what's up Ninja nerds in this video today we're going to be talking about dysphasia that includes oral fenial dysphasia and esophageal dysphasia this is a part of our clinical medicine section if you guys really do like these videos they help you they support your understanding please support us and you can do that by hitting that like button you can comment down in the comment section or you can subscribe another thing that I really urge just for your overall benefit because I think it really will be crucial to your understanding of this topic is if you go down the description box below there's a link that goes to our website on our website we have amazing things that our team has really worked hard to develop things like notes illustrations quiz questions as well as we're even developing an exam prep course so go check that out and really help yourself to understand these topics even more let's talk a little bit about now dysphasia so what is dysphasia so it's difficulty swallowing but we have to take a little bit more of them a detailed look at this so when we talk about oral fenial dysphasia it's really the difficulty in being able to initiate swallowing so you know the process of swallowing called Del glutation it really involves so many muscles and whenever there is this difficulty in being able to initiate the swallowing process this super super suggests oral fenial dysphasia so let's write that down so it's difficulty initia and I think that really helps you to understand this and I think often times when you're going to your patients and you're asking them these things I think this is the best way to kind of describe it to them like are you having difficulty kind of initiating the swallowing process that may help you another thing that I really think kind of sets apart oral fenal from aop agal dysphasia is ask them questions because oftentimes there's a lot of these upper kind of muscles here is the fenial muscles the uila the soft pallet these not only help to initiate the swallowing process but they're supposed to prevent like regurgitation so sometimes if patients also complain of choking or they feel like they're coughing a lot or they're having a lot of like regurgitation up into the nose that's super suggestive of oral fenial dysphasia much much more so than esophageal dysphasia so really think about that difficulty initiating the swalling process plus the combination of coughing choking and really big one nasal regurgitation that really suggests more specifically the orphal so with orial it comes down to two particular things one is the nerves that come from your brain and spinal cord that come to these muscles that help to contribute to the swallowing process something's wrong with these so there's some type of neuromuscular dysfunction or there's something that's impeding the actual Lumen of the upper parts of your git so again it's some type of Str structural dysfunction or it's a neuromuscular dysfunction let's now talk about those two things now so if it's structural dysfunction it has to be in the upper parts of the git so here I have representing particularly the ferx in red and then here we come to the esophagus so in order for this to be oral fenial it can't involve the esophagus it has to involve the fings so what we use as the Lark is the upper ESOP sphincter of the esophagus right above that what ends up kind of becoming a problem is in older individuals they can develop a disease called a ziners diverticulum and I think one of the big things here is that these are usually older patients and they have very very foul smelling breath like and the reason why is when food and fluids are usually coming down this this way right to move through the ferin into the esophagus Sometimes some of this food will move in here and some of it will kind of get stuck which will represent in kind of this brownish color here some of this food will kind of get stuck in here and kind of get metabolized and this is why these patients often times have very terrible foul smelling odor odor uh to their breath but this is one potential cause so one of the reasons why these patients have difficulty swallowing is because of the ziners diverticulum that would be the structural problem here another reason would be the nerves and muscles are injured so maybe there's not anything structurally it's something nerve muscle so you have to know that your central nervous system has upper motor neurons and it has lower motor neurons that go to different parts of your body and sometimes you even have cranial nerves that also go to particular muscles so whenever you have some type of injury of any of the these nerve structures do you think you're going to get a really good Fingal contraction to help to move things along the fering and Propel it into the esophagus no and so that usually was the problem here is that the issue in this disease is that you're trying to move things from the ferx into the esophagus and it just isn't happening so there is a inhibition if you will of propulsion so you're inhibiting the propulsive action and I think that's the best way of describing this pathology so what are some of these particular CNS disorders that affect the nerves well some