Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4547_Библиотеки_им_академика_М_И_Перельмана
.pdf
Dysphagia in Systemic Disease 161
https://t.me/med1917
Fig. 3 A 64-year-old woman
with dermatomyositis and
dysphagia. a Barium
examination of the pharynx
shows retention in the
piriform sinuses. There is
misdirected swallowing that
reaches into the laryngeal
vestibule. b Contrast medium
also reaches up into the
nasopharynx. There was
very little contraction and
movement of the pharyngeal
wall
Patients with polymyositis, dermatomyositis,
and IBM may have abnormal oropharyngeal and/or
References
esophageal stages of swallowing (Darrow et al.
1992; Shapiro et al. 1996). Striated and smooth
musculature is affected, leading to weakness of
muscle strength but also fibrosis in the musculature.
When the oral and pharyngeal stages are affected,
this leads to retention with pooling in the vallecula
and piriform sinuses. This may then lead to overflow
aspiration (Selva-O’Callaghan et al. 2000). However,
there is also usually laryngeal muscle involvement
leading to defective closure of the airways as well
(Fig. 3).
Abnormal upper esophageal sphincter opening is
common in polymyositis, dermatomyositis, and IBM
(Sonies 1997). Inflammation and edema in the cricopharyngeal muscle has been observed. Muscle
fibrosis is often present. This has usually been treated
by cricopharyngeal myotomy (Berg et al. 1985).
Esophageal involvement leads to abnormal peristaltic
transportation. This is similar to that seen in scleroderma. Injection of botulinum toxin into the cricopharyngeal muscle has also been recommended. Early
treatment is important in order to avoid muscle atrophy. Treatment generally includes corticosteroids and
immunosuppressive agents.
Agah FP, Francis IR, Ellis CN (1983) Esophageal involvement
in epidermolysis bullosa dystrophica: clinical and roentgenographic manifestation. Gastrointest Radiol 8:111–117
Anselmino M, Zaninotto G, Constantini M, Ostuni P, Ianiello A,
Boccu C et al (1997a) Esophageal motor function in primary
Sjögren’s syndrome. Dig Dis Sci 42:113–118
AnselminoM, ZaninottoG, CostantiniMetal(1997b) Esophageal
motor function in primary Sjögren’s syndrome. Correlation
with dysphagia and xerostomia. Dig Dis Sci 42:113–118
Bella JR, Chad DA (1996) Inflammatory myopathies. In:
Samuel MA, Fekse SK (eds) Office practice of neurology,
2nd edn. Churchill-Livingstone, Philadelphia, pp 698–706
Berg HM, Persky MS, Jacobs JB, Cohen NL (1985)
Cricopharyngeal myotomia: a review of surgical results in
patients with cricopharyngeal achalasia of neurogenic
origin. Laryngoscope 95:1337–1340
Bredenoord AJ, Jafari J, Kadri S et al (2010) Achalasia-like
dysmotility secondary to oesophageal involvement of
sarcoidosis. Gut. doi:10.1136/gut.2010.227868
Brookes GB (1983) Pharyngeal stenosis in Behcet’s syndrome.
The first reported case. Arch Otolaryngol 109:338–340
Chandan VS, Murray JA, Abraham SC (2008) Esophageal
lichen planus. Arch Pathol Lab Med 132:1026–1029
Chen JJ, Branstetter BF IV, Myers EN (2005) Cricoarytenoid
rheumatoid arthritis: an important considerationinaggressive
lesions of the larynx. AJNR Am J Neuroradiol 26:970–972
Cook DM, Dines DE, Dycus DS (1970) Sarcoidosis: report of a
case presenting as dysphagia. Chest 57:84–86
162 T. Mandl and O. Ekberg
https://t.me/med1917
Darrow D, Hoffman H, Barnes G, Wiley C (1992) Management
of dysphagia in inclusion body myositis. Arch Otolaryngol
Head Neck Surg 118:313–317
Demetriades N, Hanford H, Laskarides C (2009) General
manifestations of Behcet’s syndrome and the success of
-laser as treatment for oral lesions: a review of the
CO
2
literature and case presentation. J Mass Dent Soc 58:24–27
Ekberg O, Redlund-Johnell I, Sjöblom KG (1987) Pharyngeal
function in patients with rheumatoid arthritis of the cervical
spine and temporomandibular joint. Acta Radiol 28:35–39
Erb N, Pace V, Delamere JP, Kitas GD (2001) Dysphagia and
stridor caused by laryngeal rheumatoid arthritis. Rheuma-
tology 40:952–953
Flors L, Domingo ML, Leiva-Salinas C, Mazón M, Roselló-
Sastre E, Vilar J (2010) Uncommon occupational lung
disease: high-resolution CT findings. AJR Am J Roentgenol
194:W20–W26
Geterud A, Bake B, Bjelle A, Jonsson R, Sandberg N, Ejnell H
(1991) Swallowing problems in the rheumatoid arthritis.
