What Is Swallowing Therapy?

Dysphagia refers to the obstruction of the pharynx, behind the sternum or esophagus when food is blocked from being delivered from the mouth to the stomach and the cardia. Clinicians must pay attention to patients with dysphagia, and dysphagia caused by organic diseases must be distinguished from pseudodysphagia. The latter has no underlying lesions of esophageal obstruction, and the patient only complains of lumps like obstruction in the pharynx and sternum But often can not clearly point out the specific location, and no difficulty in eating liquid or solid food, these patients are often accompanied by other symptoms of neurosis. Dysphagia is the most common symptom of esophageal cancer. For anyone with dysphagia, it must be determined as early as possible whether it is caused by cancer.

Basic Information

nickname: Difficulty swallowing
English name: dysphagia
Visiting department: Otorhinolaryngology

Common causes: Oropharyngeal disease, esophageal disease, neuromuscular disease, systemic disease
Common symptoms: Difficulty swallowing with hoarseness, cough, hiccup, pain behind the sternum, acid reflux, burning, asthma, dyspnea, etc.

Causes of dysphagia

Oropharyngeal disease

Oropharyngitis, oropharyngeal injury, pharyngeal diphtheria, pharyngeal tuberculosis, pharyngeal tumor, and posterior pharyngeal wall abscess.

2. Esophageal diseases

Esophagitis, esophageal benign tumors, esophageal cancer, esophageal foreign bodies, esophageal muscle dysfunction (cardiac achalasia, diffuse esophageal spasm, etc.), extreme thyroid enlargement, etc. Among them, esophageal cancer is an important cause.

3. Neuromuscular disease

Bulbar palsy, myasthenia gravis, organophosphate insecticide poisoning, polymyositis, dermatomyositis, phagocytosis, etc.

4. Systemic diseases

Rabies, tetanus, botulism, iron deficiency dysphagia (Plummer-Vinson syndrome), etc.

Clinical manifestations of dysphagia

Difficulty swallowing with hoarseness

More common in esophageal cancer, mediastinal invasion, aortic aneurysm, lymphadenopathy, and tumor compression of the recurrent laryngeal nerve.

2. Difficulty swallowing with cough

Seen in cerebral neurological diseases, esophageal diverticulum and esophageal achalasia, retention of food reflux, in addition, esophageal bronchial fistula and myasthenia gravis caused by esophageal cancer weakness, weakness in the chewing muscles, throat muscles and tongue muscles, followed by chewing and swallowing Difficulty, coughing with drinking water. Difficulty swallowing gradually increases with prolonged eating.

3. Difficulty swallowing with hiccups

Generally, the lesion is located in the lower end of the esophagus, and is found in achalasia, diaphragmatic hernia, and so on.

4. Painful swallowing

Seen in oropharyngitis or ulcers, such as acute tonsillitis, posterior pharyngeal abscess, acute pharyngitis, diphtheria, stomatitis and oral ulcers. Esophageal dysphagia with pain after eating, such as pain in the chest, back of the chest, sacrum and neck, are more common in esophagitis, esophageal ulcers, esophageal foreign bodies, advanced esophageal cancer, mediastinitis, etc. If eating cold or hot food causes pain, it is often diffuse esophageal spasm.

5. Back sternum pain and / or acid reflux, burning

Gastroesophageal reflux disease is often indicated as the main clinical manifestation of reflux esophagitis, esophageal peptic ulcer, and benign stenosis of the esophagus.

6. Difficulty swallowing with asthma and dyspnea

Found in mediastinal masses, a large number of pericardial hydrostatic esophagus and atmospheric tube. If you cough after a meal, you may see aspiration aspiration. It is found in bulbar palsy, achalasia, and reflux esophagitis.

7. Difficulty swallowing with reflux

Eating liquid food immediately returned to the nasal cavity with choking. The cause may be neuropharyngeal dysfunction of the pharynx. The occurrence of reflux for a long time after eating suggests dilation of the esophageal obstruction or retention in the esophageal diverticulum. If there is a large amount of reverse flow, and it contains hangovers, there is a fermentation odor, often suggesting that it may be esophageal cardia achalasia, which often occurs during supine at night, and often wakes up due to choking. If the reflux is bloody mucus, it is more common in advanced esophageal cancer.