of these they can really be pretty variable they're more chronic and I think that's the important thing to remember usually it's things like ALS so degeneration of the anterior motor neurons or it could be Parkinson's which is usually some type of Destruction of the substanti and sometimes it could even be multiple sclerosis and I think these are some of the more chronic diseases that you could see these particular types of factors all right but again it's some type of nerve disorder the other one is it often can be acutely and sometimes chronic it could be a neuromuscular Junction disorder and we do see this at times and a disease called we're going to abbreviate this myasthenia gravis this is a neuromuscular just Junction disorder where they have antibodies that are attacking the acetylcholine receptors but the same concept exists is that in this situation it's the nerves in this one it's a problem where the reception of the signal at the muscles is impaired okay so I think these are the big things that you have to be able to think about here is it some type of neuromuscular ular disorder or is it a structural disorder often times these don't just cause problems with just dysphasia you may have just weakness you may have features of Tremors you may have optic neuritis opthal plasia types of features with this one you may have other muscles that are weak besides this one you may also have diplopia due to weakness of some of the extraocular muscles so there's not just one particular area look for other ones that are affected and if you see multiple types of nerves that could be affected you're thinking more neuromuscular dysfunction if you aren't really seeing that then you're starting to think more about the ziners especially in an older individual okay let's come down now and talk about a Sagal dysphasia so with a Sagal dysphasia the issue with this one is it's not an issue with initiating swallowing you can initiate it so food will move easily from the ferx into the esophagus but it's getting it through the esophagus into the stomach that's the problem so often times with this one it's it's kind of What patients usually describe as is food is kind of getting stuck in their esophagus but it's difficulty moving substance we'll say put food or fluid through esophagus and often times they'll describe this as a sensation of food is getting stuck in their kind of throat or in this case the esophagus though and it's usually because something is impairing the movement through here maybe it's an actual obstruction or maybe it's the nerves and the muscles that are involved in the wall of that esophagus aren't functioning correctly so let's talk about those if it's a structural dysfunction there's a lot of different causes all I'm doing is I'm taking a section of the ESOP esophagus here and I'm zooming in on it what if I have a kind of like really narrow esophageal Lumen maybe in this particular situation it's super inflamed really inflamed you know there's a disease it's called esophagitis esophagitis you know there's so many different types I'd say reflux esophagitis in the scenario of gird is probably the most common so look for patients who have heartburn but it could also be pill induced it could also be EOS cilic so look for patients who have histories of allergies and then on top of that it could be potentially infectious usually you're looking for that in a patient who has HIV AIDS or they're immunosuppressed but I'd say out of these esophagitis will definitely be one thing that it's going to cause inflammation and it's going to make it hard to move things through this tiny little hole okay another one is especially with reflux esophagitis can cause these things called strictures which is like fibrosis so now just add a little bit bit of fibrous tissue here around this and again you kind of have like an inflamed or fibrotic area there it's going to narrow the Lumen it's going to interfere with interfere with the normal movement of substances through the esophagus so those are two things that I would want you guys to remember something that's super narrowing that esophagus another one is we see this in the upper esophagus I would really want you to remember that this is more in Upper esophagus and this is usually something where patients have like this weird like web it kind of like protrudes in only on one side so imagine it kind of like a shelf and it protrudes in only on kind of like one side it doesn't completely circumferentially kind of olude the actual Lumin of the esoph is it kind of just butts in out of one side and usually this is what we call an esophageal web we call this an esophageal web usually this one can be associated with iron deficiency anemia and it can also be associated with like inflammation of the tongue they call this disease plumber vinen syndrome and so often times you may see that terminology of plumber vinon syndrome where patients have iron deficiency anemia glossitis and an esophageal web so they're having dysphasia so these are things that I want you to think about with that one the next one is it is circumferential so you have a ring if you will a very thin kind of shelf and it protrudes in to the entire Lumen and