Acta Otolaryngol 111:1153–1161
Goust J, Tsokos G (1993) Systemic lupus erythematosus. In:
Virella G (ed) Introduction to medical immunology, 3rd
edn. Dekker, New York, pp 437–450
Hardy WE, Tulgan H, Haidak G, Budnitz J (1967) Sarcoidosis:
a case presenting with dysphagia and dysphonia. Ann Int
Med 66:353–357
Hradsky M, Hybasek J, Cernoch V, Sazmova V, Juran J (1967)
Oesophageal abnormalities in Sjögren’s syndrome. Scand J
Gastroenterol 2:200–203
International Pemphigus and Pemphigoid Foundation (2011)
What is pemphigus? http://pemphigus.org/index.php?option=
com_content&view=article&id=364&Itemid=100073/.
Accessed 2 Aug 2011
Katzka DA, Smyrk TC, Bruce AJ, Romero Y, Alexander JA,
Murray JA (2010) Variations in presentations of esophageal
involvement in lichen planus. Clin Gastroenterol Hepatol
8:777–782
Kjellen G, Fransson SG, Lindström F, Sokjer H, Tibblin L
(1986) Esophageal function, radiography and dysphagia in
Sjögren’s syndrome. Dig Dis Sci 31:225–229
Levack B, Hanson D (1979) Behcet’s disease of the esophagus.
J Laryngol Otol 93:99–101
Levine MS, Ekberg O, Rubesin SE, Gatenby RA (1989)
Gastrointestinal sarcoidosis: radiographic findings. AJR Am
J Roentgenol 153:293–295
Lindqvist C, Santavirta S, Sandelin J, Konttinen Y (1986)
Dysphagia and micrognathia in a patient with juvenile
rheumatoid arthritis. Clin Rheumatol 5:410–415
Liquidato BM, Bussoloti Filho I (2005) Evaluation of sialom-
etry and minor salivary gland biopsy in classification of
Sjögren’s syndrome patients. Rev Bras Otorrinolaringol
71:346–354. doi:10.1590/S0034-72992005000300014
Madhusudhan KS, Sharma R (2008) Esophageal lichen planus: a
case reportandreviewofliterature.IndianJ Dermatol 53:26–27
Mandl T, Ekberg O, Wollmer P, Manthorpe R, Jacobsson LTH
(2007) Dysphagia and dysmotility of the pharynx and
oesophagus in patients with primary Sjögren’s syndrome.
Scand J Rheumatol 36:394–401
Menditti D, Palomba F, Rullo R, Minervini G (1990)
Progressive systemic sclerosis (sclerodermal): oral manifestations. Arch Stomatol 31:537–548
Messadi DV, Younai F (2010) Aphthous ulcers. Dermatol Ther
23:281–290
Ntoumazios SK, Voulgari PV, Potsis K, Koutis E, Tsifetaki N,
Assimakopoulos DA (2006) Esophageal involvement in
scleroderma: gastroesophageal reflux, the common problem.
