Dysphagia Notes

?Types:
_Oropharyngeal dysphagia (difficulty in the initial phase of swallowing).
_Esophageal dysphagia (difficulty in the esophagus).

Oropharyngeal dysphagia

*?Symptoms:
Includes difficulty initiating swallowing, coughing, choking, nasal regurgitation, and a sensation of food sticking in the throat.
*?Causes:
Can be due to neurological disorders (e.g., stroke, Parkinson's disease), muscular disorders, structural abnormalities, or radiation therapy effects.
?Diagnosis:
Clinical history, physical examination, and diagnostic tests like videofluoroscopic swallow study (VFSS) or fiberoptic endoscopic evaluation of swallowing (FEES).
?Treatment:**
Speech and swallowing therapy, dietary modifications, and in some cases, surgical interventions.

Esophageal Dysphagia
?Symptoms:
Sensation of food sticking in the chest, regurgitation of undigested food, chest pain, and heartburn.
*?Causes:
Can include esophageal stricture, gastroesophageal reflux disease (GERD), esophageal cancer, achalasia, and eosinophilic esophagitis.
?Diagnosis:*
Barium swallow, upper endoscopy (esophagogastroduodenoscopy or EGD), and esophageal manometry.
?Treatment:**
Depends on the underlying cause and may involve esophageal dilation, proton pump inhibitors (PPIs), surgical interventions, and dietary changes.

Swallowing Mechanism

?Phases:
Includes the voluntary oral stage, the involuntary pharyngeal stage, and the esophageal stage.

*?Muscles and Nerves:*
Key muscles involved are the mylohyoid, superior, middle, and inferior pharyngeal constrictors.

Primary cranial nerves include the trigeminal (CN V), facial (CN VII), glossopharyngeal (CN IX), vagus (CN X), and hypoglossal (CN XII).

Anatomy of Facial Nerve

??Arises from the brainstem at the lower border of the pons.

???Enters the internal auditory meatus with the cochlear nerve and labyrinthine vessels.

?????‍♂Forms the trunk of the facial nerve and bends posteriorly in the medial wall of the middle ear.

??Exits the skull through the stylomastoid foramen and pierces the parotid gland to give off several branches.

Greater Petrosal Nerve: Secretomotor supply to lacrimal, nasal, and palatal glands.
Nerve to Stapedius: Innervates the stapedius muscle.
Chorda Tympani:
Carries taste sensation from the anterior two-thirds of the tongue.
Posterior Auricular Nerve: Supplies the occipitalis and posterior auricular muscles.
Terminal Branches:
Temporal, zygomatic, buccal, mandibular, and cervical branches to muscles of facial expression

Examination of Motor Function

⭕️Inspection for asymmetry or differences in blinking or eye closure.
⭕️Observation of spontaneous or involuntary movements.
⭕️Demonstration and patient actions:
1_Raise eyebrows:
Symmetrical wrinkling of the forehead.
2_Shut eyes tightly:
Check the strength of orbicularis oculi.
3_Bare teeth:
Symmetrical movement of orbicularis oris.
4_Blow out cheeks:
Equal puffing of buccinators and orbicularis oris.

General Management Strategies

⬜️Reassurance to the patient.
⬜️Pain relief using analgesics.
⬜️Eye protection: Artificial tears, eye ointment, taping, or patching.
⬜️Physiotherapy or facial muscle massage.
⬜️Good oral hygiene to prevent infections.
⬜️Avoid exposure to aggravating factors.

*⬛️Pharyngeal indications
Pharyngitis:
Etiology:
_Viral:
Adenovirus
rhinovirus
influenza virus,
Epstein-Barr virus (EBV)
herpes simplex virus (HSV)
_Bacterial:
_Most common:
Group A Streptococcus (Streptococcus pyogenes)
Less common: Arcanobacterium haemolyticum Corynebacterium diphtheriae and Neisseria gonorrhoeae
Symptoms
Sore throat
Fever
Headache
Swollen and tender lymph nodes in the neck
Red and swollen pharynx
Tonsillar exudates (white or yellow patches on the tonsils)
Cough (more common in viral cases)
Rash (in some cases, such as scarlet fever)
Diagnosis
Rapid antigen detection test (RADT) for streptococcus
throat culture for confirmation clinical scoring systems like Centor criteria.
Complications:*
Rheumatic fever post-streptococcal glomerulonephritis
peritonsillar abscess

_Peritonsillar Abscess:
Etiology
Secondary to Tonsillitis:
Usually arises as a complication of untreated or severe tonsillitis caused by Group A Streptococcus and occasionally Staphylococcus aureus.
Symptoms
Severe sore throat usually on one side
Fever
Difficulty swallowing
Trismus (difficulty opening the mouth)
Muffled voice (hot potato voice)
Swelling and redness of one side of the throat
Uvula deviation to the opposite side
Ear pain on the affected side
Diagnosis:
Ultrasound or CT scan Management:
Aspiration or surgical drainage
Broad-spectrum antibiotics
corticosteroids to reduce swelling.

