TITLE: DYSPHAGIA AND
SOURCE: UTMB Department of Otolaryngology Grand Rounds
DATE: March 16, 1997
RESIDENT PHYSICIAN: Gregory Young, M.D.
FACULTY PHYSICIAN: Brian Driscoll, M.D.
SERIES EDITOR: Francis B. Quinn, Jr., M.D.
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should not be used for purposes of diagnosis or treatment without consulting appropriate
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The diagnosis of the cause of dysphagia relies heavily on an accurate
history and physical examination. Endoscopy and biopsies, as well as
radiographic examinations are confirmatory. Functional alterations
in swallowing may be evaluated with modified barium swallow or
pharyngeal manometry with fluoroscopy. Treatment is directed towards
the etiology of the dysphagia. Treatment is also directed towards
compensation for the alteration in swallowing, especially if the
etiology is unknown or the effect is irreversible.
PHYSIOLOGY OF SWALLOWING:
Normal swallowing is divided into four stages, the oral preparatory
stage, the oral stage, the pharyngeal stage, and the esophageal
stage. The first 2 stages are mechanical and under voluntary
control. The last 2 stages are reflexive.
Oral Preparatory Stage:
The oral preparatory stage is essentially chewing. It involves the
coordination of lip, buccal, jaw, tongue, and soft palate movements
in order to prepare food for swallowing. At the end of this phase,
the tongue pulls the food into a bolus, and holds it against the hard
palate. The most important neuromuscular function in this phase is
the lateral rolling motion of the tongue, as those without normal
tongue mobility have great difficulty chewing.
The oral stage is the second stage of swallowing. It lasts about 1
second, and does not vary with age, sex, or consistency of the bolus.
It moves food from the front of the oral cavity to the anterior
faucial arches. Again, tongue movement is the most important aspect
of this phase of swallowing, since it shapes, lifts, and squeezes the
bolus upward and backward along the hard palate.
The pharyngeal stage begins when the bolus reaches the anterior
faucial arches. Here, the bolus triggers the swallowing reflex which
occurs via the glossopharyngeal nerve. The swallowing reflex may
also be triggered by the superior laryngeal nerve at the laryngeal
inlet. When a swallow reflex occurs late by this second mechanism,
the patient is said to have a delayed swallowing reflex. While the
first two phases of swallowing can be bypassed by using liquid feeds
and syringing the bolus to the back of the mouth or extending the
head, the reflexive stage of swallowing cannot be bypassed. The
swallowing reflex is mediated in the reticular formation of the
brainstem, adjacent to the respiratory center. It is modulated by
input from the respiratory center, and cortical areas. The
pharyngeal stage lasts a maximum of 1 second and does not vary with
food consistency, age or sex.
Swallowing Reflex (Pharyngeal Stage):
When triggered, the swallowing reflex results in four neuromuscular
functions, which occur in rapid sequence in the following order:
1) Velopharyngeal closure (to prevent nasopharyngeal reflux)
2) Pharyngeal peristalsis (to propel the bolus into the pharynx)
Pharyngeal peristalsis occurs in a sequential fashion, from superior
to inferior constrictor. It functions to clear material from the
pharyngeal recesses. Vallecular or pyriform sinus pooling on
modified barium swallow is an indication of reduced pharyngeal
3) Elevation and closure of the larynx (for airway protection
Laryngeal elevation occurs by contraction of the strap muscles, which
positions the larynx anterosuperiorly (under the tongue base).
Laryngeal closure occurs at three sphincters:
1) the epiglottis and aryepiglottic folds,
2) the false vocal folds, and
3) the true vocal folds.
(Epiglottic closure is probably of relatively minor importance.
Closure actually begins at the glottic level, followed soon after by
closure of the false cords and epiglottis. Airway protection is the
most important aspect of swallowing.)