Semin Arthritis Rheum 36:173–181
Palma R, Freire J, Freitas J, Morbey A, Costa T, Saraiva F et al
(1994) Esophageal motility disorders in patients with
Sjögren’s syndrome. Dig Dis Sci 38:758–761
Pizzo G, Scardina GA, Messina P (2003) Effects of a
nonsurgical exercise program on the decreased mouth
opening in patients with systemic scleroderma. Clin Oral
Invest 7:175–178
Pope J (2005) Other manifestations of mixed connective tissue
disease. Rheum Dis Clin North Am 31:519–533
Ramos-Casals M, Brito-Zerón P (2007) Emerging biological
therapies in primary Sjögren’s syndrome. Rheumatology
46:1389–1396
Richeldi L,SorrentinoR, Saltini C(1993) HLA-DPB1 glutamate
69: a genetic marker of beryllium disease. Science 262:
242–244
Rosztóczy A, Kovács L, Wittmann T, Lonovics J, Pokorny G
(2001) Manometric assessment of impaired esophageal
motor function in primary Sjögren’s syndrome. Clin Exp
Rheumatol 19:147–152
Rout PG, Hamburger J, Potts AJ (1996) Orofacial radiological
manifestations of systemic sclerosis. Dentomaxillofac
Radiol 25:193–196
Selva-O’Callaghan A, Sanchez-Sitjes L, Munoz-Gall X,
Mijares-Boeckh-Behrens T, Solans-Laque R, Angel-BoschGilJetal(2000)Respiratoryfailuredue tomuscleweakness in
inflammatory myopathies: maintenance therapy with home
mechanical ventilation. Rheumatology 39:914–916
Shapiro J, Marin S, DeGirolami U, Goyal R (1996) Inflamma-
tory myopathy causing pharyngeal dysphagia: a new entity.
Ann Otol Rhinol Laryngol 105:331–335
Sonies BC (1997) Evaluation and treatment of speech and
swallowing disorders associated with myopathies. Curr
Opin Rheumatol 9:486–495
Sood A (2009) Current treatment of chronic beryllium disease.
J Occup Environ Hyg 6:762–765
Sugerman PB, Porter SR (2010) Oral lichen planus.
http://emedicine.medscape.com/article/1078327-overview.
Accessed 2 Aug 2011
Sun DCH, Roth SH, Mitchell CS, Englund DW (1974) Upper
gastrointestinal disease in rheumatoid arthritis. Dig Dis 19:
405–410
Thanou-Stavraki A, James JA (2008) Primary Sjögren’s
syndrome: current and prospective therapies. Semin Arthritis Rheum 37:273–292
Tsianos EB, Chiras CD, Drosos AA, Moutsopoulos HM (1985)
Oesophageal dysfunction in patients with primary Sjögren’s
syndrome. Ann Rheum Dis 44:610–613
Tsianos EB, Vasakos S, Drosos AA, Malamou-Mitsi VD,
Moutsopoulos HM (1986) The gastrointestinal involvement
Dysphagia in Systemic Disease 163
https://t.me/med1917
in primary Sjögren’s syndrome. Scand J Rheumatol Suppl
61:151–155
Türk T, Pirildar T, Tunc E, Bor S, Doganavsargil E (2005)
Manometric assessment of esophageal motility in patients
with primary Sjögren’s syndrome. Rheumatol Int 25:
246–249
Virella G (1993) Introduction. In: Virella G (ed) Introduction to
medical immunology, 3rd edn. Dekker, New York, pp 1–8
Volter F, Fain O, Mathieu E, Thomas M (2004) Esophageal
function and Sjögren’s syndrome. Dig Dis Sci 49:248–253
Yeh SW, Ahmed B, Sami N, Ahmed AR (2003) Blistering
disorders: diagnosis and treatment. Derm Ther 16:214–223
The Geriatric Pharynx and Esophagus
https://t.me/med1917
Olle Ekberg
Contents
1 Introduction.............................................................. 165
1.1 The Ageing Brain...................................................... 166
1.2 Primary Ageing.......................................................... 166
2 The Oral Stage......................................................... 166
3 The Pharyngeal Stage ............................................. 167
3.1 Misdirected Swallowing ............................................ 167
3.2 Pharyngeal Constrictors............................................. 167
3.3 The Pharyngoesophageal Segment ........................... 168
4 Examination Techniques......................................... 168
5 The Nondysphagic Elderly ..................................... 168
6 Dementia ................................................................... 169
7 The Ageing Esophagus............................................ 170
8 Gastroesophageal Reflux......................................... 172
References.......................................................................... 172
O. Ekberg (&)
Diagnostic Centre of Imaging and Functional Medicine,
Skåne University Hospital, 205 02 Malmö, Sweden
e-mail: olle.ekberg@med.lu.se
Abstract
Dysphagia is common in the elderly. This is
mainly due to neurodegenerative abnormalities
in the central nervous system. The elderly may
be able to compensate, to a certain degree, for
deterioration of function but the reserve capacity is
much less than in younger. Understanding of the
normal aging process as well as disease processes
common in the elderly is important for diagnosis
and treatment of dysphagia in the elderly.
