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.