4) Pharyngoesophageal segment opening(to allow the bolus to pass into
Pharyngoesophageal segment opening depends on:
1) relaxation of the cricopharyngeus,
2) the upward, anterior pull of the larynx(probably most important),
3) the bolus pressure. After the bolus passes through the PE
segment, this sphincter immediately closes to prevent reflux.
The fourth and final stage of swallowing is the esophageal stage. It
is more variable and prolonged than the other phases of swallowing,
lasting from between 8 and 20 seconds. Esophageal transit time
significantly increases with age.
DIAGNOSIS OF DYSPHAGIA:
Initially, it is important to determine whether dysphagia(difficulty
with swallowing) or odynophagia (painful swallowing) is the chief
complaint. If odynophagia is the chief complaint, the location,
timing, and duration of the pain, as well as any associated ear pain,
change in pain with swallowing, weight loss, change in voice, or
bloody sputum should be documented. If dysphagia is present, then
the duration and timing of the dysphagia should be sought. In
addition, dysphagia for solids vs. liquids is important.
A complete head and neck examination should be performed. Especially
important are a mirror and fiberoptic examination of the tongue base
and hypopharynx, and careful palpation of the neck, oral cavity and
tongue base. A cranial nerve examination, especially of CN IX, X,
XI, and XII is essential. The patient should also be observed
chewing and swallowing, with special attention paid to the degree of
oral control, mastication ability, and the presence or absence of
coughing. Aspiration is the entry of material into the airway below
the true vocal cords. It is important because it may lead to acute
and chronic pulmonary complications. However, the timing of
aspiration in relation to swallowing can help elucidate the cause of
the swallowing disorder. For example, aspiration that occurs prior
to the reflexive swallow is due to either reduced tongue control or a
delayed or absent swallow reflex. Aspiration during swallowing is
due to inadequate airway closure. Aspiration after swallowing occurs
because of retained pharyngeal residue, due to reduced laryngeal
elevation, reduced pharyngeal peristalsis, unilateral pharyngeal
paralysis, or pharyngoesophageal dysfunction.
Barium swallow is commonly ordered to evaluate a patientís complaint
of dysphagia. Structural abnormalities such as webs, stenoses,
diverticuli, and cancer may be found. However, functional
abnormalities are more difficult to evaluate with this study.
Direct Laryngoscopy and Esophagoscopy:
Direct laryngoscopy and esophagoscopy should be performed when
malignancy is suspected, or the diagnosis is unclear.
Modified Barium Swallow:
The modified barium swallow is a radiographic videofluoroscopic
technique that is used to evaluate the oral and pharyngeal stages of
swallowing. It is the method of choice to evaluate suspected
aspiration, and is helpful is diagnosing functional deficits such as
those caused by neurologic disorders. The swallowing mechanism with
both small and large boluses, and both liquids and solids can be
evaluated. From information obtained through the modified barium
swallow, the etiology of the swallowing dysfunction can often be
found. In addition, recommendations can be made regarding
compensatory maneuvers to facilitate swallowing without aspiration.
These compensatory maneuvers can then be tested during the modified
barium swallow to rule out silent aspiration(i.e. aspiration without
associated cough). The modified barium swallow also provides
radiographic support when procedures such as vocal cord medialization
or cricopharyngeal myotomy may be indicated.
Manometry is useful in evaluating disorders of esophageal motility.
