Two cases of submucosal haematoma of the oesophagus and Mallory-Weiss tear

Submucosal haematoma of the oesophagus is an uncommon condition which may be under-recognised. Presentation may be with chest pain, dysphagia or haematemesis. Endoscopy, CT scan, barium meal or a combination of these modalities makes the diagnosis. Most patients make a full recovery.     

An unusual cause of 'ptosis'

A 29-year-old man with a history of dental restoration procedure was referred for a left Bell's palsy. At the emergency department, he complained instead of deteriorating unilateral ptosis and dysphagia. Incidentally, trismus was also noted. He was diagnosed with cephalic tetanus, which rapidly progressed to generalized tetanus. Ptosis is an unusual presenting complaint of tetanus. In this case, we attempt to explain how facial weakness, ptosis, and cephalic tetanus are all related. We also highlight the key aspects of tetanus in relation to the emergency physician.     

A case of cephalic tetanus with unilateral ptosis and facial palsy

Cephalic tetanus is defined as a combination of trismus and paralysis of one or more cranial nerves. Cranial nerves III, IV, VI, VII, and XII may be affected, but the facial nerve is most frequently implicated. A 64-year-old female visited hospital for left ptosis followed by facial palsy after a left forehead abrasion in a car accident. At nine days post injury, left ptosis developed, left facial palsy developed twelve days post injury, and at fifteen days post injury, trismus and dysphagia developed. The following day, there was progression of symptoms to generalized tetanus, such as dyspnea and generalized rigidity. Videofluoroscopic swallow study showed penetration and aspiration. We report a case of cephalic tetanus with ptosis, facial palsy, and dysphagia, which progressed to generalized tetanus.     

Rapidly growing esophageal leiomyosarcoma: case report and review of the literature

We evaluated a 72-year-old woman who was experiencing dysphagia. Esophageal leiomyosarcoma was diagnosed by barium meal study, upper gastrointestinal endoscopy, endoscopic ultrasonography (EUS), by computed tomography (CT). A barium meal study and esophagoscopy performed 3 months before the diagnosis of esophageal leiomyosarcoma showed no abnormalities. Therefore, the tumor appeared to have grown rapidly during the 3-month period.     

Exposure risks and tetanus immunization in women of family owned farms. Implications for occupational and environmental health nursing.

A sampling pool of 4,808 farms in 10 parishes across southeast Louisiana was used to examine the risk factors of farm women who engage in activities putting them at risk for tetanus and to examine the circumstances related to vaccination. Data were collected, via stratified random sampling, in summer 1998 resulting in 657 completed interviews. Only 53.6% of women were current with a tetanus booster, having received their immunization within the past 10 years. Just as many women received tetanus vaccination following an injury or accident as for prevention. As women aged, they were less likely to be compliant. In the South, a number of environmental factors contribute to the risk for tetanus exposure and infection. These risk factors were examined in light of compliance with tetanus booster compliance. Increasing awareness of risk is essential because although tetanus is uncommon, the death rate from tetanus is greater than 30%.     

Does Dysphagia Indicate Recurrence of Benign Esophageal Strictures?

Esophageal dilatation in dysphagic patients with benign strictures is usually considered successful if the patients' dysphagia is alleviated. However, the relation between dysphagia and the diameter of a stricture is not well understood. Moreover, the dysphagia may also be caused by an underlying esophageal motor disorder. In order to compare symptoms and objective measurements of esophageal stricture, 28 patients were studied with interview and a radiologic esophagram. The latter included swallowing of a solid bolus. All patients underwent successful balloon dilatation at least one month prior to this study. Recurrence of a stricture with a diameter of less than 13 mm was diagnosed by the barium swallow in 21 patients. Recurrence of dysphagia was seen in 15 patients. Thirteen patients denied any swallowing symptoms. Chest pain was present in 9 patients. Of 15 patients with dysphagia 2 (13%) had no narrowing but severe esophageal dysmotility. Of 13 patients without dysphagia 9 (69%) had a stricture with a diameter of 13 mm or less. Of 21 patients with a stricture of 13 mm or less 14 (67%) were symptomatic while 7 (33%) were asymptomatic. Four of 11 patients with retrosternal pain had a stricture of less than 10 mm. Three patients with retrosternal pain and obstruction had severe esophageal dysmotility. Whether or not the patients have dysphagia may be more related to diet and eating habits than to the true diameter of their esophageal narrowing. We conclude that the clinical history is non-reliable for evaluating the results of esophageal stricture dilatation. In order to get an objective measurement of therapeutic outcome, barium swallow including a solid bolus is recommended.     