1 Introduction
There are several age-related alterations in oral,
pharyngeal, and esophageal morphology and function. These variations in the healthy elderly
(primary ageing) must be taken into account during
clinical and radiological evaluation. In fact, these
changes do not normally impair the swallowing
process and are thereby not symptomatic. However,
when disease processes (secondary ageing) add
to primary ageing, they may result in significant
impairment.
Deglutition disorders are common and costly in the
elderly. The actual prevalence and natural history of
such dysphagia is not very well known. Dysphagia is
more commonly detected in the hospitalized and
institutionalized elderly than in individuals who live
in their own homes. In hospitals and nursing homes
with predominantly an elderly population, the prevalence of dysphagia is up to 50% of the population
(Groher and Bukatman 1986). Dysphagia is also much
more common in the very old (over the age of 85)
O. Ekberg (ed.), Dysphagia, Medical Radiology. Diagnostic Imaging, DOI: 10.1007/174_2011_389,
Ó Springer-Verlag Berlin Heidelberg 2012
165
166 O. Ekberg
https://t.me/med1917
than in any other group. Neurologic diseases such
as stroke, dementia, and Parkinson’s disease are
common in these populations. The central nervous
system regulates oropharyngeal function in an integrated complex sensory and motor activity pattern.
Especially the coordination between the oral and
pharyngeal stage, i.e., between a voluntary and an
automatic function, is vulnerable. In the elderly this
coordination is frequently impaired.
Many elderly people with dysphagia seem to be
in reasonably good health, and are not frail or
bedridden. They do not seem to suffer from clinically apparent neurologic disease. Oropharyngeal
impairment is usually insidious and chronic in these
individuals, although acute, transient cases do occur.
A rational approach to understanding deglutition in
the elderly requires that we differentiate expected, if
not clearly predictable, senescent changes (primary
ageing) from those caused by disease (secondary
ageing). Unfortunately, subclinical disease, especially cerebral vascular disease, makes this distinction difficult.
From other organ systems we know that there is
roughly a 1% yearly decline in function beginning at
30 years of age. Overall ageing is a progressive
generalized impairment of function resulting in a loss
of adaptive response to stress and in a growing risk of
age-associated disease (Kirkwood 2000).
The morphodynamics of deglutition can be
measured in terms of timing, movement of anatomical structures, pressure generation, and bolus
movements (Tracy et al. 1989; Sonies et al. 1988;
Shaw et al. 1990; Shaker et al. 1990). Senescent
changes in oropharyngeal function can be characterized as ‘‘less efficient.’’ However, the relationship
between symptoms and morphodynamic abnormalities, especially in the context of compensation/
decompensation, is very complex (Jones and
Donner 1991).
One important feature of ageing is an inability to
adapt to stress, and the videofluorographic examination is certainly a stressful situation. Abnormalities, or differences from younger, presumably
normal individuals, may induce alterations that
reflect senescent decline in function. Similarly, the
examination itself may induce decompensation in
those with existing dysfunction due to known
disease and minor abnormalities may become major
ones.