Water infusion manometers are sometimes used to evaluate esophageal
motility. The following disorders are associated with specific
manometric findings: Achalasia- Absent peristalsis, increased LES
pressure, incomplete LES relaxation Diffuse Esophageal Spasm-
Simulataneous contractions, Intermittent normal peristalsis
Nutcracker esophagus- Increased amplitude of peristalsis Hypertensive
LES- Elevated LES pressure, normal LES relaxation
Pharyngeal function involves rapid changes in pressure and motion,
and so requires simultaneous fluoroscopy and solid state manometry,
or manofluorography. Pressure, anatomic events, and bolus transit
are simultaneously recorded in manofluorography. During swallowing,
pharyngeal pressures are generated by the tongue, palate, larynx, and
the pharyngeal walls. Manofluorography can quantitate the pressure
applied to the bolus from each of these structures. Therefore, the
structure(s) responsible for the swallowing dysfunction may be
identified. Determination of intrabolus forces is the most sensitive
method for determining pharyngeal dysfunction. The mechanism of
pressure generation during swallowing has been described as a two
pump system, the oropharyngeal propulsion pump and the hypopharyngeal
suction pump. The tongue and upper pharynx form the oropharyngeal
propulsion pump, with the tongue being the piston, and the pharynx
being the chamber. Any pathology that affects mobility or control of
the tongue or pharyngeal wall may compromise the oropharyngeal
propulsion pump. It is also affected by changes in the
pharyngo-esophageal sphincter. An increased oropharyngeal pump
pressure is measured when the PE sphincter is obstructed. The
oropharyngeal propulsion pump is best measured in the pharynx just
superior to the arytenoids.
The hypopharyngeal suction pump is formed by the larynx and
hypopharynx. Laryngeal elevation combined with inferior constrictor
relaxation results in a negative pressure exerted on the bolus. The
following disorders are associated with changes in the oropharyngeal
propulsion and/or hypopharyngeal suction pumps.
Manofluorography has been used to study the abnormal swallowing
characteristics of several disorders that cause dysphagia. Examples
include Wallenburg's syndrome, dermatomyositis, Guillian-Barre,
oculopharyngeal muscular dystrophy, and irradiation fibrosis.
Wallenberg's syndrome (lateral medullary syndrome) is due to
thrombosis of the posteroinferior cerebellar artery which results in
ischemia of the lateral medullary region of the brain stem. In
addition to vertigo, nystagmus, nausea, vomiting, Horner's syndrome,
dysphonia, ataxia, falling to the side of the lesion, and loss of
pain and temperature sensation to the ipsilateral head and
contralateral body, this syndrome also leads to dysphagia. It is the
most common brain stem vascular disorder. Ipsilateral palate
paralysis occurs. It differs from many other types of dysphagia in
that the tongue driving force and oropharyngeal propulsion pump force
are greatly increased, compared to normal values. This is in part
due to the failure of pharyngoesophageal sphincter opening during
swallowing. The hypopharyngeal suction pump is decreased, and the
pharyngeal transit time is mildly increased. There is some bolus
residue after swallowing. Aspiration is not a problem.
Dermatomyositis causes dysphagia that is similar to Wallenberg's
syndrome. In contrast, those with Guillian-Barre, oculopharyngeal
muscular dystrophy, and irradiation fibrosis have very low tongue
driving force and oropharyngeal propulsion pump, greatly prolonged
pharyngeal transit time, mild(Oculopharyngeal muscular dystrophy) to
severe(irradiation fibrosis) aspiration, and high bolus residue.
Patients with deficits of the oral or pharyngeal phases of swallowing
may benefit from swallowing therapy. This may include strengthening
and coordination exercises, or compensatory maneuvers to aid in
swallowing. The supraglottic swallow, Mendelsohn maneuver, and neck
turning with swallowing are examples of compensatory maneuvers. The
supraglottic swallow involves voluntarily holding the breath at the
height of inspiration before and during swallowing, thereby closing
the vocal fords before and during the swallow. The patient coughs
after the swallow to clear any residual food from the larynx. The
Mendelsohn maneuver is performed by voluntarily elevating the larynx
during the swallow, which tucks the laryngeal inlet anteriorly and
opens the PE segments, thereby facilitating the swallow. Patients
with unilateral pharyngeal paralysis can turn their head towards the
paralyzed side, which diverts the bolus down the functioning side of
If possible, treatment for dysphagia should be directed towards the
etiology of the symptom. Dysphagia secondary to thyroid disease,
myasthenia gravis, and Parkinson's disease are potentially treatable.
Gastroesophageal reflux, the most common medically treated cause of
dysphagia, is treated with H2 blockers and GERD precautions.
