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Dysphagia - Pathophysiology of Swallowing Dysfunction, Symptoms, Diagnosis and Treatment

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ISSN: 2572-4193 Philipsen. J Otolaryngol Rhinol 2019, 5:063 DOI: 10.23937/2572-4193.1510063 Volume 5 | Issue 3 Journal of Open Access Otolaryngology and Rhinology REVIEW ARTICLE Dysphagia - Pathophysiology of Swallowing Dysfunction, Symptoms, Diagnosis and Treatment * Bahareh Bakhshaie Philipsen Check for updates Department of Otorhinolaryngology-Head and Neck Surgery, Odense University Hospital, Denmark *Corresponding author: Dr. Bahareh Bakhshaie Philipsen, Department of Otorhinolaryngology-Head and Neck Surgery, Odense University Hospital, Sdr. Boulevard 29, 5000 Odense C, Denmark, Tel: +45 31329298, Fax: +45 66192615 the vocal folds adduct to prevent aspiration. The esoph- Abstract ageal phase is completely involuntary and consists of Difficulty swallowing is called dysphagia. There is a wide peristaltic waves [2]. range of potential causes of dysphagia. Because there are many reasons why dysphagia can occur, treatment Dysphagia is classified into the following major depends on the underlying cause. Thorough examination types: is important, and implementation of a treatment strategy should be based on evaluation by a multidisciplinary team. 1. Oropharyngeal dysphagia In this article, we will describe the mechanism of swallowing, the pathophysiology of swallowing dysfunction and different 2. Esophageal dysphagia causes of dysphagia, along with signs and symptoms asso- 3. Complex neuromuscular disorders ciated with dysphagia, diagnosis, and potential treatments. 4. Functional dysphagia Keywords Pathophysiology Dysphagia, Deglutition, Deglutition disorders, FEES, Video- fluoroscopy Swallowing is a complex process and many distur- bances in oropharyngeal and esophageal physiology including neurologic deficits, obstruction, fibrosis, struc- Introduction tural damage or congenital and developmental condi- Dysphagia is derived from the Greek phagein, means tions can result in dysphagia. Breathing difficulties can “to eat” [1]. Dysphagia is any disruption in the swallow- sometimes affect the ability to swallow [3]. Some causes ing process during bolus transport from the oral cavity of dysphagia are explained here. to the stomach. The swallowing process is divided into Causes of oral dysphagia four stages: Pre-oral, oral, pharyngeal and esophageal [2]. Various reasons for this type of dysphagia can be [4]: Pre-oral phase is when the food is transferred from • Bad teeth plate to mouth. The oral phase is completely voluntary • Problems with the jaw and involves the entry of food into the oral cavity and • Xerostomia - dry mouth preparation for swallowing. The pharyngeal phase is ini- tiated as the tongue propels the bolus posteriorly and • Tumors - cavum oris cancer, pharyngeal or laryngeal the base of tongue contacts the posterior pharyngeal cancer wall, starting a reflexive action. The soft palate elevates • Masses outside the pharynx, such as osteophytosis to prevent nasal reflux. The pharyngeal constrictor on the vertebrae that press on pharynx musculature contracts to push the bolus through the pharynx. The epiglottis inverts to cover the larynx and • Complication of head or neck surgery Citation: Philipsen BB (2019) Dysphagia - Pathophysiology of Swallowing Dysfunction, Symptoms, Diagnosis and Treatment. J Otolaryngol Rhinol 5:063. doi.org/10.23937/2572-4193.1510063 Accepted: August 19, 2019: Published: August 21, 2019 Copyright: © 2019 Philipsen BB. This is an open-access article distributed under the terms of the Cre- ative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Philipsen. J Otolaryngol Rhinol 2019, 5:063 • Page 1 of 4 • DOI: 10.23937/2572-4193.1510063 ISSN: 2572-4193 • Radiation leading to fibrosis, structural, mechanical, come weak and neurologic deficits • Dementia • Stroke or some neurological disease like Parkinson’s • Brain tumor disease, multiple sclerosis or ALS • Scleroderma - a rheumatic disease leading to a Functional dysphagia thickening, fibrosis and scarring of tissue Functional dysphagia, defined in some patients as having no organic cause for dysphagia that can be found. • Immune system diseases such as polymyositis There are several different causes to functional dysphagia • Cricopharyngeal dysfunction- can result in material [7]: remaining in posterior pharynx with risk of aspiration • Post traumatic syndrome stress disorder of material into the airway after the swallow • Stress attack • Age-related changes in swallow function • Anxiety Causes of esophageal dysphagia • Different psychosocial disorders Diseases that can cause esophageal dysphagia can be grouped into different categories. Diseases that narrow Symptoms the esophageal lumen through