​Kembara Xtra - Medicine - Dysphagia

​Kembara Xtra - Medicine - Dysphagia 
Introduction 

Impaired passage of the alimentary bolus from the mouth to the stomach Oropharyngeal: trouble moving food bolus from the oropharynx to the proximal esophagus Esophageal: difficulty moving food bolus through the body of the esophagus to the pylorus Impaired passage of the alimentary bolus from the mouth to the stomach Impaired passage of the alimentary bolus from the mouth to the stomach

Prevalence and Incidence 

5–8 percent of the overall population that is above the age of 50
Incidence
25 cases of food becoming lodged in the esophagus for every 100,000 people per year.

The prevalence can range from 14% to 33% among people who live in the community and are 65 years old or older; it can reach as high as 40% in hospital settings; and the prevalence among nursing home residents can range from 29% to 32%.
30–40% in older adults who are still living freely 44% in patients who are receiving acute care for geriatric conditions 60% in older patients who are being cared for in an institution

Causes and effects: etiology and pathophysiology 
● Oropharyngeal (transfer dysphagia):
- Functional as a result of disturbances in the motor function of the oropharynx
- Mechanical causes include pharyngeal and laryngeal cancer, acute epiglottitis, carotid body tumor, pharyngitis, tonsillitis, strep throat, lymphoid hyperplasia of lingual tonsil, lateral pharyngeal pouch, and hypopharyngeal diverticulum. Other causes include strep throat, strep infection, and lymphoid hyperplasia of lingual - Neuromyogenic: alcoholism, thyrotoxicosis, hypothyroidism, amyloidosis, Cushing syndrome, Parkinson and parkinsonism, amyotrophic lateral sclerosis, myasthenia, myopathies (polymyositis, dermatomyositis, muscular dystrophies), stroke, head trauma, Parkinson and parkinsonism, amyotrophic lateral sclerosis, myas
● Esophageal:
- Mechanical causes include carcinomas, esophageal diverticula, esophageal webs, Schatzki rings, structures (peptic, chemical, trauma, radiation), and foreign bodies. - Extrinsic mechanical lesions, such as peritonsillar abscess, thyroid problems, tumors, mediastinal compression, vascular compression (enlarged left atrium, aberrant subclavius, aortic aneurysm), osteoarthritis of the cervical spine, adenopathy, and esophageal duplication cyst; mediastinal compression; vascular compression; mediastinal compression; mediastinal compression; vascular compression; media
skeletal muscle disease (polymyositis, dermatomyositis), neuromuscular junction disease (myasthenia gravis, Lambert-Eaton syndrome, botulism), hyper- and hypothyroidism, Guillain-Barré syndrome, systemic lupus erythematosus, acute lymphoblastic leukemia, Alzheimer disease, Huntington chorea, Parkinson disease, multiple sclerosis, skeletal muscle disease (polymyo
Infections: diphtheria, chronic meningitis, tertiary syphilis, Lyme disease, rabies, poliomyelitis, CMV, esophagitis (Candida, herpetic), poliomyelitis

factors of danger 

Malformations in children that may be inherited or be present at birth.

Adults: age greater than 50 years; the elderly: GERD, stroke, COPD, and chronic pain
Tobacco use, excessive consumption of alcoholic beverages, and obesity
Medications: quinine, potassium chloride, vitamin C, tetracycline, Bactrim, clindamycin, nonsteroidal anti-inflammatory drugs (NSAIDs), procainamide, anticholinergics, bisphosphates, anticonvulsants (phenobarbital, carbamazepine, and phenytoin); antihistaminics, antidepressants (amitriptyline, imipramine), antipsychotic
cytotoxic chemotherapy plus molecular target treatment such as sunitinib and everolimus for mucositis
Disorders or diseases of the nervous system, include cerebral vasospasm, myasthenia gravis, multiple sclerosis, Parkinson disease, amyotrophic lateral sclerosis (ALS), Huntington chorea, and dementia
AIDS patients having a CD4 cell count of less than 100 cells per millimeter 3

