Книга_4440_Библиотеки_им_академика_М_И_Перельмана

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8.5 Clinical Atlas ofHypopharyngeal andLaryngeal Disease

n om

q rp

311

Fig. 8.7 (continued)

312

8 History andExamination ofLaryngeal andHypopharyngeal Disorders

z aa

ac ad

ae af ag

Fig. 8.7 (continued)

History andExamination ofOesophagus, Trachea andTracheobronchial Tree

Deglutition or Swallowing

Swallowing is the process by which food is transported from the mouth to the stomach. Functionally, it may be divided into three phases—preparatory, transfer, and transport phases—that follow each other in a sequence.

Oral phase—The oral phase includes prepa-

ratory as well as early transfer phases.

Pharyngeal phase—This is an involuntary phase. During this phase, the tongue seals the oropharynx. The soft palate and proximal pharyngeal wall seal off the nasopharynx. The vocal cords and arytenoids close off the laryngeal opening and the epiglottis swings down to cover the laryngeal vestibule. These actions seal the airway from the pharyngeal cavity. In addition, the hyoid bone and larynx move superiorly and anteriorly, bringing the larynx to a position outside of the path of the bolus. The pharynx also widens and shortens, which is accompanied by an elevation of the upper oesophageal sphincter (UES) by several centimetres. These activities move food bolus through the already open UES into the oesophagus, and this action is completed by pharyngeal peristaltic contraction.

After the bolus enters the oropharynx, a ridgelike contraction (passavant ridge) appears in the uppermost part of the posterior pharyngeal wall and progressive aboral contraction of the posterior pharyngeal wall against the contracting posterior part of the tongue propels the bolus into the

pharynx. A bolus of food travels through the pharynx in <1s because of the fast velocity (up to 40cm/sec) of the pharyngeal peristalsis.

Oesophageal phase—In the oesophageal phase, the bolus is propelled downward by a peristaltic movement. The lower oesophageal sphincter relaxes at the initiation of the swallow, and this relaxation persists until the food bolus has been propelled into the stomach.

(a) Dysphagia—It is dened as difculty in

swallowing. It can occur in any of three phases of swallowing oral, oropharyngeal or oesophageal phase. This is the most common symptom of oesophageal disorder.

• Oral dysphagia – Pocketing of food in the mouth, cir-

cumoral leakage and early pharyngeal spill can occur with weakness and poor coordination of the lips, cheeks and tongue.

– Weak posterior tongue can lead to

abnormal tongue thrusting.

– Aspiration of food or drink, especially

during inhalation, can occur before pharyngeal swallowing due to premature pharyngeal spillage.

– Changes in mental status with cognitive

decits also may affect the initiation of swallowing, increasing the tendency to pocket food in the lateral sulci and leading to possible aspiration.

© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2025 S. K. Kashyap, S. Sagar, Clinical Methods of Otorhinolaryngology, Skull Base & Head Neck Surgery, https://doi.org/10.1007/978-981-96-1765-4_9

313

314

9 History andExamination ofOesophagus, Trachea andTracheobronchial Tree

Logemann’s Manual for the Videouoro- graphic Study of Swallowing cites the fol-

lowing oral-phase swallowing symptoms and disorders

– Inability to hold food in the mouth ante-

riorly due to reduced lip closure

– Inability to form a bolus or residue on

the oor of the mouth due to reduced range of tongue motion or coordination

– Inability to hold a bolus due to reduced

tongue shaping and coordination

– Inability to align teeth due to reduced

mandibular movement

– Entry of food material into the anterior

sulcus or the presence of residue in the anterior sulcus due to reduced labial tension or tone

– Entry of food material into the lateral

sulcus or the presence of residue in the lateral sulcus due to reduced buccal tension or tone

