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Oropharyngeal types: A inability or excessive delay in initiation of pharyngeal swallow. B aspiration of ingestate. C nasopharyngeal regurgitation. D post swallow residue in pharynx. Neuromuscular
CVA PD O L I O SLE Polymyositis Botulism Tabes Rabies Meningitis/Viral suspicious if: a)more than 30 minutes to eat meal b)Only eats half meal c)Cough during swallowing (RR4 aspiration-74%) d)Regurgitation through nose e)Difficulty chewing/facial weakness Stroke: dysphagia-bad prognostic sign 30% present in acute stroke (due to tongue and pharynx problems) majority recover in 4 weeks Parkinson's: more than 50% dysphagia-usually late If early suggests alternative diagnosis Oropharyngeal plus oesophageal dysmotility No improvement with levodopa Drooling correlated with severity-gets better with chewing gum Mechanical Upper oesophageal sphincter disorder 1 Zenker's diverticulum 2 Crycopharyngeal bars 3 Primary crycopharyngeal dysfunction (=crycopharyngeal achalasia) Intrinsic compression 1 Rings -A ring (2cm proximal to OGJ) -B ring-Schatzki -C ring-diaphragmatic indentation of oesophagus 2 Webs-post crycoid (Patterson - Brown - Kelly) 3 Diverticula (Zenker's/traction/epiphrenic) 4 Benign stricture/malignant stricture Extrinsic compression thyromegaly/cervical spine hyperostosis/adenopathy
Tests Systemic problem ? Yes Videofluoroscopy To assess a) need for non oral feed b)Need for crycopharyngeal myotomy c)D iet modification/swallow treatment Video fluoroscopy-aspiration of 10% of bolus not associated with complications Also-single point assessment No Nasendoscopy Plus barium swallow For structural lesions
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Evagination of the sphincter is thought to result from chronic increased pressure on the weakened area, which may be due to two causes.: High intrabolus pressures during swallowing is implicated. Resistance to swallowing due to abnormalities of the UES is also a possible cause. Written by Dr Sebastian Zeki
Zenker’s Pathogenesis Zenker's diverticula and epiphrenic diverticula are probably due to motor abnormalities of the esophagus. Zenker's diverticula emerge from a defect in the muscular wall of the hypopharynx in a natural area of weakness known as "Killian's hiatus," which is formed by the oblique fibers of the inferior pharyngeal constrictor muscle and the cricopharyngeal sphincter. MD MND MG (most likely to present as aspiration) Globus sensation Persistent or intermittent nonpainful sensation of a lump or foreign body in the throat without dysphagia or organic problem. F>M if <50 M=F if >50 Causes: Upper esophageal sphincter —Function of this implicated but the juries out. Psychologic abnormalities — Not all patients with globus have psychologic or psychiatric abnormalities. Stress — Not proven Treatment Psychiatric referral is unlikely to cure the problem but consultation may help cope. PPI helps in 30% Pharmacologic therapy for depression may be useful Clinical Manifestations of Zenker’s Diverticulum It usually occurs in male adults, above the age of 60 (often above age 75). Symptoms range from weeks to years. Transient dysphagia may be noted early in the course if food is preferentially diverted into the diverticulum. Patients can also get pharyngeal pouch type symptoms. Diagnosis in made with with barium examinations. The classification of esophageal diverticula depends upon their location. They predominantly occur in three areas: Immediately above the upper esophageal sphincter (UES) (Zenker's diverticulum) Near the midpoint of the esophagus (traction diverticulum) Immediately above the lower esophageal sphincter (epiphrenic diverticulum) Zenker's diverticulum It is an outpouching of the mucosa through Killian's triangle, an area of muscular weakness between the transverse fibers of the cricopharyngeus and the oblique fibers of the lower inferior constrictor. The incidence has been estimated at 2 per 100,000 per year in the UK. Zenker's diverticulum is defined as a posterior diverticulum, which has a neck proximal to the cricopharyngeal muscle. D Y S P H A G I A Treatment of Zenker’s Diverticulum is usually done by ENT. There are four methods of surgical correction of a ZD. A 2-stage operation involving mobilization of the ZD with a later excision stage when granulation tissue has formed around the ZD. Excision of the ZD in one step is an option. Cricopharyngeal myotomy can be done, leaving the ZD undisturbed. Cricopharyngeal myotomy with diverticulectomy or diverticulopexy is another option. One stage cricopharyngeal myotomy and diverticulectomy has been the preferred approach in patients who are good surgical candidates.
