Schluckstörungen

Abstract

Dysphagia is related to the impairment of food passage from the mouth to the stomach. Globus pharyngis implies the frequent and often painful sensation of a lump in the throat that usually does not interfere with swallowing and may even be relieved by food intake. The diagnosis is based upon a careful history, clinical examination, endoscopy, dynamic imaging (videofluoroscopy, cinematography, videosonography) and electrophysiologic procedures (including pharyngoesophageal manometry, electromyography and pH determinations). Structural lesions of the cervical spine such as diffuse idiopathic skeletal hyperostosis are rare causes of dysphagia. Dysphagia following anterior cervical fusion as well as globus and dysphonia due to dysfunction of the vertebral joints are more likely. Symptoms with swallowing fluids indicate a neurogenic origin. Dyscoordinated swallowing, nasal reflux, dysphonia or general weakness may also occur. Chronic aspiration with respiratory compromize is the main consequence in a variety of neurological disorders as well as in cases of postsurgical dysphagia. Relaxation of the upper esophageal sphincter indicates coordinated muscle movement between the pharynx and esophagus. Dysfunction of the pharyngoesophageal segment may lead to cricopharyngeal achalasia. A dyskinetic sphincter commonly represents an extrapharyngeal cause: i.e., disease associated with gastroesophageal reflux. Disorders of the esophageal phase of deglutition can produce retrosternal pain, heartburn, regurgitation and vomiting, as well as laryngeal and respiratory signs. Esophageal motility disorders include lower achalasia, tumors, peptic strictures, inflammatory diseases, drug-induced ulcers, rings and webs. Motility disorders present with aperistaltic, spontaneous contractions, diffuse esophagospasm, or a hypermotile esophagus. Gastroesophageal reflux with esophagitis must always be excluded, especially in patients with a globus sensation. The multiple features of the appearance of the symptoms of dysphagia and globus makes multidisciplinary approach necessary in order to establish a diagnosis and begin effective treatment.

Drug-Induced Dysphagia

“…The modification of the LESP by hormones, drugs, food such as chocolate and peppermint, and liquids such as coffee and alcohol, is an important pathogenetic mechanism, which causes gastroesophageal reflux disease by decreasing the LESP (Table 2). 1,2 Drugs affecting the striated muscle portion of the esophagus act mostly via the central nervous system; these substances include sedative and narcotic agents. A direct effect on the striated muscle can be caused by muscle relaxants such as pancuronium or succinylcholine, generally used in anesthesia or intensive care units.…”

“…1,4 The multiple features of the appearance of the symptoms of dysphagia and globus make a multidisciplinary approach necessary to establish a diagnosis and begin effective treatment. The evaluation of a patient with symptoms of dysphagia involves two principal aspects: determining the functional level of swallowing ability and the etiology of the swallowing disorder.…”

“…The swallowing evaluation itself, and the impact of these other factors on decisions about the patient's swallowing safety are defined as the functional diagnosis of swallowing. 1 Dysphagia is a common clinical symptom in patients with a reduced perception of the pharyngeal mucosa, which leads to a subjective impairment of swallowing. Dysphagia may also result from viral or fungal esophagitis in patients treated with immunosuppressive drugs or cancer therapeutic agents, or antibiotics, and from immunological reactions to certain drugs such as erythema exudative multiforme or Stevens-Johnson syndrome.…”

Was bringt die chirurgische Therapie von Schluckstörungen nach dem Denecke-Konzept?

“…Schluckstörungen reichen von banalen und vorübergehenden Schluckbeschwerden bei akuten Halsentzündun-gen bis hin zu schweren Störungen mit lebensbedrohender Aspiration und der Unfähigkeit zur Ernährung [19,34]. Wir sprechen von Schlucklähmungen aufgrund nervaler Ausfälle, die als Folge von Tumoroperationen an der Schädelbasis [14] und im Schädelinneren, als Defektzustände schwerster Schädel-Hirn-Traumata und bei neurologischen Erkrankungen heute deutlich zunehmen.…”

Zur Diagnostik der postoperativen Dysphagie und Aspiration

“…Ursächlich hierfür ist meist die Resektion für das Schlucken wichtiger anatomischer Strukturen sowie auch die aus postoperativen Heilungs-und Vernarbungsvorgängen resultierenden Bewegungseinschränkungen der Pharynxmuskulatur und Sensibilitätsstörungen im Pharynx-und Larynxbereich [10,14]. Die videoendoskopische Aufzeichnung erlaubt später bestimmte Phasen des Schlukkens in Zeitlupe zu betrachten; eine Lokalanästhesie wird in der Regel nicht benötigt.…”