by Richard Mitchell, MD, PhD

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    00:01 Okay. This talk is gonna be about things that are hard to swallow, dysphagia.

    00:07 And in fact, literally, if we deconstruct what the word means, it means abnormal or dys, phagia, eating.

    00:14 But it's really all about swallowing and making sure that the food gets from the oropharynx into the stomach.

    00:22 So dysphagia more technically is gonna be disruption of the swallowing process that interferes with eating and/or drinking, hence, the name dysphagia.

    00:32 There are really two flavors of this and we're gonna mostly focus on this talk on the oropharyngeal dysphagia, so things involving the mouth and the initiation of the swallow.

    00:45 But there's also esophageal dysphagia.

    00:47 We'll talk briefly about that in this particular talk but we'll revisit it in a lot of detail at a later time.

    00:55 So oropharyngeal dysphagia, this is difficulty initiating a swallow.

    00:59 Think about it. We can actually start a swallow and it's voluntary.

    01:04 It involves skeletal muscle up in the oropharynx.

    01:08 If you can't start that process, it's usually due to some sort of pathology in the oral or the pharyngeal phase of the swallow.

    01:17 So it's not just beginning to swallow but it's opening the upper esophageal sphincter and getting fluid and/or food into the esophagus.

    01:27 Once it gets there, yes, there's a peristaltic wave that carries it all the way down into the stomach but after initiating the swallow, that process is more or less autonomous.

    01:39 Esophageal dysphagia is the other flavor.

    01:42 So you can start the swallowing process, but now, it can't get all the way down.

    01:47 So there's some sort of motor or parenchymal smooth muscle disorder that's interfering with the movement of that bolus of food from top to bottom.

    01:59 It doesn't start with the initial swallowing.

    02:01 It happens after a couple of seconds after you initiate the swallow and it's accompanied by that kind of bad feeling that something is stuck in the tube and it is literally.

    02:12 And there are multiple causes as we will discuss.

    02:15 So as I said, we're gonna focus here primarily on oropharyngeal dysphagia.

    02:18 And we'll start with the epidemiology.

    02:21 So in this flavor, there are three kind of basic categories that can cause it.

    02:26 You may not have enough lubricant.

    02:28 You may not make enough saliva to get the food into a place where it can start down into the esophagus.

    02:35 There may be inflammation that is narrowing the upper tube or causing dysfunction.

    02:41 Or there may be underlying neuromuscular pathology.

    02:45 This is a voluntary process of initiating the swallow and that may be compromised.

    02:52 So typically, for oropharyngeal dysphagia, it's gonna be someone who is of a certain vintage, like me, over 60, 65 years of age.

    03:01 Interestingly, in that population, a remarkably high percentage will have some degree, not complete and not pathologically important, pathologically important dysphagia.

    03:10 and not pathological important, pathologically important dysphagia.

    03:13 But a very high percentage, 14 to 33% in that age range will have some degree of oropharyngeal dysphagia.

    03:20 And in the hospitalized patient population, the numbers are even higher, about 40%.

    03:28 And about a third of Parkinson's patients.

    03:31 A neuromuscular disorder involved in voluntary muscular control, a third of those patients will have oropharyngeal dysphagia.

    03:40 So the etiology of this. So it can be poor dentition.

    03:44 And poor dentition may be a secondary consequence of not making enough saliva but may also be primary and that that will cause inflammation that can potentially cause edema that will limit the movement of salivary juices from the salivary glands into the salivary ducts, and then, into the mouth.

    04:01 You can have primary defects in salivary gland production, such as Sjogren's syndrome, an autoimmune disease of the salivary glands or ducts.

    04:08 You can have inflammation of mucosa such as mucositis and the rarely neuromuscular pathology such as a stroke.

    04:17 There may also be structural abnormalities within the oropharynx, so a tumor that may limit the ability of initiating a swallow.

    04:25 And then, stroke, or myasthenia gravis, multiple sclerosis, a whole variety of neurodegenerative processes can also disrupt swallow coordination.

    04:35 In fact, there are a lot of muscles that have to act altogether.

    04:38 And then, you also have to relax the upper esophageal sphincter in order to get food to start down its journey into the lower esophagus.

    04:48 So how does this clinically present? Well, clearly, you're not able to move things that are in the oropharynx, whether it be food, or liquid, or even saliva, down into the esophagus.

    05:01 So the patient will frequently have coughing or choking, drooling, or frank regurgitation.

    05:06 There may be associated with the inflammatory process, some lymphadenopathy that may also be associated with very poor oral hygiene.

    05:16 Poor dentition because often, the salivary glands are not able to dump their contents which include a bunch of bacteriostatic compounds, not being able to dump into the oropharynx will lead to poor dentition.

    05:30 And then, there may be frankly, masses.