8. There is a sense of blocking

When you are not eating, you also feel that there is a blockage of objects moving up and down in the pharyngeal or sternal area, often suggesting hysteria. More common in young women, the course of the disease is delayed, and the symptoms are mild and severe.

9. Other

Should pay attention to nutritional status, whether the lymph nodes are swollen, whether there is inflammation and ulcers in the pharynx and vigilant pharynx, esophagus, cardia cancer and pharyngeal inflammatory lesions cause swallowing difficulties. Watch for signs of the nervous system, such as soft palate palsy, taste disorders, vocal cord paralysis, abnormal swallowing movements, and signs of neurological damage.

Dysphagia test

Laboratory inspection

(1) Patients in the drinking test take a seated position, place the stethoscope between the patient's xiphoid process and the left costal arch, and ask for a sip of water. Normal people can hear jet murmurs after 8 to 10 seconds. If there is esophageal obstruction or dyskinesia, No sound is heard or delayed, and severe obstruction can even vomit water.

(2) The esophagus acid test is of great help in the diagnosis of esophagitis or esophageal ulcers.

(3) 24-hour pH monitoring of the esophagus is important for diagnosing acidic or alkaline reflux.

(4) Carry out examinations on immunology and tumor markers.

2. Other auxiliary inspections

(1) X-ray examination of chest X-ray can understand whether the mediastinal space occupying lesions compress the esophagus and foreign body, etc .; Esophageal X-ray barium meal inspection can observe the presence of barium agent to determine whether the lesion is obstructive or muscular Peristalsis. If necessary, use gas-barium double angiography to understand esophageal mucosal fold changes. Endoscopy and biopsy can directly observe esophageal lesions, such as esophageal mucosal congestion, edema, erosion, ulcers or polyps, cancer, etc. Endoscopic biopsy under gastroscopy is of great significance in distinguishing esophageal ulcers, benign tumors, and esophageal cancer.

(2) Esophageal manometry Esophageal manometry can determine the state of esophageal motor function. Generally, the low pressure irrigation method of the side hole of the catheter is used. Such as pressure 10mmHg, LES pressure / intragastric pressure <0.8, suggesting gastroesophageal reflux. However, it was found that those with gastroesophageal reflux had normal LES pressure and normal people. Later, they used catheter extraction to measure the pressure, and the end-expiratory LES pressure was used as the standard.

Diagnosis of dysphagia

Patients with a history of caustic injury to the esophagus should consider esophagitis and benign stenosis; patients with a history of frequent reflux of gastric acid or bile are mostly reflux esophagitis (acid or alkaline reflux); patients with high incidence of esophageal cancer should first consider esophageal cancer; Dysphagia is induced by emotional arousal, suggesting that it may be caused by esophageal and esophageal achalasia, primary esophageal spasm, or neurosis (hydatid disease).

Difficulty swallowing caused by gastrointestinal diseases is often caused by esophageal and cardiac abnormalities, such as weakened, disappeared or abnormal esophageal peristalsis, and esophageal stricture caused by various reasons. This includes simple esophageal lesions, such as achalasia, diffuse esophageal spasm, and esophageal cancer; the reflection of certain systemic diseases in the esophagus, such as dermatomyositis and scleroderma; and diseases of adjacent organs of the esophagus Effects on the esophagus, such as mediastinal tumors and aortic aneurysms. Imaging studies can help determine the cause of the disease.

Differential diagnosis of dysphagia

Esophageal cancer

It is more common in male patients over 40 years of age. The typical symptom is progressive dysphagia. Most patients can clearly point out that the obstruction site is behind the sternum and may be accompanied by swallowing pain. In advanced patients, esophageal reflux may be present. Diagnosis is important, and esophagoscopy or gastroscopy combined with biopsy can determine the diagnosis of esophageal cancer.