Esophageal motility disorders causing chest pain are the second most
commonly medically treated cause of dysphagia, and these are often
treated with nitrates or calcium channel blockers.
Surgical treatment for dysphagia includes dilation and
cricopharyngeal myotomy. Strictures, webs, Schatzki's rings, and
achalasia are often treated with dilation. Dilation is the most
common procedure performed for dysphagia. Cricopharyngeal myotomy is
the second most common procedure performed for dysphagia. This
procedure involves cutting the lower half of the inferior
constrictor, the cricopharyngeus, and the circular muscles of the
upper cervical esophagus.
The indications for cricopharyngeal myotomy are controversial. This
is in part due to the finding that pharyngoesophageal (PE) segment
opening depends on both relaxation of the PE segment and elevation of
the larynx. These two functions cana be evaluated separately with
manofluorography. Cricopharyngeal myotomy would likely improve only
those disorders with PE segment relaxation problems. For this reason,
current recommendations are that cricopharyngeal myotomy should be
considered for disorders in which there is incomplete PE segment
relaxation(pressure greater than 0mm Hg) or abnormal muscular
contractions during the relaxation period. In practice, however, is
manofluorography is not yet widely available and so the exact
anatomic cause of dysphagia may be difficult to elucidate.
Lower esophageal sphincter incompetence with reflux is a
contraindication to cricopharyngeal myotomy, because this procedure
may lead to worsening reflux with significant aspiration.
Treatment of dysphagia must include treatment of any significant
aspiration. If Oral feeding should be suspended is aspiration is
significant, and a feeding tube should be placed. If NPO status is
predicted to be required more than 2 months, a percutaneous or open
gastrostomy tube should be considered. A feeding tube and/or
gastrostomy tube are also employed if oral nutrition cannot be
Aspiration may require surgical management if chronic in duration and
unresponsive to swallowing therapy. Surgery can sometimes completely
correct aspiration. Examples are aspiration due to a paralyzed
abducted vocal cord, and aspiration due to Zenker's diverticulum. A
paralyzed abducted vocal cord can be corrected with Teflon injection
or surgical medialization.
In patients with unremitting chronic aspiration, a tracheostomy may
be indicated. However, tracheostomy does not prevent aspiration, and
may actually increase it. If patients with this severe form of
aspiration desire to resume oral feeding, some type of laryngeal
closure procedure may be required. These include supraglottic or
glottic closure, laryngeal stints, cricoid resection, laryngoplasty,
laryngotracheal diversion, or laryngectomy. None of the procedures
is appropriate in all cases of refractory aspiration, and treatment
must be individualized.
A Zenker's diverticulum is a pulsion diverticulum through Killian's
triangle that occurs primarily in middle and older age. 40% of these
patients also have a hiatal hernia, compared to 15% of the general
population. Complaints and symptoms range from dysphagia, weight
loss, and coughing in the supine position, to severe aspiration with
recurrent pneumonia. Regurgitation of undigested food boluses,
rather than liquid, should raise suspicion of Zenker's diverticulum.
A positive Quinn's sign is virtually diagnostic of Zenker's
diverticulum. This is the regurgitation of food into the mouth upon
external decompression of the pouch (by pressing the left side of neck
near the cricoid cartilage). A barium swallow is the gold standard
for diagnosis, because it shows the size and location of the
diverticulum, and may document aspiration. In addition, other
esophageal pathology may be identified. Treatment
Controversy exists concerning the removal of asymptomatic Zenker's
diverticuli. Due to the potential for complications from this or any
surgical procedure, some authors prefer in many cases to wait for
symptoms to develop. Others site potentially silent aspiration as a
reason to proceed with surgery for even asymptomatic diverticuli.