– Abnormal hold position or dropping of

material to the oor of the mouth due to tongue thrust or reduced tongue control

– Delayed oral onset of swallow due to

apraxia of swallow or reduced oral sensation

– Searching motion or inability to orga-

nize tongue movements due to apraxia of swallow

– Forward tongue movement to start the

swallow due to tongue thrust

– Residue of food on the tongue due to

reduced tongue range of movement or strength

– Disturbed lingual contraction (peristal-

sis) due to lingual discoordination

– Incomplete tongue-to-palate contact

due to reduced tongue elevation

– Inability to mash material due to reduced

tongue elevation

– Adherence of food to hard palate due to

reduced tongue elevation or reduced lingual strength

– Reduced anterior-posterior lingual

action due to reduced lingual coordination

– Repetitive lingual rolling in Parkinson’s

disease

– Uncontrolled bolus or premature loss of

liquid or pudding consistency into the pharynx due to reduced tongue control

or linguavelar seal – Piecemeal deglutition – Delayed oral transit time

• Pharyngeal dysphagia—If pharyngeal clearance is severely impaired, a patient may be unable to ingest sufcient amounts of food and drink to sustain life. In people without dysphagia, small amounts of food commonly are retained in the vallecula or pyriform sinus after swallowing. If there is weakness in or a lack of coordination of the pharyngeal muscles or if there is a poor opening of the upper oesophageal sphincter, patients may retain excessive amounts of food in the pharynx and experience overow aspiration after swallowing. Dysfunction or abnormalities of the soft palate and superior pharynx (e.g. cleft palate) can lead to nasopharyngeal reux following uvulectomy (Table9.1).

9 History andExamination ofOesophagus, Trachea andTracheobronchial Tree

315

Logemann’s Manual for the Videouorographic Study of Swallowing

cites the following pharyngeal-phase swallowing symptoms and disorders

– Delayed pharyngeal swallow – Nasal penetration during swallow due to

reduced velopharyngeal closure

– Pseudo epiglottis (after total laryngec-

tomy): Fold of mucosa at the base of the

tongue – Cervical osteophytes – Coating of pharyngeal walls after the

swallow due to bilateral reduction of

pharyngeal contraction – Vallecular residue due to reduced poste-

rior movement of the tongue base – Coating in a depression on the pharyn-

geal wall due to scar tissue or pharyn-

geal pouch

Causes of pharyngeal dysphagia (Table9.1)

• Oesophageal dysphagia—Oesophageal dysphagia is the feeling that something is stuck in throat.

– Residue at the top of the airway due to

reduced laryngeal elevation

– Laryngeal penetration and aspiration

due to reduced closure of the airway entrance (arytenoid to base of epiglottis)

– Aspiration during swallow due to

reduced laryngeal closure

– Stasis of residue in pyriform sinuses due

to reduced anterior laryngeal pressure

– Delayed pharyngeal transit time

Causes of oesophageal dysphagia (Table9.2).

Table 9.1 Pharyngeal causes of dysphagia

Neuromuscular lesions Obstructive lesions

1. Central nervous disease—Cerebrovascular accident, Parkinson’s disease, brain stem tumour

Degenerative disease, ALS, MS, poliomyelitis, syphilis

2. Pheripheral nervous disease—Peripheral neuropathy, motor endplate dysfunction, myasthenia gravis, skeletal muscle ds, dermatomyositis, muscular dystrophy, cricopharyngeal achalasia, UES

Table 9.2 Causes of oesophageal dysphagia

Neuromuscular disorder Obstructive intrinsic lesion Obstructive extrinsic lesion Achalasia

Spastic motor disorder – Diffuse oesophageal spasm – Hypertensive lower oesophageal

sphincter

– Nutcracker oesophagus scleroderma

Tumour Stricture Oesophageal web Foreign body Lower oesophageal ring (Schatzki’s ring) Radiation induced Chemical induced

Tumours, inammatory masses, trauma, iatrogenic, Zenker’s diverticulam Oesophageal web, anterior mediastinal mass Extrinsic structural lesion Cervical spodylytis