Injuries to the head, neck, and chest, including radiation exposure; mechanical wounds
Iron deficiency Extrinsic mechanical lesions, including lung and thyroid cancers, lymphoma, and metastasis

Surgery of the front of the cervical spine (up to 71% in the first 2 weeks postoperatively; 12–14% at 1 year postoperatively).
Dysphagia lusoria (vascular anomalies that cause dysphagia): full vascular ring, double aortic arch, right aortic arch with retroesophageal left subclavian artery and left ligamentum arteriosum, right aortic arch with mirrorimage branching and left ligamentum arteriosum, and right aortic arch with retroesophageal left subclavian artery and left ligamentum arteriosum

Prevention 
Dentures that don't fit properly should be adjusted.
Encourage them to take their time chewing their food and to consume sufficient amounts of water when eating.
Diet consisting of liquids and soft foods, as necessary
Avoid drinking alcohol when you are eating.
Swallowing exercises as a preventative measure for individuals having chemotherapy or radiation treatment for head and neck cancer

Conditions That Often Occur Together 

Peptic structure, esophageal webs and rings, cancer, history of stroke, dementia, and pneumonia are some of the risk factors that should be considered.

Providing an Account of History 

Having difficulty swallowing solids as well as liquids right from the beginning of the process of deglutition is most likely indicative of an esophageal motility issue.
A common symptom of oropharyngeal dysphagia is having trouble getting started on the swallowing process.
It is more likely that mechanical obstruction is the cause of dysphagia that begins with solids and progresses to involve liquids.
Cancer or a peptic stricture are the most common underlying conditions in progressive dysphagia. The lower esophageal ring is the cause of intermittent dysphagia the vast majority of the time.
It is important to inquire about the patient's history of heartburn, weight loss, hematemesis, emesis of coffee grounds, anemia, regurgitation of undigested food particles, and respiratory symptoms.
If the patient experiences any of the following symptoms immediately after swallowing: regurgitation, aspiration, or drooling, you should inquire about oropharyngeal dysphagia.
Does it seem as though the food bolus is stuck?
The sensation that occurs over the upper sternum or in the back of the throat may be an indication of oropharyngeal dysphagia, whereas the sensation that occurs over the lower sternum is characteristic of esophageal dysphagia.
Is there pain in the odynophagia (throat)?
– Could be an indication of inflammation, achalasia, generalized esophageal spasm, esophagitis, pharyngitis, pill-induced esophagitis, or even malignancy.  Do you feel like there is a lump in your throat (globus sensation)?
- May be an indication of laryngeal or cricopharyngeal problems
If you have a history of heartburn or a sour sensation in the back of your throat, you may have gastroesophageal reflux disease (GERD).
Inquire about the use of tobacco and/or alcoholic beverages.
Do you have any accompanying symptoms, such as a decrease in your weight or discomfort in the chest?
– Right aortic arch with retroesophageal left subclavian artery and left ligamentum arteriosum – Left ligamentum arteriosum with double aortic arch The production of saliva can be inhibited by medications such as anticholinergics, antihistamines, and certain antihypertensives.
● Halitosis: Rule out diverticulum. A history of a condition affecting the connective tissues Have you noticed any changes in your speech, such as hoarseness, a faint cough, or dysphonia? Eliminate the possibility of neuromuscular dysfunction. Dysphagia may be the first sign of a neuromuscular illness, such as amyotrophic lateral sclerosis or myasthenia gravis, so it's important to rule out this possibility.