_Retropharyngeal Abscess:
Etiology
_Bacterial:
Streptococcus species (especially Streptococcus viridans)
Staphylococcus aureus Bacteroides species Fusobacterium species
Symptoms
Severe sore throat
Fever
Difficulty swallowing
Drooling
Neck pain and stiffness
Swelling in the neck
Stridor or difficulty breathing
Reduced neck mobility
Muffled voice
Systemic symptoms
malaise and irritability
(more common in children)
Diagnosis:
Contrast-enhanced CT scan is the gold standard
plain radiographs may show: widening of the prevertebral space.
Complications:
Airway obstruction
mediastinitis
septicemia
vertebral osteomyelitis.

?Laryngeal and pharyngeal infections:

⬛️Laryngeal indications:
_Acute laryngitis
Etiology:
_*?Viral(most common):
Rhinovirus
Influenza virus
Parainfluenza virus
Respiratory syncytial virus (RSV) Adenovirus.
_*? Bacterial (Less common):**
Group A Streptococcus Staphylococcus aureus Moraxella catarrhalis.

Symptoms:
Hoarseness or loss of voice
Sore throat
Dry cough
Throat discomfort
Difficulty speaking or vocal fatigue

Diagnosis:
laryngoscopy may show: erythema and swelling of the vocal cords.

Complications:
_Secondary bacterial infection
_Vocal cord hemorrhage.

_Chronic laryngitis
Etiology

Environmental factors:
Allergens
Alcohol
Prolonged Cigarette smoking
Chemical fumes
Functional factors:
Vocal misuse or abuse leading to chronic vocal fold inflammation.

Other medical conditions:
GERD?

*?NOTE about GERD
?*GERD as a Cause of Chronic Laryngitis:
هنا يعني الارتجاع المتكرر لحمض المعدة ممكن يسبب تهيج و التهاب متكرر للlarynx مما يؤدي لي chronic laryngitis ، والحالة الي بيرتجع فيها حمض المعدة للlarynx اسمها
Laryngopharyngeal reflux (LPR) OR
Extra-esophageal reflux.

?Chronic Laryngitis Exacerbating GERD:
بمعنى أنه ممكن الالتهاب المزمن للحنجرة يزيد الGERD سوء يعني ، كيف؟
الالتهاب المزمن ممكن يؤثر على الوظيفة حقت الحنجرة و يعمل عطب في الclosure during swallowing
الأمر الي حيسهل أكتر من ارتجاع الحمض و يزيد كذلك سوء الالتهاب.
Symptoms
Persistent hoarseness
Throat clearing
(يعني الزول بيكون يعمل الصوت داك بتاع كأنه عايز ينبه حد أو الصوت البيتعمل بداية كل كلام)
Chronic cough
Sensation of a lump in the throat
Voice changes (raspy or breathy voice)
Throat discomfort or mild pain
Diagnosis:
_History of exposure to irritants. _Laryngoscopy showing: thickened vocal cords and possible leukoplakia or polyp formation.

Management:
Removing irritants
Proton pump inhibitors for GERD
Corticosteroids in some cases.

_Epiglottitis:
Etiology:
Haemophilus influenzae type b (Hib) was the most common cause before widespread vaccination.
Streptococcus pneumoniae, Streptococcus pyogenes
Staphylococcus aureus.
Symptoms
_Sudden onset of sore throat
_Fever
_Difficulty swallowing (dysphagia)
_Drooling
( الريالة بسبب أنه في ألم و صعوبة في البلع)
_Muffled or hoarse voice (hot potato voice)
(يعني الصوت ما واضح وما تقدر تفهم كلامه)
_Stridor (صوت صرير أثناء التنفس)
_Respiratory distress
_Tripod position
(الوضعية البيكون فيها الزول قاعد أو واقف و جسمه العلوي على قدام و سانده باليد أو طاولة أو أي حاجة في محاولة لتحسين التنفس)
Diagnosis
Laryngoscopy
Lateral neck X-ray may show "thumbprint sign."
Complications:
Respiratory failure
Sepsis
Death if not promptly treated.

⭕️Mangment

وهنا حا اتبع التالي
1-good history
2-good examination (eye motalty)
3-Tests (cover عشان اعرفو uni or bi lateral
Cornea reflexعشان اعرف الزاوية حقت الانحراف

⭕️Treatment
1-Spectacles to correct the refractive error
2-Occlusion therapy for amblyopia
3-Surgery by weaken the strong muscle (recession ) and strengthen the weak muscle (resection)

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