1.1 The Ageing Brain
In the central nervous system various alterations of
the cytoarchitecture occur in ageing. For example,
motor neuron counts in the spinal cord show that the
number of cells declines by approximately 200
neurons per segment per decade (Schoenen 1991).
A study that counted the pigmented neurons in the
locus ceruleus in the brainstem found a decline
averaging 2,000 cells per decade after the age of
60 years (Vijayashankar and Brody 1979). Cell
counts in various glossopharyngeal and vagus nuclei
within the brainstem are not available in humans, but
a similar decline is likely.
1.2 Primary Ageing
The oral cavity undergoes important changes with age.
Such changes include an increase in the amount of
connective tissue in the tongue, loss of dentition, and
reduced masticatory strength (Logemann 1990). In the
pharynx ithas beenshown thatthe anteriorelevation of
the larynx is less pronounced in the elderly and that the
pharyngeal swallowing phase is significantly slowed
down (Sonies et al. 1988). The pharyngeal peristaltic
motion has been shown to be slowed down above the
age of 60 years (Tracy et al. 1989). However, another
study showed that this is not the case but that there is
instead a wider intrapersonal variability in the elderly
(Borgström and Ekberg 1988a). However, there is no
significant change in pharyngeal peak pressure, duration, or in the rate of propagation of contraction
(Robbins et al. 1992). Healthy elderly subjects therefore do not have any residual accumulation in the
pharynx after swallowing.
2 The Oral Stage
It has been shown that pressure that is generated
during swallowing by the tongue does not change
in the elderly compared with young individuals.
However, when individuals are asked to apply
maximal strength, the pressure recording increases
considerably in the young, whereas in the elderly such
reserve capacity does not seem to exist. Others have
shown that lingual peristaltic pressure decreases with
age (Shaker et al. 1988).
The Geriatric Pharynx and Esophagus 167
https://t.me/med1917
Almost as common was large bolus ingestion or
3 The Pharyngeal Stage
3.1 Misdirected Swallowing
Bolus misdirection into the airways is the most significant event observed during videofluoroscopy. The
timing and level of bolus misdirection are important
observations, but again may be extremely variable
(Dodds et al. 1990; Logemann 1983; Groher 1983).
In the elderly,itis not uncommonto see ingestion oftoo
large a bolus volume or a rapid ingestion rate during
uncontrolled administrations. This results in disruption
of sequencing between bolus ingestion, delivery,
propulsion, and laryngeal closure. Some patients aspirate only on the first liquid barium administration;
others appear relatively normal until a small amount
penetrates and then grossly deteriorate and aspirate
before, during, and after some of the subsequent
swallows. Particularlyin theelderly bolus misdirection
most often results from oral stage dysfunction even
when it occurs during the pharyngeal stage.
Another common finding in the elderly is failure of
containment during ingestion, oral processing of
bolus holding. In these individuals the glossopalatal
seal is inadequate. Lingual movements may be dyskinetic or disorganized and disrupt the glossopalatal
seal. Alternatively, there may be no oromotor activity
attempting to contain the bolus once it has been
ingested. The third oral stage cause of misdirection is
transitional dissociation. This means that the bolus is
positioned at the wrong place at the wrong time.
In young individuals the hyoid bone starts to move
anteriorly (from its posterior position) before the apex
of the bolus passes the level of the faucial isthmus as
it can be seen in a true lateral projection during
swallowing. With increasing age, the start of this
anterior hyoid bone movement is delayed. It is common in the elderly (over 75 years of age) to observe a
delay of the anterior movement of the hyoid bone for
more than 0.5 s after the apex of the bolus has passed
the faucial isthmus (Feinberg and Ekberg 1991).
In that study using the previously outlined pattern
analysis, it was found that aspiration was due to oral
stage dysfunction in 50% of patients, pharyngeal
dysfunction in 30% of patients, and combined dysfunction in 20% of patients. The most common
oral stage abnormality was failure of containment.
Transitional dissociation was seen in many patients.
rapid ingestion rate. The most common pharyngeal
stage abnormality was incomplete transportation,
i.e., retention. A mere defective laryngeal closure was
seen less frequently (Feinberg and Ekberg 1991).