The Patient's Clinical Examination 

Skin: telangiectasia, sclerodactyly, calcinosis (r/o autoimmune illness); Raynaud phenomenon; sclerodactyly may be observed in CREST syndrome or systemic scleroderma; stigmata of alcohol misuse (palmar erythema; telangiectasia). Eyes: cataracts, retinopathy of prematurity, retinopathy of prematur
The head, eye, ear, nose, and throat, often known as the HEENT:
- Oropharyngeal: pharyngeal erythema or edema, tonsillitis, pharyngeal ulcers or thrush, odynophagia (infections caused by bacteria, viruses, or fungi); tongue fasciculations (a form of amyotrophic lateral sclerosis). - Neck: lumps, lymphadenopathy, discomfort in the neck (thyroiditis), and goiter
● Neurologic:
– Cranial nerve exam: sensory: cranial nerves V, IX, and X; motor: cranial nerves V, VII, X, XI, and XII – CNS, mental status exam, strength testing, Horner syndrome, ataxia, and cogwheel rigidity (stroke, dementia, Parkinson disease, and Alzheimer disease)  Eye movement, as well as extraocular motility
Observe the patient's degree of consciousness, postural control (upright position), oral cleanliness, and the mobilization of oral secretions as part of an informal evaluation of swallowing performed at the bedside.


Findings from the Laboratory: Esophagogastroduodenoscopy (EGD) is indicated for the initial assessment of patients who present with esophageal dysphagia; barium esophagography is recommended as an adjuvant if the findings from the EGD are negative.

Esophageal manometry if history suggests dysmotility disorder achalasia, diffuse esophageal spasm, scleroderma esophagus, nutcracker esophagus, hypertensive LES, ineffective esophageal motility, collagen vascular disease (scleroderma, CREST). Fiberoptic endoscopic examination of swallowing (FEES).
Oropharyngeal dysphagia was diagnosed by a videofluoroscopic swallowing study (VFSS). 
Patients who have had strokes should not be given a "formal" swallow evaluation until they have already failed the initial swallow screen.
Initial Tests (lab, imaging)
Thyroid function studies to detect dysphagia associated with hypothyroidism or hyperthyroidism, cobalamin levels serum protein, and albumin levels for nutritional evaluation CBC (infection and inflammation) Antiacetylcholine antibodies (myasthenia) Thyroid function studies to detect dysphagia associated with hypothyroidism or hyperthyroidism 
If endoscopy is unable to identify an abnormality, a barium swallow may be performed instead. This test can reveal strictures and stenosis.

Additional Examinations, as well as Other Important Factors

a computed tomography scan of the chest, as well as an MRI of the brain and cervical spine
● VFSS (lips, tongue, palate, pharynx, larynx, proximal
esophagus)
● Fiberoptic endoscopy and videofluoroscopy
are similar in terms of diagnostic sensitivity.
● For accurate diagnosis of eosinophilic esophagitis;
biopsies from normal-appearing mucosa in the
midthoracic and distal esophagus should be requested for
all patients with unexplained solid food dysphagia.


Diagnostic Methods and Other Procedures
Patients who have chronic oropharyngeal symptoms and an initial workup that is negative should be referred for EGD to rule out esophageal pathology. This can be done by doing an endoscopy with a biopsy, esophageal manometry, and esophageal pH monitoring.


Management 

Exclude cardiac illness. Ensure that the airways are clear and that appropriate pulmonary function is present. Determine the current nutritional status.
MEDICATION for speech-language pathology
Adjust the dosage of the patient's medications in accordance with their current functional swallowing capacity.

First Line
● For esophageal spasms: calcium channel blockers: nifedipine 10 to 30 mg TID; imipramine 50 mg at bedtime; sildenafil 50 mg/day PRN
● For esophagitis: Before undergoing an endoscopy, patients younger than 50 years old who suffer from esophageal dysphagia but have no other concerning symptoms should first complete a four-week trial of acid suppression therapy.
– Antacids (calcium carbonate, magnesium hydroxide, aluminum hydroxide, sodium bicarbonate-based) – H2 blockers:
Cimetidine: up to 1,600 mg orally each day in 2 or 4 divided doses for a total of 12 weeks. Ranitidine: initial 150 mg orally four times day, followed by 150 mg orally twice daily for maintenance.
Nizatidine: 150 mg by mouth, twice a day, for a period of 12 weeks
20–40 mg of famotidine should be taken by mouth twice daily for a period of 12 weeks
Omeprazole: 20 mg once daily for 4 to 8 weeks is the recommended dosage for proton pump inhibitors.
– Lansoprazole: 30 mg orally once daily for up to 8 weeks. – Rabeprazole: 20 mg orally once daily for 4 to 8 weeks. – Esomeprazole: 20 to 40 mg orally once daily for 4 to 8 weeks. –
- Pantoprazole: 40 mg to be taken orally once per day for a maximum of eight weeks

Referral to Gastroenterology for endoscopy and evaluation of symptoms that have not responded to treatment

Surgical procedures including dilatation, esophageal myotomy, and a biopsy
When treating patients for malignancies of the head and neck, a multidisciplinary team that includes a speech-language pathologist is the best approach.

