[Dysphagia] Esophageal examination etc

[eripley at yahoo.com (Irene Campbell-Taylor)]

Michael Feinberg was one of the most highly respected radiologists in the field of swallowing. The following article is a seminal one. Often cited.
  1: AJR Am J Roentgenol. 1991 Jun;156(6):1181-4 
  Altered swallowing function in elderly patients without dysphagia: radiologic findings in 56 cases.
  Ekberg O, 
  Feinberg MJ.
  Available at:
   http://www.ajronline.org/cgi/reprint/156/6/1181.pdf
  This article describes how the esophagus was examined as well as the oropharynx.  He always included the esophagus.
   
  Of interest is
  Dysphagia and Esophageal Motility Disorders
  Peter J. Kahrilas
  At:
   
  http://www.worldgastroenterology.org/publications/archive/2006_1/sci/sci2.htm
   
  and:
  Am J Med. 2004 Sep 6;117 Suppl 5A:44S-48S. 
  Management of acid-related disorders in patients with dysphagia.
  Howden CW.
  Division of Gastroenterology, Northwestern University, Feinberg School of Medicine, Chicago, Illinois 60611, USA.
  Dysphagia affects a large and growing number of individuals in the United States, particularly the elderly and those who are neurologically impaired. Swallowing difficulties may be due to age-related changes in oropharyngeal and esophageal functioning as well as central nervous system diseases such as stroke, Parkinson disease, and dementia. Among institutionalized individuals, dysphagia is associated with increased morbidity and mortality. An appreciation of the physiology of swallowing and the pathophysiology of dysphagia is necessary for proper patient management. Careful history, physical examination, and evaluation of radiologic and endoscopic studies should differentiate oropharyngeal and esophageal etiologies of dysphagia and distinguish mechanical (anatomic) disorders from functional (motor) disorders. A significant percentage of patients with dysphagia have concomitant acid-related disorders that are managed best with proton pump inhibitor (PPI) therapy. Three of
 the currently available PPIs are manufactured as capsules containing enteric-coated granules that may be mixed with soft foods or fruit juices before oral administration to those with swallowing difficulties. In addition, omeprazole and lansoprazole may be administered via gastrostomy or nasogastric feeding tubes as suspensions in sodium bicarbonate. Novel dosage formulations of lansoprazole that may be appropriate for patients with dysphagia include the commercially manufactured lansoprazole strawberry-flavored enteric-coated granules for suspension and lansoprazole orally disintegrating tablets.
   
   
  Radiology. 1990 Sep;176(3):637-40.
  Deglutition after near-fatal choking episode: radiologic evaluation.
  Feinberg MJ, 
  Ekberg O. 
  Department of Radiology, Albert Einstein Medical Center, Philadelphia, PA 19141.
  Acute airway obstruction during oral intake is a relatively common event that may be fetal if not relieved immediately. Deglutition was studied in 75 individuals who had experienced a near-fatal choking episode (NFCE) or sudden inability to breathe during food intake that was promptly relieved by means of a Heimlich maneuver, suctioning, or intubation. Videofluoroscopy supplemented by static imaging revealed abnormal stages of deglutition in 58 individuals: oral, 32; pharyngeal, 19; pharyngoesophageal segment (PES), 28; and esophageal, 23. Forty individuals aspirated a liquid bolus; this was more often due to oral dysfunction (bolus leakage, n = 17; delayed initiation, n = 18) than pharyngeal abnormality (defective closure, n = 13; incomplete transport, n = 9). Oral-stage dysfunction was common in those with neurologic disease, a history of dysphagia, and structural or motor abnormalities of the PES or esophagus. Fourteen patients were able to vocalize during the NFCE,
 and each demonstrated an abnormality of the PES or esophagus that could obstruct a solid bolus, suggesting that symptoms were not due to airway obstruction. A variety of unsuspected deglutition abnormalities were documented, indicating the usefulness of radiographic evaluation after NFCE.
   
  Dysphagia. 1992;7(4):205-8 
  Clinical and demographic data in 75 patients with near-fatal choking episodes.
  Ekberg O, 
  Feinberg M. 
  Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia 19104.
  The clinical background and circumstances of 75 patients who had survived a near-fatal choking episode, i.e., had undergone a Heimlich maneuver, oropharyngeal suctioning, or intubation, is reported. Sixty had choked on a solid bolus (often of a complex texture like sandwiches and chicken soup). Four patients had choked on mashed banana. In 30 patients neurologic disease (such as cerebrovascular disease, Parkinson disease, or dementia) was present. Choking occurred during breakfast (16 patients), lunch (21), dinner (26), and snacks (12). Twenty-five choked at home, 18 in nursing homes, 14 in hospitals, nine in restaurants, and nine in drinking establishments. Twelve were being fed at the time of choking. Fifty-eight of the individuals had oral, pharyngeal, or esophageal abnormalities on radiographic examination that could explain the choking episode. Fourteen patients who were able to vocalize during the choking episode had probably suffered from esophageal impaction. Our
 study indicates that elderly individuals and those with neurogenic dysphagia are at risk for choking. Dysphagia diet (semisolids) may actually contribute to the risk in these patients. Young adults may also be at risk during episodes of consumption of alcohol and snacks.
   


Dr I Campbell-Taylor
Clinical Neuroscientist
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