circumferentially udes that Lumen what is this one called big thing to remember is that this is primarily in the lower esophagus this one is a ring and so we call this an esophagal ring they also call this shotsky ring this one is usually associated with gird so sometimes in patients who have gir you can get a lot of reflux you can cause esophagitis but sometimes you create this circumferential ring that includes the Lumen so in this one we're occluding the Lumen and this one we're occluding the Lumen this one we're occluding the Lumen okay it's just in different scenarios look for patients who have history of reflux or strictures because of their reflux usually benign strictures it could be malignant look for history of Plummer vinen Syndrome look for anything that makes you think about shotski's Rings okay usually lower esophagus the last one is you have a tumor and this is probably a really sad one but if you have some type of neoplasia that's kind of protruding into the Lumen here that would also be a big one so if I see some type of like vascular type of like Mass here that would definitely be a trigger so think about esophageal cancer okay and this could be in the form of cancer or malignant strictures but either way in this concept here these are uding the Lumen usually with this one you would see other features potentially GI bleeding nausea vomiting anorexia weight loss so you'll see other features that suggest more of a cancer presentation as compared to a lot of these but it can be difficult at times so if it's not structural the next thing that you have to think about is it could it be neuromuscular or functional and so with this one this is usually a nerve or muscle disorder and there is a bunch of nerves that actually kind of Supply the muscle here it's called the mayic plexus I'll represent this in kind of this purplish maroonish color there's a disease called acalasia and in acalasia the problem with this disease is that these these nerves aren't working very well okay there's decreased function of this myeric plexus and what happens is is these patients they have a very high lower sulag sphincter tone because these M Flex are supposed to kind of relax that it doesn't and they have decreased contraction of the mid distal esophagus right so decrease contractility of esophagus but they can't relax their lower esophagal sphincter and so the pressure there is really high and often times when you look at this under Imaging it shows that class bird's beak type of appearance that's one really big thing so acalasia could be one these patients will have dysphasia the other one though is going to be causes an intense chest pain usually so this one usually causes an intense retrosternal chest pain and it's called esophagal spasm sometimes they even call it diffuse esophageal spasm because it really does affect the entire esophagus in this sense but what happens here is it's not to do with the the nerves it's the muscles the muscles for some weird reason create this kind of like rhythmic but irregular High amplitude contractions so the muscle will just go ham and it'll really cause the contractility of the esophagus to be disorganized and just really funky and it won't be synchronized and so what you'll see is is you'll see multiple areas of peristalsis occurring here but not in a sensial type of manner because it's supposed to be contract relax contract relax here you have a bu a bunch of different areas Contracting at the same time one thing to remember is that it doesn't really affect the lower Sagal sphincter so that pressure there is usually kind of like normal and so when you get a chest x-ray um on this one I'm sorry a barium swallow on this one often times these patients have like this weird type of cork screw pattern um on their their actual barium esophogram the last one is called Scleroderma and this one's kind of interesting in the sense that it's just usually the muscle is becoming fibrotic so all this muscle tissue is kind of atrophying and you're having lots and lots of fibrosis due to autoimmune disease so you're having destruction of the actual smooth muscle and then tons of fibrosis that is occurring of this actual tissue here and so what these patients usually experience is is really low contra ility and low esophagal spinter pressure right so they have low contractility of esophagus and their lower esophageal sphincter pressure is relatively low and I think this is really important to remember for this one it's usually kind of look for other features so this one intends chest pain this one usually not super super obvious except if you get that kind of barium swallow for this this one you're usually looking for that classic Crest syndrome so calcinosis rain outs phenomenon esophageal dismotility sclerodactyly so they have weird hands and then tangc Tasia some of those skin manifestations and so I think that's a big thing to look out for as kind of a cue to think about Scleroderma but at this point now we have a patient they come in they're having man I'm having difficulty being able to initiate swallowing coughing choking regurgitation or fenial if they say I'm having difficult we're kind of getting the food through my sophus it feels like