inflammation, fibrosis, Signs and symptoms associated with dysphagia may or tumors, diseases that compromise the esophageal include: lumen, and diseases that disrupt esophageal peristalsis and/or lower esophageal sphincter function by their • Salvia, food, liquid, or pills are sticking in the throat effects on esophageal smooth muscle [5]: • Coughing or choking food or liquid • Gastroesophageal reflux disease • Sensing of a “lump” in the throat • Esophagitis-can be caused by different problems, • Having the sensation of food getting stuck behind such as infections sternum • Eosinophilic esophagitis • Wet voice • Esophageal spasm • Bringing food back up (regurgitation) • Achalasia-muscles in the esophagus lose their ability • Having food or stomach acid back up into the throat to relax and open • Unexpected weight loss • Diverticula • Pain • Tumors in the esophagus • Developing aspirations pneumonia • Masses outside the esophagus, such as tumors and osteophytosis on the vertebrae Diagnosis • Radiotherapy treatment that causes stricture, fibro- When the dysphagia is frequent, and the cause is not sis and stenosis clear, a comprehensive evaluation of dysphagia should • Scleroderma-a rare condition that causes stiffening include several medical disciplines including ENT doc- of the esophagus muscle tors, gastroenterologist, occupational therapist, speech pathologist and dietitian. An examination begins with a • Immune system diseases such as polymyositis clinical examination that includes a detailed history of • Age-related changes subjective complaints and medical status. The ENT spe- cialist will examine the mouth and throat and with flex- Causes of dysphagia in patient with complex neu- ible laryngoscope through the nose examine the throat romuscular disorder in greater detail [8]. Damage to the neuromuscular system can interfere Several instrumental assessments of swallowing ex- with the nerves responsible for starting and controlling ist to provide objective information about swallowing swallowing. Some neurological causes of dysphagia function and safety. The most widely used procedure include [6]: is a videofluoroscopic assessment of swallowing (Figure • Stroke 1) and fiber-optic endoscopic evaluation of swallowing (FEES) (Figure 2). Videofluoroscopy describes X-rays re- • Neurological conditions that cause damage to the cords and shows how food and liquids move down, and brain and nervous system, including Parkinson’s dis- helps to evaluate the entire swallowing process, the ease, multiple sclerosis, motor neuron disease anatomy changes and dynamics of the swallow, identify • Myasthenia gravis-that causes the muscles to be- the etiology of residue, penetration and aspiration, and Philipsen. J Otolaryngol Rhinol 2019, 5:063 • Page 2 of 4 • DOI: 10.23937/2572-4193.1510063 ISSN: 2572-4193 Figure 1: Videofluoroscopic assessment of swallowing. assess the benefit of treatment strategies during the study. FEES consist of passing a thin, flexible endoscope into the pharynx and observing the act of swallowing. It provides excellent visualization of anatomical changes Figure 2: Fiber-optic endoscopic evaluation of swallowing (FEES). and identifies the etiology of residue, penetration and aspiration. Videofluoroscopy and FEES is thought to be the “gold standard” for assessment of in oropharyngeal in pharynx, larynx and esophagus are often treated with dysphagia [8]. antibiotic medicines. Botox injection of cricopharyngeus muscle and esophagus is used to treat dysphagia in pa- Esophagoscopy is used to look at the esophagus and tients with underlying muscle spasm and hypertonicity ventricle. Manometry evaluates pressure created by [15,16]. the throat and esophagus muscles. The pH monitoring is used to see how often acid from the stomach gets Complications of Dysphagia into the esophagus and how long it stays there. In The most common complications of dysphagia are some patients medical imaging modalities, for example pulmonary complications, dehydration and malnutri- ultrasound, computed tomography scanners, magnetic tion. Other possible complications, such as social isola- resonance imaging or proton emission tomography are tion, mental and emotional health issues or intellectual necessary [9]. and body development deficit in children with dyspha- Treatment gia, have not been studied thoroughly. The main pul- Treatment usually depends on the cause and type of monary complications are aspiration pneumonia, toxic dysphagia. Many cases of dysphagia can be improved aspiration syndromes and pulmonary fibrosis [17]. with careful management, but a cure is not always pos- Summary sible [10,11]. Successful management requires multidis- ciplinary collaboration, accurate diagnostic workup and Dysphagia is the medical term for the symptom of effective therapeutic
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