STUDY - Technical - New Dacian's Medicine
Dysphagia
(Classical / Allopathic Medicine)
Dysphagia -
difficulty swallowing - is a common symptom that's usually
easy to localize. It may be constant or intermittent and is
classified by the phase of swallowing it affects. (See
Classifying dysphagia.) Among the factors that interfere with
swallowing are severe pain, obstruction, abnormal peristalsis,
impaired gag reflex, and excessive, scanty, or thick oral
secretions.
Dysphagia is the
most common - and sometimes the only - symptom of an
esophageal disorder. However, it may also result from an
oropharyngeal, respiratory, neurologic, or collagen disorder
or from the effects of toxins or treatments. Dysphagia
increases the risk of choking and aspiration and may lead to
malnutrition and dehydration.
ALERT:
If the patient suddenly complains of dysphagia:
- assess him for signs of respiratory distress, such as dyspnea and stridor
- secure and maintain an open airway, performing the abdominal thrust maneuver if necessary
- initiate emergency measures, if necessary.
If the patient's dysphagia doesn't suggest airway obstruction, perform a focused assessment.
If the patient suddenly complains of dysphagia:
- assess him for signs of respiratory distress, such as dyspnea and stridor
- secure and maintain an open airway, performing the abdominal thrust maneuver if necessary
- initiate emergency measures, if necessary.
If the patient's dysphagia doesn't suggest airway obstruction, perform a focused assessment.
Classifying
dysphagia
Because swallowing occurs in three distinct phases, dysphagia can be classified by the phase that it affects. Each phase suggests a specific pathology for dysphagia.
Because swallowing occurs in three distinct phases, dysphagia can be classified by the phase that it affects. Each phase suggests a specific pathology for dysphagia.
Phase 1
Swallowing begins in the transfer phase with chewing and moistening of food with saliva. The tongue presses against the hard palate to transfer the chewed food to the back of the throat; the fifth cranial nerve then stimulates the swallowing reflex. Phase 1 dysphagia typically results from a neuromuscular disorder.
Swallowing begins in the transfer phase with chewing and moistening of food with saliva. The tongue presses against the hard palate to transfer the chewed food to the back of the throat; the fifth cranial nerve then stimulates the swallowing reflex. Phase 1 dysphagia typically results from a neuromuscular disorder.
Phase 2
In the transport phase, the soft palate closes against the pharyngeal wall to prevent nasal regurgitation. At the same time, the larynx rises and the vocal cords close to keep food out of the lungs; breathing stops momentarily as the throat muscles constrict to move food into the esophagus. Phase 2 dysphagia usually indicates spasm or cancer.
In the transport phase, the soft palate closes against the pharyngeal wall to prevent nasal regurgitation. At the same time, the larynx rises and the vocal cords close to keep food out of the lungs; breathing stops momentarily as the throat muscles constrict to move food into the esophagus. Phase 2 dysphagia usually indicates spasm or cancer.
Phase 3
Peristalsis and gravity work together in the entrance phase to move food through the esophageal sphincter and into the stomach. Phase 3 dysphagia results from lower esophageal narrowing by diverticula, esophagitis, and other disorders.
HISTORY:
Ask the patient if swallowing is painful. If so, is the pain constant or intermittent? Have the patient point to where dysphagia feels most intense.
Ask the patient if eating alleviates or aggravates the symptom. Are solids or liquids more difficult to swallow? If the answer is liquids, ask if hot, cold, and lukewarm fluids affect him differently.
Ask the patient if the symptom disappears after several attempts to swallow. Is swallowing easier in different positions?
Ask the patient if he has recently experienced vomiting, regurgitation, weight loss, anorexia, hoarseness, dyspnea, or a cough.
Peristalsis and gravity work together in the entrance phase to move food through the esophageal sphincter and into the stomach. Phase 3 dysphagia results from lower esophageal narrowing by diverticula, esophagitis, and other disorders.
HISTORY:
Ask the patient if swallowing is painful. If so, is the pain constant or intermittent? Have the patient point to where dysphagia feels most intense.
Ask the patient if eating alleviates or aggravates the symptom. Are solids or liquids more difficult to swallow? If the answer is liquids, ask if hot, cold, and lukewarm fluids affect him differently.
Ask the patient if the symptom disappears after several attempts to swallow. Is swallowing easier in different positions?
Ask the patient if he has recently experienced vomiting, regurgitation, weight loss, anorexia, hoarseness, dyspnea, or a cough.
PHYSICAL
ASSESSMENT:
Evaluate the swallowing reflex by placing your finger along the patient's thyroid notch and then instructing him to swallow. If you feel the larynx rise, the reflex is intact.
Assess the cough and gag reflex.
Listen closely to the patient's speech for signs of muscle weakness. Does he have aphasia or dysarthria? Is his voice nasal, hoarse, or breathy?
Assess the patient's mouth carefully, check for dry mucous membranes and thick, sticky secretions. Check for tongue and facial weakness.
Evaluate the swallowing reflex by placing your finger along the patient's thyroid notch and then instructing him to swallow. If you feel the larynx rise, the reflex is intact.
Assess the cough and gag reflex.
Listen closely to the patient's speech for signs of muscle weakness. Does he have aphasia or dysarthria? Is his voice nasal, hoarse, or breathy?
Assess the patient's mouth carefully, check for dry mucous membranes and thick, sticky secretions. Check for tongue and facial weakness.
SPECIAL
CONSIDERATIONS:
Administer an anticholinergic or antiemetic to control excess salivation. If the patient has decreased saliva production, moisten his food with a little liquid. If he has a weak or absent cough reflex, begin tube feedings.
Administer an anticholinergic or antiemetic to control excess salivation. If the patient has decreased saliva production, moisten his food with a little liquid. If he has a weak or absent cough reflex, begin tube feedings.
PEDIATRIC
POINTERS:
In looking for dysphagia in an infant or a small child, be sure to pay close attention to his sucking and swallowing ability. Coughing, choking, or regurgitation during feeding suggests dysphagia.
Corrosive esophagitis and esophageal obstruction by a foreign body are more common causes of dysphagia in children than in adults.
Dysphagia may result from a congenital anomaly, such as annular stenosis, dysphagia lusoria, or esophageal atresia.
In looking for dysphagia in an infant or a small child, be sure to pay close attention to his sucking and swallowing ability. Coughing, choking, or regurgitation during feeding suggests dysphagia.
Corrosive esophagitis and esophageal obstruction by a foreign body are more common causes of dysphagia in children than in adults.
Dysphagia may result from a congenital anomaly, such as annular stenosis, dysphagia lusoria, or esophageal atresia.
AGING ISSUES:
In patients older than age 50 with head or neck cancer, dysphagia is a common reason for seeking care. The incidence of such cancers increases markedly in this age-group.
In patients older than age 50 with head or neck cancer, dysphagia is a common reason for seeking care. The incidence of such cancers increases markedly in this age-group.
PATIENT
COUNSELING:
Advise the patient to prepare foods that are easy to swallow. Consult with the dietitian to help the patient select foods with distinct temperatures and textures.
Advise the patient to prepare foods that are easy to swallow. Consult with the dietitian to help the patient select foods with distinct temperatures and textures.
Bibliography:
1. Rapid Assessment, A
Flowchart Guide to Evaluating Signs & Symptoms, Lippincott
Williams & Wilkins, 2004.
2. Professional Guide to
Signs and symptoms, Edition V, Lippincott
Williams & Wilkins, 2007.
3. Guide to common
symptoms, Edition V, McGraw - Hill, 2002.
Dorin,
Merticaru (2010)