Dysphagia

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Classification according to ICD-10
R13 Dysphagia
ICD-10 online (WHO version 2019)

A dysphagia or swallowing disorder occurs when one of the swallowing structures involved and their interaction is impaired in their function. Thus, all diseases and ailments in the area of ​​the oral cavity and its limitations, the throat , the esophagus and the stomach entrance , in addition, especially neurological problems and mental disorders can play a causal role. The dysphagia can be associated with or without pain. The painful act of swallowing is also known as odynophagia .

Since swallowing disorders result in considerable impairment of physical, psychological and social well-being, they always require clarification.

Symptoms

Possible symptoms of a swallowing disorder are

  • a feeling of pressure or lump in the throat
  • Gag reflex during the act of swallowing,
  • a regurgitation of food already geschluckter (v. a. at Ösophagusdivertikeln (bulges of the esophagus)),
  • Coughing during the meal as an expression of penetration (entry of food or liquids into the upper respiratory tract before swallowing) or aspiration (the entry of food or liquids into the lower airways),
  • Hypersalivation ,
  • in extreme cases, a general inability to eat.

As accompanying symptoms a nasal voice (especially when swallowing paralysis ) and hoarseness occur.

The consequences can be acute and recurring pneumonia and fever.

frequency

45% of the over 75 year olds suffer from swallowing difficulties, whereby neurological, psychiatric and general chronic illnesses usually influence each other negatively due to the multimorbidity often existing in old age .

It should be emphasized that not all patients with a swallowing disorder are aware of it. Especially with multiple sclerosis and ALS , aspiration pneumonia leads to the diagnosis.

causes

There are various reasons for a swallowing disorder, whereby a psychological cause can be assumed more easily the younger the patient is and the more varied the symptoms are. The appearance of the patient can give indications of a psychological genesis of the problem, but in principle every swallowing disorder must be carefully clarified.

Physical causes

Injuries and tumors of the oral cavity, throat and esophagus, disorders of the motor innervation of the muscles involved in the swallowing process

Oral cavity and throat

esophagus

thyroid

Neurological diseases

In specialist circles ( nutritional medicine , rehabilitation medicine ) one speaks of the step concept of neurogenic oropharyngeal dysphagia (NOD) with four degrees of severity. The graduation increases from NOD grade 0 (= no dysphagia, i.e. normal food) to NOD grade 1 (= slight dysphagia) and NOD grade 2 (= moderate dysphagia with thickened liquids and passed food) to NOD grade 4 (= massive dysphagia with 100% intravenous tube feeding ).

Mental causes

The undisturbed swallowing process enables life-sustaining fluid and food intake, but also the experience of pleasure and well-being. Thus, a disturbance of the act of swallowing can itself indicate disturbances of the psychological well- being - after physical causes have been excluded.

See also: globe syndrome .

Diagnosis

  • Observation of the act of swallowing (mobility of the larynx or Adam's apple )
  • Review of the gag reflex , tongue function and all the other muscles involved in swallowing by Phoniater , neurologist and / or speech therapy , speech therapy educators , clinical linguistics , occupational therapists
  • Assessment of the severity of the swallowing disorder by means of clinical screening (e.g. "Daniels test" [Daniels et al., 1998]). Clinical signs allow a prediction of the severity of dysphagia and the risk of aspiration:
    • abnormal voluntary cough
    • abnormal gag reflex
    • Dysarthria
    • Dysphonia
    • Cough after drinking predetermined amounts of water
    • Change in the tone of your voice after a drink of water.

A clinical examination of the swallowing function also includes the following parameters:

  • clinical anamnesis (medical record, interview with affected persons and relatives)
  • descriptive observations (posture, facial expressions, breathing)
  • Check of orofacial mobility and sensitivity (both outside and inside the mouth)
  • Oral inspection (prosthesis fitting, mucous membranes, atrophies, plaque, etc.)
  • Examination of the reflexes (palatal reflex, gag reflex, cough reflex, swallow reflex)
  • FEES (fiberendoscopic evaluation of swallowing) - checking of food intake (pulpy, liquid, solid and crumbly) by means of a flexible endoscopy via the nose
  • Gastroscopy
  • X-ray examination :
    • Esophageal swallow (video cinematography of the act of swallowing) for functional assessment
    • Videofluoroscopy for the functional, time-critical assessment of different consistencies (pulpy, liquid, solid, crumbly)
    • still experimental: high-speed MRI
    • X-ray of the cervical spine
  • Gastroscopy examination
  • Neurological examination
  • Examination of the thyroid
  • internal examination
  • Dental or orthodontic evaluation
  • phoniatric examination
  • ENT medical examination
  • psychosomatic evaluation - if no physical cause could be found or this does not fully explain the symptoms.

Complications

Every act of swallowing carries the risk of "swallowing" food and fluid (including one's own saliva) and ultimately aspirating them into deeper parts of the lungs . As a result, aspiration pneumonia can develop, which in stroke patients z. B. is responsible for 20% of deaths in the first year of illness.