There is, however, no significant relationship between
a patient’s specific disease and the pattern of abnormalities during barium swallow. This means that the
observed dysfunctions are nonspecific in terms of
their cause. The high frequency of oral dysfunction
indicates that oral stage abnormalities must be routinely looked for during videofluoroscopy.
The presence of anterior osteophytes larger than
10 mm that impinge on the pharynx may explain
aspiration in dysphagic patients (Strasser et al. 2000).
Coexisting clinical conditions and diseases such as
stroke and partial laryngeal resection increase the risk
of aspiration in patients with smaller osteophytes of
the cervical spine.
Pneumonia is common in the elderly and it may be
due to defective closure of the airways during
swallowing, i.e., penetration/aspiration. However, the
cause and effect relationship is complex and few
studies have addressed this accordingly (Doggett
et al. 2001; Feinberg et al. 1996). The most plausible
explanation is that infected saliva reaches the lower
airways by means of the larynx and causes the
infection (Langmore et al. 1998).
3.2 Pharyngeal Constrictors
There are conflicting opinions concerning the effect of
ageingondeglutitivepharyngealpressures.Whereasone
study showed that there was no pressure difference
(Robbins et al. 1992), other studies have shown differences (Tracy et al. 1989; Perlman et al. 1993; Shaker
et al. 1993). However, there are a multitude of method-
ological differences that makes comparison difficult. In
fact, one of the studies (Shaker et al. 1990) showed that
the amplitude and duration of the peristaltic pressure
wave were significantly greater in the elderly than in the
young.Suchalterationswithage,alterationsthatactually
could be seen as improvements, may actually be regarded as compensatory responses to, for instance, reduced
cross-sectional area of the deglutitive pharyngoesophageal segment (PES) opening in the elderly (Shaw et al.
1990). A study supporting this theory was presented by
Shaker (1993). In this study he found that intrabolus
168 O. Ekberg
https://t.me/med1917
pressure in the pharynx was significantly higher in the
elderly than in young patients, on swallowing in both
upright and supine positions and with both liquid and
mashed potatoes. This again may indicate that there is
lack of distension of the PES in the elderly.
3.3 The Pharyngoesophageal Segment
The PES pressure has also been studied in the elderly
and has been compared with that in younger subjects.
Cook et al. (1989) did not find significant age-related
changes in resting PES pressure measured with a
sleeve device; however, they only studied individuals
under 55 years of age. Wilson et al. (1989) made the
same observation in healthy subjects under 62 years
of age. On the other hand, Fulp et al. (1990) showed
that normal elderly subjects over 62 years of age have
lower resting PES pressure than younger controls.
Shaker et al. (1993) studied the effect of ageing
(70 years and over) on the resting PES pressure and
its response to esophageal air and balloon distension.
The results of this study indicate that ageing significantly reduces the resting PES pressure. However,
this latter study (Shaker et al. 1990, 1993) also
showed that there were normal PES pressure
responses to swallowing and esophageal distension by
air and balloon in the elderly. Therefore, the protective role of the PES against pharyngeal reflux of
gastric acid is preserved in the elderly.
Kendall and Leonard (2001) showed that there is
pharyngeal weakness in the elderly dysphagic patient.
They also concluded that poor pharyngeal constrictions suggestive of pharyngeal weakness contributed
to 75% of cases of aspiration in their study. Feeding
and respiratory pattern was studied in normal elderly
people (Hirst et al. 2002). Hirst et al. found a fairly
stable pattern. It has been shown that particularly in
the elderly incoordination commonly leads to aspiration (Nilsson et al. 1997). Solid aspirators also have
a lower oxygen saturation level compared with
normal individuals (Colodny 2001).
4 Examination Techniques
The examination technique in the elderly does not
differ from that in young individuals. However, many
elderly people are severely impaired and cannot
cooperate. The examination should be customtailored to the patient’s symptoms, and in a very
impaired elderly patient there are very few relevant
clinical questions that should be addressed. Therefore,
such an examination is usually very easy to perform.