Vascular compression Enlarged aorta or atrium Aberrant vessels Lymphadenopathy Substernal thyroid

316

9 History andExamination ofOesophagus, Trachea andTracheobronchial Tree

9.1 Clinical Features/ Presentation ofOesophageal Disorders

9.1.1 Presentation/History/ Symptoms ofOesophageal Disorder

(a) Dysphagia (Fig.9.1)

• Mode of onset of dysphagia – Sudden—FB ingestion, stroke, acute

oesophagitis, impaction of food in preexisting stricture or malignancy, neurological disorder

– Gradual—benign stricture

• Duration of dysphagia – Short duration (acute)—FB ingestion,

acute oesophagitis

– Long duration (chronic)—Stricture, car-

cinoma, diffuse oesophageal spasm, achalasia

• Dysphagia to types of food – Dysphagia to liquid—Achalasia, para-

lytic lesion

– Dysphagia to solid—Obstructive lesion

like carcinoma, stricture

– Dysphagia to liquid + solid—Motility

disorder, upper oesophageal dysphagia (striated muscle dystrophy): dermatomyositis, myasthenia gravis, stroke. Lower oesophageal dysphagia (smooth muscle dystrophy)-systemic sclerosis, CREST syndrome

• Nature of dysphagia – Intermittent—Spasm or spasmodic epi-

sode over the organic lesion, ring and webs, nutcracker oesophagus

– Persisting dysphagia—Carcinoma

oesophagus, stricture, oesophageal web

• Progression of dysphagia – Progressive—Oesophageal carcinoma,

neuromuscular dysphagia

– Non-progressive/slow progressive—

Motility disorder, stable peptic oesophageal stricture

• Aggravating factors – Cold food—Neuromuscular motility

disorders

• Relieving factors – Repeated swallow—Achalasia

• Associated symptoms linked to oesopha-

geal dysphagia

– Age >50, smoking history, obesity, male

sex—Barret’s oesophagus

– Coughing or gagging when swallowing

or after eating

– Pain while swallowing (odynophagia)—

oesophagitis, post radiation, infectious

– Pain worsens by solid food—obstruc-

tive dysphagia

– Pain worsens by solid and liquid—

Neuromuscular dysphagia

– Having the sensation of food getting

stuck in your throat or chest – Drooling – Change of voice (hoarseness or Hot

potato voice) – Frequent heartburn and regurgitation – Regurgitation of undigested food and

nocturnal cough—hypopharyngeal

diverticulum – History of FB ingestion—Present or

absent – History of regurgitation—Present or

absent – History of aspiration pneumonia, mal-

nutrition, dehydration, weight loss and

airway obstruction – Halitosis—Zenker diverticulum – Acid reux (Hurt burn) GERD – Chest pain—Caused by GERD, oesoph-

agitis, hiatal hernia, oesophageal stric-

ture, primary oesophageal motility

disorder, oesophageal tear – Cough—If cough present early in swal-

low in neuromuscular dysphagia and late

in swallow in obstructive dysphagia.

• Other symptoms of oesophageal disorder – Burning sensation in throat and chest pain – Odynophagia – Change of voice – Odynophagia – Food impaction – Failure to thrive – Shortness of breath – Cough

9.2 History/Chief Complaints ofTrachea andBroncho Alveolar Tree Diseases

Table 9.3 Clinical features of various causes of dysphagia

Clinical features Diagnosis Dysphasia is more for liquid, unexplained weight loss, heartburn, dry mouth, dry

eyes Dysphagia with chest pain, haematemesis, melena, cough and wheezing Barrett’s oesophagus H/o—Aspiration pneumonia, halitosis, regurgitation, dysphagia (from globus

sensation to obstruction), bleeding. O/E—Neck mass + Dysphagia with regurgitation of food, unintentional weight loss, food stuck in

throat, heartburn, coughing or choking, drooling, Dysphagia with sensation of something stuck in throat, choking, cough, crack

around the corner of mouth, sore tongue, nasopharyngeal reux Dysphagia with or without odynophagia, chest pain, acid regurgitation, or

something stuck in throat Dysphagia with heartburn, regurgitation, chest pain, haematemesis, shortness of

breath, chest or abdominal pain, feeling of fullness after eating Dysphagia with regurgitation, bad breath, hoarse voice, persistent cough, h/o

aspiration, sensation of lump in throat Dysphagia with chest pain, lump in throat burning sensation in throat Gastro- oesophageal disorder

