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Home , Dysphagia, Esophageal dysphagia, Oropharyngeal dysphagia, Xerostomia

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 - Pathophysiology of Dysfunction, Symptoms, Diagnosis and Treatment

* Bahareh Bakhshaie Philipsen Check for updates Department of Otorhinolaryngology-Head and 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 awide 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. In this article, we will describe the mechanism of swallowing, the pathophysiology of swallowing dysfunction and different 2. causes of dysphagia, along with 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 . 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 . The oral phase is completely voluntary • Problems with the jaw and involves the entry of food into the oral cavity and • - dry mouth preparation for swallowing. The pharyngeal phase is ini- tiated as the propels the bolus posteriorly and • Tumors - cavum oris , pharyngeal or laryngeal the base of tongue contacts the posterior pharyngeal cancer wall, starting a reflexive action. The soft palate elevates • Masses outside the , 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 and • 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 • • or some neurological like Parkinson’s • Brain tumor disease, or ALS • - 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 such as 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 • 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 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 • -can be caused by different problems, • Having the sensation of food getting stuck behind such as infections sternum • • Wet voice • • Bringing food back up (regurgitation) • Achalasia-muscles in the lose their ability • Having food or stomach acid back up into the throat to relax and open • Unexpected weight loss • Diverticula • • Tumors in the esophagus • Developing aspirations • 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 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, anatomy changes and dynamics of the swallow, identify • -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, 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 , 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 strategies. Treatments for dyspha- difficulty in swallowing. It is a common symptom in a gia include occupational therapist or speech and lan- wide group of patients. Patients with untreated dyspha- guage therapy to learn new swallowing techniques, us- gia are at high risk of aspiration and . Thor- ing texture modified foods and thickened fluids, chang- ough examination is important, and successful manage- ing the consistency of food and liquids to make them ment requires multidisciplinary collaboration, accurate safer to swallow and in sometimes other forms of feed- diagnostic workup and effective therapeutic strategies. ing – such as tube feeding through the nose or stomach Treatment usually depends on the cause and type of [10,12]. Treatment to rehabilitate swallowing function dysphagia. Many cases of dysphagia can be improved and compensation techniques are common pathways with careful management, but a cure is not always pos- for managing some cases of dysphagia [10,11]. Surgery sible. is used in patients who have some changes (such as a Funding tumor or diverticula) blocking the pharynx or esophagus or patients who have a problem that affects the lower No funding to declare. esophageal muscle. Dilation is used to expand any nar- Conflict of Interest row areas of the esophagus [13,14]. If dysphagia is relat- ed to GERD or esophagitis, medicines may help prevent Author declares that there is no conflict of interest stomach acid from entering the esophagus. Infections regarding the publication of this article.

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Ethical Approval 10. Bath PM, Lee HS, Everton LF (2018) Swallowing therapy for dysphagia in acute and subacute stroke. Cochrane No ethical approval was obtained. Database Syst Rev 10: CD030032. Informed Consent 11. Brooks M, McLaughlin E, Shields N (2019) Expiratory muscle strength training improves swallowing and respiratory Informed consent not required. outcomes in people with dysphagia: A systematic review. Int J Speech Lang Pathol 21: 89-100. References 12. Tolstrup Anderson U, Beck AM, Kjaersgaard A, Hansen T, 1. (2018) International classification of diseases (ICD). World Poulsen I (2013) Systematic review and evidence based Health Organisation. recommendations on texture modified foods and thickened fluids for adults (≥ 18 years) with oropharyngeal dysphagia. 2. J Larry Jameson, Anthony S Fauci, Dennis L Kasper, e-SPEN Journal 8: e127-e134. Stephen L Hauser, Dan L Longo, et al. (2009) Harrison’s principles of internal medicine. (19th edn). 13. Poincloux L Rouquette O, Abergel A (2017) Endoscopic treatment of benign esophageal strictures: A literature 3. Logemann JA (1988) Swallowing physiology and patho- review. Expert Rev Gastroenterol Hepatol 11: 53-64. physiology. Otolaryngol Clin North Am 21: 613-623. 14. Sato H, Takeuchi M, Hashimoto S, Mizuno KI, Furukawa K, 4. Reza Shaker (2006) Oropharyngeal Dysphagia. Gastroen- et al. (2019) Esophageal : New perspectives in terol Hepatol (N Y) 2: 633-634. the era of minimally invasive endoscopic treatment. World 5. Ian T MacQueen, David Chen (2019) Esophageal Dyspha- J Gastroenterol 25: 1457-1464. gia. Dysphagia Evaluation and Management in Otolaryn- 15. Lightbody KA, Wilkie MD, Kinshuck AJ, Gilmartin E, Lew- gology. is-Jones H, et al. (2015) Injection of for 6. Willig TN, Paulus J, Lacau Saint Guily J, Beon C, Navarro the treatment of post- pharyngoesophageal J (1994) Swallowing problems in neuromuscular disorders. spasm-related disorders. Ann R Coll Surg Engl 97: 508- Arch Phys Med Rehabil 75: 1175-1181. 512. 7. Baumann A, Katz PO (2016) Functional disorders of 16. Vanuytsel T, Bisschops R, Farré R, Pauwels A, Holvoet L, swallowing. Handb Clin Neurol 139: 483-488. et al. (2013) Botulinum toxin reduces Dysphagia in patients with nonachalasia primary esophageal motility disorders. 8. (2012) ESSD position Statements: Oropharyngeal dyspha- Clin Gastroenterol Hepatol 11: 1115-1121. gia in adult patients. European Society for Swallowing Dis- orders. 17. Schindler A, Ginocchio D, Ruoppolo G (2008) What we don’t know about dysphagia complications? Rev Laryngol 9. WGO Practice Guideline - Dysphagia. World Gastroenter- Otol Rhinol (Bord) 129: 75-78. ology Organization.

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