Oropharyngeal dysphagia . A disease that hinders the penetration of food, from the oropharynx to the cervical esophagus.
Summary
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- 1 Features
- 2 Diagnosis
- 3 Methods of exploration
- 1 Radiological studies
- 2 Endoscopic studies
- 3 Manometric studies
- 4 Isotopic studies
- 4 Diagnostic management
- 5 Treatment
- 1 Surgical Indications
- 2 Summary
- 6 Sources
characteristics
Oropharyngeal dysphagia (DO) can manifest itself variably, from a slight difficulty in initiating swallowing, to the inability to swallow saliva. The consequences of DO can be serious: dehydration, malnutrition, aspiration, pneumonia and even death.
OD arises as a consequence of dysfunction of the oropharyngeal phase of swallowing or of the upper esophageal sphincter (ESD), appearing when there are alterations in the anatomical, nervous or muscular structures involved in swallowing, which will determine an obstacle, mechanical, in the first case, or functional (due to poor preparation of the bolus in the oral cavity, weakness of the pharyngeal contraction and alterations in the relaxation of the EES) that conditions poor oropharyngeal emptying. Although the causes that can cause this obstructive syndrome are multiple, the most frequent are those of neuromuscular origin, which represent 80% of cases.
Diagnosis
Syndromic diagnosis
The clinical history is very useful to identify the existence of OD and its probable etiology. The anamnesis allows:
- a) distinguish OD from other symptoms, such as ballooning, xerostomia, or esophageal dysphagia;
- b) facilitate the identification of systemic or metabolic diseases,
- c) identify drugs that can contribute to dysfunction (anticholinergics, phenothiazines, penicillamine, metoclopramide, amiodarone, procainamide, high doses of aminoglycosides).
The primary objectives of the physical examination are aimed at the following:
- a) identify signs of structural alterations or possible systemic or metabolic diseases;
- b) identify evidence and severity of neurological injuries,
- c) identify pulmonary or nutritional sequelae of dysphagia.
Exploration methods
The clinical history allows in a high percentage of cases a correct diagnostic approach; however, in some patients different complementary examinations are required for a correct evaluation.
Radiological studies
If the OD is acute, a “plain radiography” of the area should be performed, since soft tissue edema (epiglottitis, retropharyngeal abscess) or radiopaque foreign bodies that can cause dysphagia can be seen.
Conventional “barium radiology” allows pharyngeal tumor masses to be detected, but is ineffective in diagnosing cricopharyngeal motor abnormalities . The “video radiology” makes it possible to verify the four categories of oropharyngeal swallowing dysfunction, although it does not allow quantifying the pharyngeal contraction force or detecting incomplete relaxation of the EES. Likewise, video radiology makes it easier to assess the effectiveness of diet, posture and swallowing maneuvers used to correct the observed dysfunction.
Endoscopic studies
Nasoendoscopy is the best method for the identification of intracavitary structural lesions, as well as for the identification and biopsy of mucosal abnormalities. It also allows identifying the first two categories of oropharyngeal swallowing dysfunction.
Manometric studies
“Esophagomanometry” allows the detection and quantification of static (hypertonia / hypotonia of the EES) and dynamic (insufficient / no relaxation, swallowing incoordination and reduction of pharyngeal contraction), being therefore very useful in the diagnosis of cryopharyngeal motor disorders, although a series of technical details must be kept in mind (low compliance infusion system, microtransducers, catheters with several radially distributed holes) for this exploration to be effective and reproducible. When manometry is performed in isolation, it offers only indirect evidence of oropharyngeal swallowing dysfunction.
To increase its diagnostic performance, it can be carried out simultaneously with video radiology (“manorradiology”), allowing all categories of oropharyngeal dysfunction to be detected and radiological events to be correlated with manometric data.
Isotopic studies
It is the most recently incorporated diagnostic technique. 10 ml of 99Tc-labeled water is used, and the data, collected through a gamma camera and computerized, can perfectly and mathematically evaluate swallowing dynamics. It allows to quantify the transit time and the oropharyngeal emptying, which makes it a complementary exploration of the previous ones, especially useful to evaluate the therapeutic response.