Since the sense of taste and smell are impaired in old age and the appetite has been lost for mostly unknown reasons, a slight swallowing disorder can ultimately lead to complete refusal of food with all subsequent problems such as weight loss, desiccosis and a further reduction in general condition.

therapy

Treatment is based on the results of the physical or psychosomatic examinations. A nasogastric tube or a PEG (tube with percutaneous endoscopic gastrostomy) may be indicated if oral feeding is not possible and the patient needs to be fed by gastric tube.

In every swallowing phase (pre-oral, oral, pharyngeal and esophageal) there are therapeutic intervention options through speech and swallowing therapy. Goals are initially restoring the intraoral sensitivity and the structure of the protective reflexes ( gag , cough reflex , swallowing reflex ). The spectrum ranges from motor exercises for individual muscle groups, massages, thermal stimulation, changes in posture while eating (e.g. by changing the position of the head) to changes in food consistency (e.g. pureeing the food or thickening liquids). The so-called swallowing maneuvers (e.g. Mendelsohn maneuvers or supraglottic swallowing), which enable improved protection of the respiratory tract when swallowing and can thus prevent food being aspirated, are evidence-based.

etymology

Dysphagia is derived from the ancient Greek prefix δυς- (which denotes something unfortunate or adverse, corresponding to the prefix 'miss-' or 'un-' in German ) and the verb φαγεῖν phagein 'essen'. Literally, dysphagia means a disorder in eating . In odynophagia, the first word component can be traced back to ὀδύνη odýnē 'pain'.

literature

  • due to Revising mom. offline (as of 01/2017): S1 guidelines for neurogenic dysphagia of the German Society for Neurology (DGN). In: AWMF online (as of September 30, 2012)
  • G. Bartolome, H. Schröter-Morasch: Swallowing disorders - diagnostics and rehabilitation . 4th edition. Urban & Fischer, Munich 2010, ISBN 978-3-437-47161-2 .
  • Nusser-Müller-Busch: Language-Voice-Hearing 23 (1999) Focus on dysphagia. Thieme, Stuttgart
  • M. Prosiegel, (Ed.) Among others: Practice Guide Dysphagia - Diagnosis and Therapy of Swallowing Disorders. Hygieneplan Publishing House, 2002.
  • JA Logemann: Evaluation and Treatment of Swallowing Disorders. Pro-ed Verlag, 1998.
  • R. Nusser-Müller-Busch: The therapy of the Facio-Oralen Trakt. - FOTT after K. Coombes. Jumper. 2007 2nd ed.
  • W. Herbst: Neurogenic dysphagia and its therapy in patients with tracheostomy tubes . Schulz-Kirchner publishing house. Idstein 2002.
  • C. Graz, D. Woite: Therapy of the facio-oral tract in neurological patients. Schulz-Kirchner-Verlag, 2000.
  • CM Morales: Orofacial Regulation Therapy. Plum Physiotherapy, 1998.
  • D. Steube, M. Hermes: Neurogenic Dysphagia; Diagnosis, clinical management and follow-up care. Scientific publishing department of ABBOTT GmbH, 1999.
  • Friedel Schalch: Swallowing disorders and facial paralysis - therapeutic aids. Fischer, Stuttgart 1992, ISBN 3-437-46470-1 .
  • S. Stanschus (Ed.): Methods in Clinical Dysphagiology. Schulz-Kirchner-Verlag 2002.
  • G. Kolb (Ed.): Dysphagia; Compendium for doctors and speech therapists in clinics. Rehabilitation and Geriatrics, Medicine and Knowledge 2000.
  • H. Behrbohm, O. Kasche, T. Nawka: Endoscopic diagnostics and therapy in ENT . Gustav Fischer 1997.
  • PA Sullivan, AM Guliford: Swallowing Intervention in Oncology . Singular Publishing Group, 1999.
  • JC Arvedson, L. Brodsky: Pediatric Swallowing and Feeding - Assessment and Management . Singular Publishing House. Early childhood intervention series. 2002.

Individual evidence

  1. ^ Hoffmann-La Roche AG, Urban & Schwarzenberg (ed.): Roche Lexicon Medicine. 5th edition. Urban & Schwarzenberg 2003, online edition , keywords: "Dysphagia" and "Odynophygia"
  2. ↑ Guntram W. Ickenstein et al .: Standardization of diagnostic and therapeutic procedures for neurogenic oropharyngeal dysphagia (NOD) , in: Neurol. & Rehabil. 2009; 15 (5): pp. 290-300.
  3. ^ Daniels, SK: Aspiration in patients with acute stroke . In: Arch Phys Med Rehabil . No. 79 (1), 14-19. , 1998.
  4. ↑ A. Olthoff, S. Zhang, F. Frahm: High-speed magnetic resonance tomography for the dynamic representation of the normal swallowing act. In: Current Phoniatric-Pedaudiological Aspects. 2011; 19, pp. 44-47.
  5. ^ Wilhelm Gemoll : Greek-German school and hand dictionary . G. Freytag Verlag / Hölder-Pichler-Tempsky, Munich / Vienna 1965.