it get stuck somewhere Sagal then think is it structural is it an obstruction like a iners or is it strictures webs Rings cancer or is it neuromuscular is it ALS Parkinson's is it a stroke that they had in the past is myasthenia gravis or is it neuromuscular for esophagal is it acalasia are they having terrible chest pain the gagal spasm do they have any Crest bindings think about Scleroderma all right now that we've talked about dysphasia pretty decently let's now go into how do we diagnose dysphasia so first thing is it difficulty initiating swallowing if it is that's likely oral fenial and then I just got to think it's either structural or functional well structural usually one of the best tests that's easy it's noninvasive is a barium swallow and what they'll do is you have the patient chug some barium and it's really kind of like highlights on x-rays so you'll have them do that and if it's abnormal it's probably a structural cause meaning I filled a little defect that little kind of like pocket so it's probably as zers reticulum and if you see here on this barium swallow here's the filling of that contrast into that little ziners and that would tell you that's likely their cause if it's normal it really doesn't again exclude the fact that it's not a neuro problem and so from here we say Okay it definitely could be a neuromuscular disease I got to do a full neuromuscular workup do they have a stroke do they have a history of Parkinson's disease do they have a history of ALS or do I need to work them up for Myasthenia that's a little bit more of an in-depth discussion that we won't kind of talk about here the next one is if a patient has sensation of food getting stuck that really fits more of the Gambit of esophageal dysphasia again it's not a bad thing to obtain a barium swall I just think it's important to remember that it's not going to be very specific it may help you to see that there's kind of a narrowing of parts of the esophagus which could tell you hey there's probably some type of like structural cause but it won't tell you the exact type of structural cause and I think that's important to remember so we're still kind of left after that doing it saying H still could be a structural or neuromuscular cause there is some things that we'll highlight that we'll talk about a little bit more for example in the esophagitis lecture and in the um esophagal motility disorders lecture but for right now what I want you to trust is that when a patient has a really significant esophagal dysphasia one of the kind of perfect tests to go to here is an EGD so this is kind of like a esophago gastroscopy and you're basically looking at the ESOP esophagus the stomach and the dadum but in this case you're really just looking at the esophagus and you get a good visualization of it if it's abnormal then we can kind of say oh what is it if I can visualize these uh kind of anomalies I can say oh look at that there's a complete circumferential ring here and this is usually at the lower esophagus this is probably a shotsky ring all right beautiful that's likely the diagnosis oh I see this incomplete or kind of asymmetric kind of shelf popping out from the upper part of the esophagus oh that's probably esophagal web correlated if they have Plum rincent syndrome as well esophagal cancer you'll be able to see a pretty nasty neoplastic Mass we'll talk about that in the Cancer's lectures and then esophagitis will'll talk about that more in the actual lecture itself because there's different forms of esophagitis that we should have an idea of what those types of esophagitis pictures look like but you'll be able to see pretty significantly the esophagitis now for most part usually you do an EGD to rule out things like cancer and then to ex you know include is it these types of diagnoses here if it's normal it doesn't mean that there isn't a neuromuscular cause and so usually what we do is we for the gold standard of esophagal motility disorders is you do manometry you take a probe you put it down the esophagus and you measure the pressures in the esophagus and it's really cool we'll talk about it more in the esophagal motility lecture but it will really help you to identify the neuromuscular cause it is the gold standard because it'll show acalasia has poor motility in the mid distal esophagus and high lower esophageal sphincter tone the next one that I want you guys to remember here is Scleroderma Scleroderma we'll talk about a little bit more in the sage motility disorders but usually there's really not a good contraction of their mid disal sagus so they have low amplitude waves there and then their lower Sagal spinter also pretty weak so you have low amplitude waves there and the last one is diffusive Sagal spasm intense contraction High amplitude waves that you'll be able to see and their mid distal sagus whereas their tone in lower Sagal fingers is relatively normal and that'll really help to kind of outline the causes of dysphasia especially the esophageal type all right my friends so I hope that you guys enjoyed this lecture um thank you guys for everything thank you guys for watching these videos and as always until 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