Diagnostic management
Due to the complexity of OD (multiple etiology, disparate pathogenesis, specific evaluation methods, limited collaboration, sometimes by the patient due to his underlying neurological disease, etc.), a multidisciplinary professional participation is required, being impossible develop a single strategy that covers all clinical aspects of the disease. However, it is necessary to prioritize the diagnostic objectives that will determine the therapeutic approach to these patients.
Treatment
In the case of OD caused by diseases that can be cured / improved by drug therapy (Parkinson’s disease, myasthenia gravis, myotonic dystrophy, polymyositis, hyperthyroidism or hypothyroidism, etc.), the administration of the corresponding drugs cures / improves the causal disease, and With this, dysphagia disappears or improves.
If structural injury has been excluded and OD is secondary to neuromuscular dysfunction without specific treatment (stroke, trauma, etc.), the first step will be to establish the indication to maintain or not oral feeding, to reduce the risk of aspiration pneumonia. , according to the information provided by video radiology, the etiology of DO, and the cognitive capacity of the patient.
If the dysfunction does not impede oral feeding, it is indicated, according to the information obtained, to make the appropriate modifications in the diet (variation in the thickness of the food), swallowing maneuvers (supraglottic swallowing, Mendelsohn’s maneuver), postural adjustments (inclination / turns of the head) or techniques that facilitate swallowing.
In cases of disabling OD and at risk of pulmonary aspiration, non-oral feeding should be considered, temporarily using a nasogastric tube or more permanently with the “endoscopic percutaneous gastrostomy”, a technique that is easy to perform and affordable for any endoscopist.
The use of botulinum toxin has recently been proposed in the treatment of some diseases that cause OD, as is the case of cryopharyngeal achalasia, with promising results, however its real utility is pending evaluation.
Surgical Indications
The treatment of structural lesions that has a specific surgical therapy (tumors, Zenker’s diverticulum, etc.) is clearly indicated. However, surgical treatment in the rest of the patients is controversial given the results.
The “cryopharyngeal myotomy”, which is an easy surgical technique in expert hands, and which can even be performed with local anesthesia or endoscopic route, produces a decrease in the basal pressure of the EES, favoring the opening of the sphincter and decreasing resistance to transsphincterial flow . The results obtained with this surgical technique are variable and unpredictable, being more effective when performed in patients with structural lesions that limit the opening of the cryopharyngeal and in which the contractile capacity of the pharynx is preserved (Zenker’s diverticulum, postcricoid stenosis, membranes ) and less effective in patients with neuromuscular diseases, which may affect both motor and sensory innervation.
In order for the cryopharyngeal myotomy to achieve good clinical results with low morbidity, it is essential to take into account a series of requirements: a) perform it in patients with intense clinical manifestations (dysphagia, weight loss, bronchoaspiration, etc.); b) confirmation by video radiology and / or manometry of the EES dysfunction; c) to safely exclude structural pathologies (prior nasoendoscopy is mandatory), and d) acceptable general condition of the patient, achieved after hydroelectrolytic replacement, parenteral nutrition, antibiotic therapy, etc., if necessary.
Summary
OD is a syndrome with a multiple etiology, in which a mechanical or functional obstacle to the progression of food occurs during the oropharyngeal phase of swallowing, clinically manifested by the sensation of food stagnation at the cervical level. We have complementary techniques for evaluation (video radiology, manometry, endoscopy and isotopes), and given their complexity, multidisciplinary professional participation is required in their diagnostic-therapeutic management, making it necessary to prioritize the diagnostic objectives, which will mark the therapeutic approach these patients.
When OD is caused by structural lesions or diseases that can be cured / improved, specific surgical or pharmacological therapy cures / improves the causative disease, thereby eliminating or improving dysphagia. If the OD is secondary to neuromuscular dysfunction without specific treatment, the first step will be to establish the indication to maintain oral feeding or not, to reduce the risk of aspiration pneumonia. In cases of disabling OD and at risk of pulmonary aspiration, non-oral feeding should be considered, temporarily using a nasogastric tube or more permanently with percutaneous endoscopic gastrostomy.
