«Einschluckstörungen»

Transcription

1 18. Fortbildungskurs der SGG Brunnen «Einschluckstörungen» Troubles de la déglutition Swallowing disorders Dr Valérie Schweizer Unité de Phoniatrie Service ORL et chirurgie cervicofaciale CHUV Lausanne

2 Dysphagia Difficulty to swallow; real or subjective impression that liquids or solids are not swallowed properly Logemann Jerilyn. Evaluation and treatment of swallowing disorders. Pro-Ed Austin (Texas),

3 Dysphagia basic questions Location Progressive or intermittent Duration of symptoms Types of food and/or liquids Weight

4 Dysphagia semiological classification (signs and symptoms) Painful swallowing (= odynophagia) solid & liquid Mechanical Paralytic (neurogen) food stuck in mouth or throat (solid, then solid & liquid) aspiration, choking, food stuck in mouth or throat (liquid, then solid & liquid) Pseudo-dysphagia (psychogenic) : saliva, solid, liquid, 4

5 Painfull swallowing gingivitis epiglottitis tonsillitis pharyngeal tumor 5

6 Oropharyngeal mycosis Painful & mechanical dysphagia May cause aphagia. Debilitated patients, elderly, or after antibiotic and corticosteroid therapy. Often only in the pharyngolarynx. If dental prostheses, clean them thoroughly, then let them to air dry without soaking overnight. 6

7 Mechanical dysphagia Zenker's diverticulum Etiology : crico-pharyngeal hypertonicity Symptoms : hypopharyngeal discomfort foreign body sensation postprandial regurgitation aspiration pneumonia Image from P. Dulguerov, HUG Radiological exam (videofluoroscopy with baryum) 7

8 «Frozen» pharyngolarynx - after chemoradiotherapy; - the movements are limited, slow and incomplete, because of progressive fibrosis and mucosal modifications; - definitive! Mechanical dysphagia

9 Dysphagia semiological classification Painful Mechanical Paralytic (neurogen) Pseudo-dysphagia (psychogenic) WHEN? AT WHAT PHASE OF SWALLOWING? 9

10 The 4 phases of swallowing 1. Oral preparatory phase (phase orale préparatoire) 2. Oral phase «itself» (phase orale «proprement dite») 3. Pharyngeal phase 4. Esophageal phase Woisard Virginie & al. La réhabilitation de la déglutition chez l adulte. Ed. Solal, Marseille,

11 1. Oral preparatory phase - Bolus mixed with saliva - Chewing (teeth, tongue) (V, XII) - Lip closure (VII) - Glosso-velar occlusion (X, XII) THE PLEASURE TO EAT! 2. Oral phase «itself» Passage through the pharyngeal isthmus (between tonsils)(x, XII) Passage of the bolus from the mouth to the pharynx Semi-reflex / apnea 0.5 seconds 11

12 Preparatory oral phase dysfunctions Drooling Abnormal movements of the tongue Buccal or palatal food residue (they stick!) Pharyngeal leaks and choking 12

13 Denture : efficiency of chewing < 30-75% Preparatory oral phase dysfunctions Drooling Facial paralysis Tongue paralysis Abnormal movements of the tongue Buccal or palatal food residue (they stick!) Pharyngeal leaks and choking Amyotrophic lateral sclerosis Lingual dystonia Postraumatic cerebral palsy 13

14 Oral phase «itself» dysfunctions Prolonged chewing, delayed swallow initiation. Choking during chewing. Failure to propulse the bolus towards the pharynx (deficit of movement of the tongue) 14

15 Oral phase «itself» dysfunctions Prolonged chewing, delayed swallow initiation. Choking during chewing. Amyotrophic lateral sclerosis Failure to propulse the bolus towards the pharynx (deficit of movement of the tongue) Parkinson and related disorders : «rolling» of the tongue (festination) 15

16 3. Pharyngeal phase 16 Duration : 0.5 to 0.7 seconds Reflex Velopharyngeal closure Closure and elevation of the larynx Propulsion of the bolus through the pharynx (pharyngeal peristalsis, pharyngeal squeeze) Upper esophageal sphincter opening X, IX

17 Laryngeal closure: 1. glottis 2. ventricular folds 3. epiglottis

18 Upper esophageal sphincter = cricopharyngeal muscle Innervation : nerve X Cricopharyngeal muscle: - contracted and tonic at rest. - relaxation by inhibition of the vagal tone, after the onset of pharyngeal peristaltism; 0.5 to 1 seconds. - opening by elevation and anterior traction of the larynx (stretching of the cricopharyngeal muscle).

19 Pharyngeal phase dysfunctions Nasal reflux of liquid and food Primary and secondary aspirations, choking «Wet» voice after swallowing Cough after swallowing Multiple swallowing pattern Hypopharyngeal food stuck (blockage)

20 Pharyngeal phase dysfunctions Nasal reflux of liquid and food Primary and secondary aspirations, choking «Wet» voice after swallowing Cough after swallowing Multiple swallowing pattern Hypopharyngeal food stuck (blockage) Cerebrovascular accident : % with dysphagia % will die from aspiration in the years following stroke Myasthenia gravis Myopathies: -Inclusion body myositis -Oculopharyngeal muscular dystrophy -Myotonic dystrophy (Steinert) Parkinson and related disorders

21 STASIS Yoghurt (normal) Colored water (before initiation of swallowing) Epiglottic vallecula (Image: Dr D. Robert, CHU Marseille) Wallenberg Syndroma Paralysis of nerve X, right side

22 4. Esophageal phase Transfer of food from the upper esophageal sphincter to the entrance of the stomach (gastric cardia) Esophageal peristalsis (speed : 3 to 5 cm/second) and gravity. Duration : 2 seconds for liquids 7 to 9 seconds for solids 22

23 Esophageal phase dysfunctions Food blockage behind the sternum Pain and spasm during a few seconds (esophageal spasms) Regurgitation of food Significantly delayed aspiration

24 Esophageal phase dysfunctions Food blocades behind the sternum Pain and spasm during a few seconds (esophageal spasms) Regurgitation of food Significantly delayed aspiration Tumors Strictures, stenosis (peptic, after radiotherapy) Scleroderma Eosinophilic esophagitis Achalasia Parkinson and related disorders

25 Supragastric belching Air is rapidly sucked through the upper esophageal sphincter (UES) and immediately expulsed (no swallowing) without ever reaching the stomach. Can be due to a local irritation (reflux). Gradually, becomes a tic, with some psychogenic component. Negative pressure Movement of the diaphragm UES relaxation Exam of choice : Combined high resolution manometry and impedance monitoring, which can detect the specific pattern of supragastric belching. Bredenoord et al. Aerophagia, gastric, and supragastric belching: a study using intraluminal electrical impedance monitoring. Gut. 2004; 53 (11):

26 Conclusion Dysphagia is a common problem, with a prevalence of about 11% (United Kingdom) in the general population, up to 40-70% of patients after stroke, 60-80% with a neurodegenerative disease and more than 50% of institutionalized patients. It needs a multidisciplinary evaluation. Its evaluation step by step, phase by phase allows to precise its etiology and management.

27 Thank you for your attention!