Achalasia

Oesophageal diverticula

Oesophageal stricture

Oesophageal web or ring

Esophagitis

Hiatus hernia

Zenker diverticulum

317

Differential Diagnosis Oesophageal Dysphagia (Table9.3)

9.1.2 Examination ofPatient withOesophageal Disorder

Examination of patient with esophageal disorder includes a general physical examination and focused organ- or symptom-specific examinations based on the patient’s history to identify the aetiology of oesophageal disorders.

(a) General examination—Pallor, built, icterus,

pedal oedema, lymphadenopathy, consciousness, etc.

(b) Systemic examination

• Neurological examination—This is done to assess the patient’s mental status, motor and sensory function, cranial nerves and cerebellar examination.

– Motor and sensory examinations may

reveal a new stroke or identify a longterm illness.

– A decreased gag reex is associated

with an increased risk of aspiration.

– A ‘wet voice’ may suggest long-term

laryngeal aspiration, while a weak, breathy voice may indicate vocal cord pathology.

• Abdominal examination—organomegaly

• Chest examination – Wide anteroposterior diameter of chest

• Examination of neck—Thyroid masses,

lymphadenopathy

• Laryngopharyngeal examination is done

with Indirect laryngoscopy for growth, pooling of saliva in pyriform sinus, movement of vocal cords

• Movement of larynx while swallowing

• Oropharyngeal examination—It includes

gag reex, growth

• Laryngeal crepitus—The loss of laryn-

geal crepitus suggests growth cricopharynx or swelling in retropharyngeal space.

9.2 History/Chief Complaints ofTrachea andBroncho Alveolar Tree Diseases

9.2.1 History ofPatient withTracheobronchial andAlveolar Tree Disease

(a) Dyspnoea (difcult/ labored breathing or

shortness of breath)—It is a subjective

experience of breathing discomfort that consists of qualitatively distinct sensations that vary in intensity. It may be a symptom of air-

318

9 History andExamination ofOesophagus, Trachea andTracheobronchial Tree

way, lung or heart. Dyspnoea is a debilitating symptom that affects the quality of life, exercise tolerance and mortality in various disease conditions/states and is also an important predictor of quality of life, exercise tolerance and mortality in various conditions.

• Mode of onset of dyspnoea – Sudden onset

Obstructions to Airow—Sudden blockage of airways is a medical emergency and can be caused by inhaling objects, food particles or uids.

Lung Tissue Diseases—Bacterial Infection (pneumonia, acute bronchitis

from bacteria, viruses), fungal infection, cancer, chemical and radiation toxicity, occupational toxicity (mines), haemosiderosis, allergic reaction, drug toxicity, connective tissue disease.

– Insidious onset

Chest Wall and Chest Muscle Diseases—muscular dystrophy,

Nervous system diseases, such as paralysis. Heart Diseases—These conditions include valve diseases of the heart.

• Duration of dyspnoea—Dyspnoea can

be either acute or chronic.

– Causes of acute and chronic dysphagia

(Table9.4).

• Progression of dyspnoea.

– Progressive—carcinoma larynx, vegeta-

tive foreign body, pulmonary brosis, pneumothorax

– Non-progressive-non-vegetative FB

• Associated symptoms—There are associated symptoms or history to be asked.

– Any H/o FB aspiration—present or

absent – Anxiousness – Bloody sputum – Chest injury – Chest pain

– Chest tightness—bronchoconstriction,

interstitial oedema.