5 The Nondysphagic Elderly
An important aspect is, of course, the prevalence of
videofluorographic abnormalities in nondysphagic
elderly patients. Ekberg and Feinberg (1991) found
that only 16% of the elderly population (mean age 83)
were normal. Oral and pharyngeal dysfunction was
very prevalent in their study (63 and 25%, respectively) (Fig. 1). Combined dysfunction was present in
60% of patients. Sixty-five percent of patients showed
bolus misdirection into the airways (20% showed
penetration into the vestibule, 45% showed minor
aspiration to the trachea). No major aspiration was
observed. Misdirection was due to oral dysfunction
4 times as often as pharyngeal dysfunction and twice
as often as combined oral and pharyngeal dysfunction. In that study 36% of patients had dissociation
between the oral and pharyngeal stage. This was the
pathophysiological process of oral dysfunction leading to misdirected swallowing. However, in that
study, half of the patients had a history of neurologic
disease such as dementia, Parkinson’s disease, and
stroke, although none had a history of dysphagia or
swallowing impairment. Pharyngeal constrictor paresis and lingual dysfunction was much more common
in those patients with neurologic disease. The high
frequency of abnormalities that was observed in that
study may have a number of explanations. Many
elderly individuals do not admit to being dysphagic
even when it is obvious that they are. Caregivers are
relatively poor at detecting dysphagia unless they
have been specifically trained (Ekberg et al. 2002).
Altered oropharyngeal function has been documented in asymptomatic elderly volunteers
(Pontoppidan and Beecher 1960; Baum and Bodner
1983; Sonies et al. 1984; Borgström and Ekberg
1988b; Tracy et al. 1989; Ekberg and Feinberg 1991;
Robbins et al. 1992). Such changes may be due to
normal age-related changes in tissues, muscles, and
neuromorphodynamics. It is not clear what is ‘‘normal
decline’’ in oropharyngeal function among the elderly
and what is really the result of disease processes
The Geriatric Pharynx and Esophagus 169
https://t.me/med1917
Fig. 1 Pharyngeal dysfunction is common in the elderly.
Weak musculature leads to impaired clearance of the pharynx.
This is mostly related to defective elevation of the pharynx. In
this patient there is pooling of contrast medium in the vallecula
which definitely are more common in the elderly,
particularly in the central nervous system (Levine
et al. 1992; Buchholz 1992). Again, it is very
important to try to compare symptoms with morphodynamic findings (Sheth and Diner 1988; Donner and
Jones 1991). There is a confusing overlap of clinical,
videofluoroscopic, and magnetic resonance imaging
findings in elderly individuals with and without
oropharyngeal dysphagia/dysfunction (Figs. 2, 3, 4).
6 Dementia
Because dementia is the most common neurologic
disease associated with misdirected swallowing, it is
of interest to study such a population more closely
(Feinberg et al. 1992). In the study of Feinberg et al.,
only 7% of patients were found to be normal during
videofluoroscopy. Oral stage dysfunction was found
in 73% of patients, pharyngeal dysfunction was found
and piriform sinus bilaterally. Contrast medium has reached
into the laryngeal vestibule and is also seen between the
arytenoids
in 43% of patients, pharyngoesophageal abnormalities
were found in 33% of patients, and combined dysfunction was found in 42% of patients. When only
one stage was abnormal, again oral dysfunction (36%)
was much more common than pharyngeal dysfunction
(14%). Common neuropsychiatric features of
dementia can explain the oral stage dysfunction that
was observed in that study. Patients frequently seem
to be displaying agnosia (inability to recognize
familiar stimuli or situations), dyspraxia (inability to
perform coordinated movements), and abulia
(psychomotor retardation). Inappropriate ingestion
behavior appears to be secondary to faulty judgment
and lack of impulse control. Transitional phase
dissociation was the most common oral abnormality,
seen in 44% of patients. Volicer et al. (1989) have
suggested that Alzheimer’s disease patients ‘‘simply
have forgotten how to initiate the swallowing reflex,’’
and a high frequency of dissociation in the aforementioned study may reflect such a deficit.