Surgical treatment options for Zenker's diverticuli include
endoscopic procedures, diverticulopexy, imbrication,
diverticulectomy. Each of these procedures should be performed in
conjunction with cricopharyngeal myotomy, in order to prevent
recurrence. Endoscopic diverticulectomy involves transecting the
party wall between the esophagus and the diverticulum and sectioning
of the cricopharyngeal muscle. With this procedure, hospitalization
is decreased and the risk of mediastinitis is reduced. However,
specialized equipment is required, and cannot be performed on small
or oblique pouches. In elderly or debilitated patients, a
diverticulopexy and cricopharyngeal myotomy may be indicated. With
this procedure, patients may be fed sooner, hospital stay is shorter
than with diverticulectomy, and there is no risk of salivary leak
from the resected sac neck.
In this procedure, a esophageal bougie is placed, then the external
cricopharyngeal myotomy is made, including division of fibers from
the distal inferior constrictor, cervical esophageal fibers, and
cricopharyngeus. (Note that with the endoscopic technique, only the
cricopharyngeus is divided.) This sectioning is performed posterior
to the cricothyroid joint in order to avoid injury to the recurrent
laryngeal nerve. The apex of the sac is then suspended to the
prevertebral fascia with 3-0 silk ties.
For small pouches, imbrication along with cricopharyngeal myotomy has
been successful. With imbrication, the mucosa is not violated, so
there is minimal risk of salivary leak. Larger pouches cannot be
imbricated due to problems with esophageal obstruction.
Diverticulectomy is usually performed in conjunction with
cricopharyngeal myotomy, and the surgical approach is the same. An
esophagoscopy and laryngoscopy are performed first, and the
diverticulum is identified either posteriorly or left
posterolaterally in most cases. The pouch is examined to rule out
coincidental carcinoma, and then is packed with 1 inch plain gauze.
Packing the pouch facilitates its identification and dissection
within the neck. A #40 bougie is inserted into the esophagus to
prevent overly aggressive resection of the pouch, which can lead to
stenosis. In addition, it provides a stable structure to facilitate
performing the myotomy without inadvertent entry in the lumen.
Dissection should occur along the posterior aspect of the cricoid, in
order to minimize risk of recurrent laryngeal nerve injury. The wound
is closed in 2 layers, either with suture, or with suture and
staples. Closures are tested by filling the mouth and pharynx with
saline. A #12 soft Silastic feeding tube is then placed under direct
visualization. A penrose drain is placed in the neck wound, and oral
feeds are not started for 5 days. Complications include
mediastinitis, pharyngocutaneous fistula, stricture, and recurrent
laryngeal nerve injury.
Regardless of the type of surgical treatment chosen for Zenker's
diverticulum, cricopharyngeal myotomy is the key to prevent
recurrence. Smaller diverticuli have been treated successfully with
cricopharyngeal myotomy alone.
Discussion by Dr. Faculty (Dr. Driscoll):
Dr. Driscoll pointed out that a great deal can be learned about the
patient's swallowing difficulty during the physical examination.
Function of cranial nerves VII, IX, and XII influences the oral
phase of swallowing. Inserting the examining finger into the mouth
and having the patient press his tongue against the hard palate gives
one an appreciation of any lingual muscular weakness. Asking the
patient to say repeatedly the phrase, "putaka putaka putaka...."
allows an estimate of fine motor coordination mediated by the VIIn
and XIIn. Mirror examination will reveal puddling of secretions in
the valleculae and/or pyriform sinuses, as well as vocal cord
(Ed. note: "Quinn's sign" referred to here is actually "Quinn's sign
(1)" wherein as the patient protrudes his tongue for mirror
laryngoscopy, a bubble of air escapes the diverticulum into the
hypopharynx producing a characteristic mini-belch. This can be
elicited as well by manipulating the larynx and upper trachea with
the examiner's hand while the patient breathes through his mouth.
"Quinn's sign(2)" is "burpotoalgia," a sudden sharp pain the the ear
upon belching or burping, characteristic of the initial stage of
bullous myringitis. It is sometimes seen in fungal external otitis
in which myringitis may figure prominently.)
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