2. Esophageal cardia achalasia

Dysphagia often occurs intermittently, with a longer course, and the lower part of the esophagus (ie, above the stenosis) dilates significantly. Esophageal reflux is common, and the counterflow is large. It does not contain bloody mucus. It can be awakened by choking at night when lying supine, and even Causes aspiration pneumonia. X-ray barium swallowing examination showed that the cardia obstruction was fusiform or funnel-shaped, and the edges were smooth. After inhalation of isoamyl nitrite, the cardia temporarily relaxed, allowing the barium to pass through; esophageal manometry showed only small non-peristal contraction waves.

3. Gastric-esophageal reflux

The cause of esophageal sphincter dysfunction and loss of anti-gastroesophageal reflux barrier function, causing the stomach and duodenum contents to flow back into the esophagus, benign esophageal stenosis often occurs in the later stage, and the lower esophageal LES pressure measurement, 24 hours in the esophagus pH monitoring and Bilitee-2000 bile monitor measure bilirubin absorption value, which is helpful for the diagnosis of acid and alkali reflux.

4. Benign stricture of the esophagus

Stenosis is mostly caused by corrosive factors, after esophageal surgery, injury, and reflux esophagitis. X-ray barium swallowing examination showed that the lumen was narrow, but the edges were neat, and there were no signs of barium shadowing. Esophagoscopy or gastroscopy could confirm the diagnosis.

5. Diffuse esophageal spasm

It is often secondary to diseases such as reflux esophagitis and corrosive esophagitis. It is often easily confused with angina pectoris. The main symptoms are dysphagia and swallowing pain, which are mostly induced by emotional factors such as emotional excitement. Swallowing pain can be located in the forearm, even radiating to the forearm, and nitroglycerin can often relieve the pain.

6. Other

Paraesophageal palate hiatal hernia, mediastinal tumors, enlarged lymph nodes around the esophagus, significantly enlarged left atrium, aortic aneurysm, etc. Compression of the esophagus can cause difficulty in swallowing. However, diagnosis can be made separately based on symptoms, signs, X-ray, CT, MRI and other auxiliary examinations.

Dysphagia treatment

The most common causes of dysphagia are various esophageal diseases, followed by oropharyngeal diseases, neuromuscular diseases associated with swallowing, and certain systemic diseases.

Oropharyngeal disease

Laryngeal tuberculosis or tumors (including malignant granulomas), laryngeal wall abscesses and other throat diseases can cause swallowing disorders. Most of the symptomatic treatments can improve or relieve swallowing obstruction.

2. Esophageal diseases

The principle of treatment is generally to actively treat the primary disease of various esophagus, and based on this, appropriate symptomatic supportive treatment is performed.

(1) Reflux esophagitis can be selected to improve the esophageal sphincter tension and esophageal peristaltic drugs. Domperidone, mosapride, etopril, and other gastrointestinal motility agents and gastric mucosal protective agents (bismuth preparation, aluminum carbonate Magnesium, compound magnesium trisilicate or sucralfate, etc.), H2 receptor antagonists such as motidine or proton pump inhibitors such as omeprazole can also be selected.

(2) Cardiac achalasia, diffuse esophageal spasm, and other lower esophageal sphincter hypertension. In order to relax the smooth muscles, calcium channel blockers such as isosorbide dinitrate (astringency) or nitroglycerin under the tongue can be taken orally; symptoms In severe cases, bupropion scopolamine (Jiejingling) can be injected intravenously each time; if the effect of the drug treatment is not satisfactory, the lower esophageal stenosis or surgical treatment can be considered. In recent years, botulinum toxin injection in the narrowed area under direct vision has been developed to treat cardiac achalasia, and its efficacy needs to be tracked.

(3) Once the esophageal cancer is diagnosed, surgery should be performed as soon as possible. If the patient has lost the opportunity of surgery, in order to improve the quality of life or prolong his life, consider narrowing the stenosis, placing a stent, or applying laser or high-frequency electric burning. Obstruction site to obtain temporary relief effect.

3. Rehabilitation of swallowing neuromuscular diseases (such as stroke)

(1) Mild swallowing disorder Take a position that is conducive to eating; emphasize the nature of food, and gradually transition from liquid to general food; emphasize mental training.

(2) Moderate and severe dysphagia Increase movements of the oral and facial muscle groups, tongue movements, and mandible opening and closing movements; cold stimulation of the pharynx; empty swallowing exercise training; respiratory function training.