    05:32 There may be facial muscle weakness.

    05:34 So instead of being able to smile or grimace, the patient may have drooping on one side that's associated with then the oropharyngeal dysphagia.

    05:46 How do we diagnose this formally? So video fluoroscopy, a modified barium swallow.

    05:52 We will have the patient while we're under fluoroscopy, swallow some barium and then, make sure it's going down the right tube for all intents and purposes.

    06:01 What's being demonstrated here with all the arrows is a normal airway swallow.

    06:07 Here on the other hand, we have opacification not only of the normal oropharynx, but the patient is also shunting fluid into the trachea, the upper airway.

    06:21 So there has been an abnormal swallow initiation.

    06:26 Manometry will also evaluate the pressures from the oropharynx, from the mouth all the way into the upper esophageal sphincter to make sure that everything is moving in a normal, contractile wave, and at the same time, we're getting relaxation of the upper esophageal sphincter.

    06:43 You can also do fiber optic endoscopy and actually visualize directly what's going on in the swallow mechanism.

    06:51 You can also do fiber optic endoscopy and actually visualize directly what's going on in the swallow mechanism.

    06:52 So how do we manage this? And most of what we're going to do are relatively simple, practical things.

    06:57 So instead of having the patients ingest pure liquid, we'll thicken it and in most cases, that will allow the swallow such as it is, to send things in the right direction rather than into the trachea.

    07:12 Smaller bites of food, again, very practical, very simple.

    07:15 Alternating solids and liquids while eating so that you're not having all liquid at any one time.

    07:22 You can actually have the patient do physical therapy and do specific motor exercises to improve the tone of the swallowing musculature.

    07:32 And then, clearly, sitting upright while eating will also minimize the chance of having aspiration which is gonna be one of the major downsides of having this upper dysphagia.

    07:47 In addition, so we have all the things that we try to do, the simple interventions.

    07:52 And then, if the patient still has intractable aspiration or has intractable swallowing initiation problems, so the oropharyngeal swallow is just not working, we'll put in a PEG tube, so a percutaneous endoscopic gastrostomy tube and give them their food that way.

    08:14 Briefly, we're gonna talk about esophageal dysphagia. So that's the other flavor.

    08:20 You have the oropharyngeal dysphagia, now, esophageal dysphagia.

    08:24 And we're only gonna talk about that briefly because we will spend an entire talk later on in this series talking specifically about the esophagus not moving the way it's supposed to go.

    08:37 So we can have primary dysmotility of the esophagus, things like achalasia where it just doesn't move at all.

    08:42 You can have scleroderma where the tube of the esophagus becomes a thick, fibrous scarred wall.

    08:49 We can have other inflammatory processes that limit or alter the normal esophageal peristaltic wave.

    08:56 You can have actual strictures or webs which are just bits of tissue that cut across the lumen of the esophagus and limit the movement.

    09:05 We can have diverticula, so out pouchings, even formally, tears. You can have reflux disease.

    09:12 So we can have gastroesophageal content, gastric contents with acid and all the nastiness sits in the stomach, reflux up into the lower esophageal area and that will cause inflammation which will limit esophageal movement.

    09:27 And then, frank malignancy. So actual tumor that can constrict or otherwise, limit the movement of a bolus of food down the esophagus.

    09:37 As I say, we will return to each of these in some detail in other talks.

    09:42 So for now, just understand there's oropharyngeal dysphagia and esophageal dysphagia and we've talked mostly about the former and I hope that you've enjoyed this part of the GI tract and things that are hard to swallow.

    About the Lecture

    The lecture Dysphagia by Richard Mitchell, MD, PhD is from the course Disorders of the Esophagus.

    Included Quiz Questions

    1. Difficulty swallowing
    2. LES dysfunction
    3. Regurgitation
    4. Decreased secretions
    5. Increased secretions
    1. Dysphagia that arises after the swallow
    2. Dysphagia that arises before the swallow
    3. Dysphagia that lasts for five minutes after the swallow
    4. Dysphagia that lasts for ten minutes after the swallow
    5. Anticipatory dysphagia
    1. Eating slowly
    2. Decreased salivation
    3. Inflammation
    4. Neurologic abnormality
    5. Muscular abnormality
    1. Video fluoroscopy with modified barium swallow
    2. Ultrasound
    3. CBC
    4. Fine needle aspiration
    5. Excisional biopsy
    1. Pressure and constriction of muscles in the esophagus
    2. Food movement within the esophagus
    3. Flow of liquid within the stomach
    4. Flow of liquid within the esophagus
    5. Transit time of fluid from the oral cavity to the duodenum

    Author of lecture Dysphagia

     Richard Mitchell, MD, PhD

    Richard Mitchell, MD, PhD

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