Further Methods of Treatment 

Speech therapy to evaluate swallowing; dietary examination and placement; physical therapy for muscle-strengthening activity before bedtime; and remaining upright after eating are all examples of treatments that may be recommended. 
When compared to other treatments for dysphagia, self-expanding metal stents are not only safer, but also more effective and less time consuming.
Patients who have advanced dementia should not be given percutaneous feeding tubes; instead, cautious hand feeding should be offered. Patients who have a high risk of aspiration or who require extra nutrition or hydration may be required to have enteral tube feedings via an NG or gastrostomy tube.

Esophageal dilatation, either pneumatic or bougie, is a surgical procedure that can be used to treat achalasia. Stent placement in the esophagus with laser therapy for cancer palliation
Treat the underlying condition (for example, a goiter on the thyroid, a vascular ring, or an atresia in the esophagus).
● Nd:YAG laser incision of lower esophageal rings refractory
to dilation 
● Photodynamic therapy (cancer).
Myotomy of the cricoid cartilage of the oropharynx for the treatment of oropharyngeal dysphagia Surgery for Zenker diverticulum, refractory strictures, or myotomy (for the treatment of achalasia)
The use of a percutaneous endoscopic gastrostomy (PEG), as opposed to a nasogastric tube, reduces the likelihood of developing dysphagia.

Alternative Medicine 
Following a stroke, acupuncture may be used in conjunction with swallowing therapy to help improve patients' ability to swallow.
There is not enough data to support the use of botulinum toxin on a regular basis.

Admission 

Need for enteral feeding Hospitalization with total or near-total obstruction of esophageal lumen Hospitalization may be required for endoscopy and/or esophageal dilatation, and it is generally indicated for diagnostic or therapeutic surgical procedures. Complete or partial esophageal obstruction associated with malnutrition or dehydration.
Fluids administered intravenously to individuals who are hypovolemic, dehydrated, or who have impaired consciousness 
Discharge when the patient is able to tolerate an adequate diet without experiencing discomfort or nausea


Ongoing Medical Attention 
The use of swallow treatment may lower the risk of developing a chest infection or pneumonia following a stroke.


Follow Up A diet consisting of soft, pureed foods might be helpful in cases with mechanical esophageal constriction. When dysphagia is severe or lasts for an extended period of time, enteral feeding through a gastrostomy or nasogastric tube may be necessary.
Patient Monitoring
It is important to review the medications.
Safe swallowing technique: Take liquids in short, measured sips rather than gulping them down. Keep your back straight with a 90-degree angle, and never consume anything while lying down or slouching.
• Chew your food thoroughly before swallowing it, eat slowly, take tiny bites of food, and do not swallow any food or drink before taking another bite. Avoid using liquids to wash down your food. When they have something in their mouth, they should refrain from chatting.

Oropharyngeal dysphagia and aspiration are associated with a mortality rate of less than 45 percent within one year in patients who are residents of nursing homes.
In most cases, a poorer prognosis is related with oropharyngeal dysphagia.
Despite the fact that swallowing treatment resulted in a lower rate of pneumonia, there was no discernible change in patients' swallowing quality of life scores.

Oropharyngeal complications include pneumonia, lung abscess, aspiration pneumonia, and airway obstruction
Aspiration pneumonia occurs in fifty percent of patients who are undergoing modified barium swallow examinations. Malnutrition, dehydration, and frailty all contribute to the development of sarcopenia, which can lower immunity and slow the healing of wounds.

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