Oropharyngeal Dysphagia, Achalasia, and Other Esophageal Motility
Problems: Clinical Relevance and Management
Nicholas Shaheen, MD, MPHCenter for Esophageal Diseases
and SwallowingUniversity of North Carolina
Outline• Oropharyngeal Dysphagia
– Epidemiology and Clinical Impact– Pathogenesis– Work-up– Treatment
• Achalasia– Epidemiology and Clinical Impact– Pathogenesis– Work-up– Treatment
• Diffuse Esophageal Spasm (DES)• Ineffective Esophageal Motility (IEM)
All Dysphagia is Not Created Equal
• Need to differentiate thoracic vs. oropharyngealdysphagia
• DDx is different• Work-up is different
All choked up…• A 73 year old male presents to you
complaining of difficulty swallowing x 9 mos.• After eating 3-4 bites of any meal, often
gets the sensation of “choking” or “windpipe being cut off”
• Worst with drinks, better with mashed potatoes
• 10 lb weight loss, associated with voluntary food avoidance
Choked Up, cont.
• PMH – CVA 6 yrs ago with residual Left side weakness, HTN, DM
• PE – Other than weakness on left, nl• What to Do Next?
– Diagnostically– Therapeutically
Work-up of Dysphagia
• History – What Do You Want to Know?– Chronicity? Progressive or Intermittent?– Problems choking on food initially or wedged
in chest?– Liquids? Solids? Both? Which first?– Point where it is getting stuck– GERD? Wt Loss? Blood?– DM? Previous Chest RT? Meds?
What Does OropharyngealDysphagia Sound Like?
• Food “sticks in throat”• Hoarse or “Gargly” voice• Food regurgitates nasally or “strangles”• Frequent repetitive swallows• Frequent throat clearing• Cough• Pneumonia
Oropharyngeal Dysphagia, DDx
• Neurologic– CVA– MS– Parkinson’s– Huntington’s– ALS– Neuropathies/Auto-
immune
• Muscular– Poly/Dermatomyositis– MD– MG
• Lesions/Structural– Cancer– Zenker’s– Extrinsic Compression– Webs
Work-up of Oropharyngeal Dysphagia
• Involves multiple specialties:– Gastroenterologists– Neurologists– Speech pathologists– Otolaryngologists, and, – Radiologists
Work-Up of OropharyngealDysphagia
• More complicated than thoracic dysphagia, and more patient-specific– Modified BaS– FEES Study– ENT Examination– CT of the Neck and Chest– MRI of the Head– Upper endoscopy
What is the FEES Thing, Anyway?
• Flexible endoscope into nasopharynx
• Tipped back into the oropharynx to watch the patient eat
• Can tell if oral contents are inappropriately penetrating laryngeal structures
FEES vs. MBS• Indications for MBS:
– vague symptoms; – need comprehensive view – Visualize submucosal anatomy
(e.g., cervical osteophytes) – Assess oral stage/base-of-
tongue movement – UES stricture/hypertonicity? – Examine movement of multiple
structures at height of swallow – Voicing with tracheoesophageal
prosthesis : what is vibrating? – Laryngectomy
• Indications for FEES:– logistic reasons
• Fluoro not available • Transportation to radiology risky;
medically fragile patient • Positioning problematic: contractures,
quad, neck halo, obese, on ventilator • Concern about radiation
– clinical reasons• Visualize surface anatomy, mucosal
abnormalities, resection, etc. • Velopharyngeal incompetence • Visualize laryngeal movement/vocal
fold mobility • compromised pulmonary clearance • Clinical question of secretions
management • Biofeedback is desired: therapy session
SE Langmore et al, 2006.
Zenker’s Diverticulum
Multiple Sclerosis
Cervical Osteophytes
Treatment of O-P Dysphagia
• Usually directed at underlying causes– Rehabilitation and retraining by speech
pathologists• chin tuck• head rotation to the affected side• head tilt to the stronger side
– In selected cases of cricopharyngeushypertrophy, myotomy may resolve symptoms
Benign Leiomyoma
Pharyngeal Cancer
Achalasia
Pathogenesis• failure of relaxation of the lower esophageal
sphincter in response to deglutition• absence of primary peristalsis• Histologically, there is neuronal degeneration of
the myenteric plexus– preferentially effects the inhibitory, nitric oxide
producing cells– The opposing cholinergic neurons responsible for
tonic contraction are relatively spared, leading to an increased baseline tone, and inability to relax in response to swallows
Epidemiology
• Affects 0.5-1/100,000 persons• Men and women equally affected• Substantial variation in epidemiology
amongst cultures– May represent ability to diagnose the
condition
Normal E Mano
E Mano in Achalasia
Hydrostatic Dilatation of Achalasia
What is the most appropriate initial management of achalasia?
• Randomized controlled trial of pneumatic dilatation vs. open anterior myotomy– Surgery subjects had more durable relief of
symptoms– More than half of dilated patients needed re-
treatment– Late failures also more common in dilatation group
• Second RCT in Chagas patients suggested better manometric response in surgical patients.
Csendes A et al.. Gut 1989; 30(3):299-304. Felix VN, et al. Hepatogastroenterology 1998; 45(19):97-108.
DES
• EGD normal• Barium swallow
– may be normal– may show a “corkscrew”
appearance due to multiple simultaneous contractions
• E mano shows long waves that are simultaneous
DES, E Mano
DES, Treatment
• Pharmacologic– Calcium Channel Blockers– Nitrates– Anticholinergics– Centrally-acting agents for pain
• Surgical– Long myotomy is reversed for disabling,
recurrent disease
Ineffective Esophageal Motility• Characterized by:
– greater than 30% of swallows being not having complete peristalsis
– Greater than 30% of swallows having a distal peristalsis of <30 mmHg
• Often seen in association with reflux disease
• If achalasia is “esophageal asystole,”and DES is “esophageal tachycardia,”this is “Esophageal CHF”
What are the Treatment Choices in IEM?
• Metoclopramide• Erythromycin• Domperidone• Tegaserod (w/d 3 months ago)• Bethanachol
What to Do about the Subject with Functional Dysphagia
• Many gastroenterologists empirically dilate the esophagus
• More recent randomized controlled trials do not support this practice 1,2
• May consider re-assurance after work-up or a centrally-acting agent
1 K. Lavu et al, South Med J. 2004 Feb;97(2):137-40.2 JS Scolapio et al, Am J Gastroenterol. 2001 Feb;96(2):327-30.
Back to our 73 yo with O-P Dysphagia…
• Got a FEES study – showed extensive penetration of the vallecular space with food contents
• MRI of head – multiple small infarcts• Modification of diet by speech pathology
and swallowing exercises• Doing ok
Conclusions
• Dysphagia is a common symptom which requires immediate investigation
• Differentiation between thoracic and oropharyngeal dysphagia narrows the DDxand dictates the work-up
Conclusions, cont.
• First test for oropharyngeal dysphagia is more variable, and may be FEES, modified BaS, ENT eval, or head imaging. Upper endoscopy is less helpful here.
• Familiarity with the common causes of dysphagia and their treatment is essential for both PCP’s and GIs
Thank You!