Malady Wise

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Dysphagia

Maladywise

Summary of the lecture from Dr. Ryan Winters via HMRI ENT update 2023

Dysphagia

Pathology can be anywhere from lips to stomach

  • A sensation of sticking in the throat/neck/chest

  • Prolonged swallowing sensation

  • Inability to swallow

Present in 20% of the population and >60% of nursing home residents

Swallowing

  • Swallowing centre in the medulla, floor of 4th ventricle

  • Connected to emetic and respiratory centres in the brainstem

  • Swallowing is both voluntary and involuntary

  • Swallos 600 times per day

  • Oropharyngeal phase (voluntary)

  • Oesophageal (involuntary)

Categories

  • Neurological

  • Structural

History

  • Differentiate neurological versus structural

  • Oral/pharyngeal versus oesophageal

  • Onset

    • Duration

    • Sudden versus gradual

    • Progressive versus intermittent

  • Triggers

    • Solids versus liquids

    • Specific foods

    • Inciting event (Stroke, illness)

  • Lifestyle

    • Weight loss = red flag

    • Needing to chew food more

    • Taking longer to eat a meal

    • Drooling or dry mouth

  • Associated

    • Coughing or choking

    • Regurgitaiton

    • Heartburn

    • Change of voice

    • Odynophagia = Bad

    • Otalgia = Bad

    • Neck mass = Bad

PMHx

  • GORD

  • Neurological disease

  • Diabetes

  • XRT, CTx

  • Neck surgery

  • Immunosuppressants

  • Smoking and alcohol = cancer

Exam:

  • Oral cavity

  • Asymmetry is more worrying

  • Neck exam

    • Neck mass

    • Lymphadenopathy

Risk of cancer

  • Isolated dysphagia rarely HN cancer but can be oesophageal cancer

    • Dysphagia + worsening dysphonia, palpable neck mass = Bad

Risk

  • HN cancer = 1% of all

  • Oesophageal = 2% of all

  • HaNC-RC risk calculator

Dysphagia with risk factors

One study of rapid access dysphagia clinic

  • 40% GORD

  • 10% Stricture

  • 11% Oesophageal malignancy

  • 10% dysmotility

  • 0% HN Cancer

Triage

  • Dysphagia only = Gastro and MBBS

  • Dysphagia and other complaints = ENT and MBSS

Barium Swallow

  • MBSS = Modified Barium Swallow Study

  • Water soluble contrast sufficient as barium shortage

Management

Normal MBSS

  • Reassure

  • Manage GORD

  • SP

Abnormal MBSS

  • Pharyngeal pouch = ENT referral

  • All other pathology = Gastro referral

    • Cricophrayngeal dysfun, stricture, etc

References: