. Ed. 22, illustrated in full color / Philadelphia:
F.A. Davi
- Tortora, Gerard J. Principles
of Anatomy and Physiology. 15th ed. Hoboken, NJ: J. Wiley, 2009. Print.
- Moore, Keith L.,, Arthur F.
Dalley, II, and Keith L Moore. Clinically Oriented Anatomy. Fifth
edition. Baltimore: Wolters Kluwer Health, 2009. Print.
- Kleinman RE, Goulet O,
Mieli-Vergani G, et al, eds. Pediatric Gastrointestinal Disease:
Pathophysiology, Diagnosis, and Management. 5th ed. Hamilton, Ontario:
BC Decker; 2008.
- The NASPGHAN fellows concise
review of pediatric gastroenterology, hepatology, and nutrition. 1st
edition (2011)
- Wyllie, Robert & Hyams,
J.S.. (2011). Pediatric Gastrointestinal and Liver Disease.
10.1016/C2009-0-53242-4. (Accessed online Feb 2020)