Читать книгу The Esophagus - Группа авторов - Страница 74

Most patients with OPD seek help because of symptoms, although a subset are silent aspirators who may present with recurrent pneumonia. Dysphagia symptoms reflect a breakdown in the transport or protective functions of oropharyngeal swallowing (Table 3.1). These symptoms are highly specific and should not be simply dismissed as functional or psychogenic. Every effort should be exerted to arrive at a specific diagnosis, although subtle abnormalities often escape detection.

A sensation of “food sticking in my throat” is often reported and reflects inadequate clearance of the bolus from the pharynx. Although this sensation may be caused by the presence of a large amount of residue in the pyriform sinus or vallecula, an obstructive lesion of the proximal or distal esophagus may lead to the very same complaint. Thus, patients with complaints of cervical dysphagia should undergo a thorough evaluation of the esophagus. Of course, careful direct visualization of the hypopharyngeal area must also rule out inflammation, abrasion, or tumors in this area.

Misdirection of the bolus into the airway leading to swallow‐related coughing or choking is another common complaint. Invasion of the upper airway by the bolus may occur before initiation of, during, or after completion of oropharyngeal swallowing, and results in a coughing or choking sensation [52]. Aspiration into the airway may occur prior to deglutition because of the premature loss of the bolus into the hypopharynx from the mouth while the path to the airway is still open, a condition commonly encountered in post‐stroke dysphagic patients. An inability to segregate the oral bolus from the pharynx by apposition of the tongue base and soft palate results in this premature spillage, called pre‐deglutitive aspiration. If pharyngeal sensation is deranged, and swallowing is not initiated by entry of the prematurely passed bolus into the pharynx, pre‐deglutitive aspiration and its concomitant complications follow. Deglutitive aspiration occurs either because of an incompetent glottis or one that does not close properly during the swallowing sequence, which leads to invasion of the airway by the bolus while it is being transported through the hypopharynx. Finally, post‐deglutitive aspiration develops when the bolus transport is incomplete and a large residue remains in the pyriform sinus or vallecula, a condition encountered in parkinsonism, post stroke, myasthenia gravis, and multiple sclerosis. When the glottis opens and respiration is resumed, the large residue is either inhaled or overflows into the trachea.

The history is helpful to distinguish OPD from globus sensation. Globus is a sensation of a lump or tightness in the throat. Globus is purely sensory and occurs between meals without impairment in bolus transfer [53–56]. It should not be diagnosed in the presence of dysphagia. Patients occasionally have associated psychiatric disorders, such as anxiety, depression, panic disorder, etc. Evaluation often involves otolaryngology.

Similar to esophageal dysphagia, the history can be helpful in narrowing the differential diagnosis in OPD. Solid food dysphagia is often indicative of a structural abnormality. Progressive symptoms associated with weight loss raise the concern for malignancy. Sudden onset of symptoms associated with a neurologic deficit suggests stroke. Foul breath and delayed regurgitation may be indicative of a Zenker’s diverticulum. Myopathies often present as slowly progressive dysphagia. Other systemic symptoms such as features of Parkinson’s or memory loss may be helpful in determining a diagnosis.

A history of aspiration pneumonia is an important clue to oropharyngeal dysphagia [57]. Langmore et al. found that dysphagia is an important risk factor in elderly patients but is generally insufficient to cause pneumonia unless other risk factors are present. Risk factors include feeding and oral care dependence, decayed teeth, tube feeding, medications, and smoking [58, 59].

In the preparatory phase of swallowing, several protective reflexes are present, including the reflexive pharyngeal swallow, pharyngoglottal reflex, and the laryngeal adductor reflex. All of these protective reflexes are impaired with aging, and the reflexive pharyngeal swallow and pharyngoglottal reflex are impaired with smoking and alcohol [3760–62]. These deficits can predispose to aspiration.

Older adults demonstrate a slower swallowing process, decreased isometric lingual pressure, unchanged deglutitive lingual pressure, decreased UES opening, and decreased functional reserve [63, 64]. As the population ages, the prevalence of swallow difficulties grows, which is evidenced by the 93% increase in Medicare beneficiaries for aspiration pneumonia from 1991 to 1998 [65]. Abnormal UES opening or pharyngeal outflow obstruction may be caused by primary mechanisms, i.e. myogenic or neurogenic, or secondary mechanisms, such as inadequate suprahyoid muscle traction, aging, deconditioning, and stroke. The evaluation and treatment of abnormal UES opening are discussed next.