170 O. Ekberg
https://t.me/med1917
Fig. 2 Barium swallow in a 79-year-old woman with dyspha-
gia. She coughs during eating. Compensation is often difficult
to detect on barium swallow. This patient has increased activity
in the middle pharyngeal constrictor (broad arrow). This is
likely to be due to a weak tongue base pressure. In this patient
there is also misdirected swallowing. Barium has passed
A recent study found a correlation between the
impairment of the oropharyngeal swallowing phase
and the presence of unidentified objects observed
incidentally on head magnetic resonance imaging
performed on elderly subjects (Levine et al. 1992).
Two other studies found alterations of pharyngeal
clearance and swallowing pressure in patients with
prominent cervical osteophytic formations (Ohmae
et al. 1993; Strasser et al. 2000).
7 The Ageing Esophagus
The term ‘‘presbyesophagus’’ has been used to
describe esophageal motility abnormalities in the
elderly. However, studies have shown that dysmotility
does not occur secondarily to ageing as such. However, esophageal diseases are common in all age
groups, including the elderly. Some diseases have a
relative frequency that increases with age, such as
adenocarcinoma. One must also take into account that
an elderly patient with suspected achalasia is much
more likely than a younger one to have a distal
through the vocal cords (arrow) into the subglottic area. There
is also an incoordination of the opening of the pharyngoesophageal segment seen as an indentation of the cricopharyngeal
muscle (open arrow). a Midpharyngeal stage of swallow. b One
quarter of a second after a
esophageal malignancy. Moreover, long-standing
achalasia that occurs in an elderly patient may
develop a secondary malignancy.
Symptoms of well-known diseases usually have a
more complex presentation in the elderly; therefore,
chest pain due to esophageal dysmotility or gastroesophageal reflux disease may be much more difficult
to distinguish from coronary artery disease. Moreover, chronic disorders present for a long time in the
elderly are more likely to cause complications. This
may be true for Barrett’s esophagus and adenocarcinoma of the esophagus. Esophageal dysmotility is a
major problem in the elderly. The symptoms are
characteristically related to abnormal transportation
of ingested material through the esophagus. Cardinal
symptoms are chest pain and vomiting. The major
differential diagnostic problem is to detect any
underlying mechanical obstruction such as reflux
(or other) stricture and malignancies. Characteristically strictures are symptomatic for solid foods but
not for liquids. Dysmotility is usually equally symptomatic for liquids and solids. It is always important
to consider endoscopy in this age group. If it is
The Geriatric Pharynx and Esophagus 171
https://t.me/med1917
Fig. 3 Zenker’s diverticula. These are usually asymptomatic
in younger persons (as in a, b). In a young person, Zenker’s
diverticulum is usually the only abnormality found. This is in
contrast to the situation in the elderly (as in c, d). In this patient
there is concomitant dysfunction with pooling of contrast
medium in the vallecula and in the piriform sinuses. There is
also misdirected swallowing. Although the diverticulum is
contraindicated or not available, the radiologic study
must include morphologic evaluation.
The effect of ageing on the esophageal motor
function has been studied by several authors.
Nonpropulsive, often repetitive contractions are
numerous in the elderly (Soergel et al. 1964;
Zboralske et al. 1964). Tertiary contractions and delay
bigger in the young patient in a, it is likely that most of the
symptoms are due to concomitant pharyngeal dysmotility.
However, in elderly patients the diverticulum might be huge as
in d. The diverticulum dislocates the cervical esophagus
anteriorly, and it was obvious during the examination that
there was an obstruction for bolus passage
of the esophageal emptying, as well as dilatation of
the esophagus, are also commonly seen. It has also
been shown that the distal esophageal peristaltic
amplitude is significantly higher in the elderly then in
the young (Richter et al. 1987). Interestingly, however, the proximal esophageal contractile amplitude
did not increase with age. Others have shown that the
Соседние файлы в папке Библиотека им академика М.И. Перельмана