– Increase effort of breathing—airway

obstruction, neuromuscular disease – Cough – Dizziness – Fainting – Fatigue – Heart palpitations – Laboured breathing – Neck pain – Pain with inspiration (pleurisy) – Rapid, shallow breathing – Wheezing

(b) Cough

• Type of cough – Dry cough/cough without sputum – Wet cough/cough with sputum

• Duration of cough – Acute—Acute pharyngitis, ALTB,

Croup, acute bronchitis

– Chronic—COPD, bronchial asthma,

chronic laryngitis

• Mode of onset – Sudden— allergic, croup, pseudocroup,

LERD

Table 9.4 Causes of acute and chronic dyspnoea

Acute Chronic

Myocardial infarction, heart failure, cardiac tamponade, bronchospasm, pulmonary embolism, pneumothorax, bronchitis, pneumonia, upper airway obstruction by obstruction or anaphylaxis, asthma, anxiety, pneumonia, choking on or inhaling something that blocks breathing passageways, allergic reactions, anaemia, serious loss of blood, resulting in anaemia, exposure to dangerous levels of carbon monoxide, heart failure, hypotension, which is low blood pressure, pulmonary embolism, which is a blood clot in an artery to the lung, collapsed lung, hiatal hernia, croup, traumatic lung injury

COPD, pleural effusion, congestive heart failure, valvular heart disease, anaemia, renal failure, neuromuscular disease, neuromuscular dysfunction, psychogenic, tuberculosis

9.2 History/Chief Complaints ofTrachea andBroncho Alveolar Tree Diseases

319

– Insidious—Chronic pharyngitis,

chronic Laryngitis

• Associated symptoms – Hoarseness of voice—Acute laryngitis,

chronic laryngitis, dysphonia, carci-

noma larynx – Hot potato voice—Ca base of tongue – Wet voice—Croup – Fever—Acute pharyngitis, ALTB – Dysphagia—Supraglottis carcinoma – Throat pain—Pharyngitis

Causes of cough

• Asthmatic cough—It is usually worse late at night or early in the morning. Many things that can trigger an asthma attack, including sulphites, which are in beer and wine as well as dried fruits and vegetables, pickled onions, and soft drinks. Patient tends to cough after eating or drinking any of these.

• Food allergies—Food allergy is usually in childhood presented as cough, wheezing and shortness of breath.

• Aspiration pneumonia—A wetsounding cough after eating is a symptom of aspiration pneumonia. Cough may also be associated with mucus that looks green or bloody. Other symptoms are painful swallowing, coughing or wheezing after eating, heartburn, fever that starts within an hour of eating, recurring pneumonia, extra saliva, congestion after eating or drinking and shortness of breath or fatigue while eating or drinking.

9.2.2 Local Examination ofPatient withTrachea Bronchial Tree Disorders

(a) General examination—Pallor, conscious-

ness, stridor, cyanosis, tachypnoea, tachycardia

(b) Systemic examination

• Cardiovascular examination

• Respiratory system – Inspection—Movement of chest, move-

ment of accessor muscles – Palpation—Palpatory thud – Percussion—Dullness its type – Auscultation—B/L air entry, Ronchi,

Crepitus

• Oropharynx

• Larynx—Indirect laryngoscopy

Approach to a Patient with Oesophageal dysphagia (Fig.9.1)

320

9 History andExamination ofOesophagus, Trachea andTracheobronchial Tree

Dysphagea

solid food(mechanical

obstrucon)

Intermiant

Progressive

Intermiant

Oesophageal

Stricture

H/O Chronic

GERD

age > 50

yrs

Chest pain

Diﬀuse esophageal

spasm

Evaluate the paent with Ba swallow and esophagoscopy

Fig. 9.1 Approach to patient present with oesophageal dysphagia

both solid and liquid

( Neuromuscular)

H/O Chr.

GERD

Scleroderma

Progressive

Respiratory

symptoms

Achalasia

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