Foreign body sensation: A rare case of dysphagia lusoria in a healthy female

Dysphagia lusoria is a rare disease due to an aberrant right subclavian artery that passes posteriorly between the esophagus and the spine. David Bayford coined the term itself meaning "freak or jest of nature" in 1761 describing a case in which the patient had long term dysphagia that eventually led to death. Most cases of dysphagia are due to an aberrant right subclavian artery running posterior to and causing esophageal compression, but only 20-40% of aberrant arteries actually lead to trachea-esophageal symptoms, including dysphagia. The majority of patients with an aberrant right subclavian artery are asymptomatic. Treatment for dysphagia lusoria varies depending on the severity of the symptoms. Dietary modifications are recommended in patients with mild to moderate symptoms while vascular reconstruction is necessary for patients with severe symptoms. We present a 44-year-old female who was diagnosed with dysphagia lusoria due to a right-sided aortic arch and aberrant left subclavian artery (ALSA) with aneurysmal dilation. Right aortic arch with ALSA is an uncommon arch anomaly, and only occurs in about 0.05% of the population. Prior case reports of dysphagia lusoria differ in that they did not report patients with an uncommon presentation of dysphagia lusoria with aneurysmal dilatation nor was the patient diagnosed in the emergency department.     

Dysphagia. Pathophysiology, causes, and evaluation

The two types of dysphagia, oropharyngeal and esophageal, involve different phases of swallowing, are accompanied by different symptom complexes, and have different etiologies. They can usually be distinguished by history, which often will also suggest the specific cause. The initial evaluation of oropharyngeal dysphagia entails a general history and physical examination, careful examination of the pharynx and hypopharynx, and barium esophagography (preferably with videotape recording). The initial evaluation for esophageal dysphagia entails barium esophagography and fiberoptic endoscopy. Esophageal manometry is indicated when a motor disorder is suspected.     

电视荧光放射录相术对脑卒中后吞咽障碍患者的评估价值

背景电视荧光放射录相术(videoflurography,VFG)可以了解吞咽过程中不同时相的通过时间,有无钡剂残留和误吸,从而了解吞咽障碍的特点,对临床制定治疗计划有一定的参考价值,在国外早已普遍应用.目的探讨VFG对脑卒中后吞咽障碍患者的评估的价值.设计非随机、标准对照、开放实验,前瞻性研究.地点和对象在中国中医研究院广安门医院神经内科病房选择脑卒中后吞咽障碍患者60例.同时向社会招募健康中老年人20例.干预以上两组由中国中医研究院广安门医院放射科王德文医师行VFG检查.主要观察指标分别记录两组受试者吞咽稀钡及半胶钡(含钡面糊)过程中的口通过时间和咽通过时间,并评价口、咽功能,记录有无舌肌运动减弱,钡剂残留梨状隐窝、会厌谿,是否误吸入气管.结果①吞咽障碍组各吞咽时间相通过时间均较健康中老年组延长.②会厌谿钡剂残留在患者中发生率最高,梨状隐窝钡剂残留发生率较高.③脑干病变组各病理征象发生率均高于大脑半球病变组.经统计学处理,脑干病变组与大脑半球病变组误吸发生率差异有显著性意义(P＜0.05).结论VFG可以对吞咽全过程特别咽时相的病理征象进行更详细的观察,是脑卒中后吞咽障碍检查的有效方法.     

Effectiveness of esophageal dilation in relieving nonobstructive esophageal dysphagia and improving quality of life

OBJECTIVES: The role of empiric esophageal dilation in improving esophageal dysphagia with nonobstructive esophageal lumen is not clear. We wished to determine the impact of esophageal dilation with a large-diameter dilator on dysphagia and quality of life in such patients. We also assessed relative prevalence of esophageal versus oropharyngeal dysphagia and nonobstructive versus obstructive esophageal dysphagia in ambulatory patients. METHODS: Ambulatory patients presenting with swallowing complaints were evaluated by history and physical examination, speech therapy evaluation, dynamic barium oropharyngeal swallowing study, and barium esophagram plus upper endoscopy. Patients diagnosed as having nonobstructive esophageal dysphagia were offered participation in the study. Eligible candidates were randomized to either 56-French (the study group) or 40-French (the control group) Pilling dilators. All patients were treated with proton pump inhibitors. Patients completed questionnaires for dysphagia score, diet score, and quality of life (SF-36) at baseline, at 1 month, and then at follow-up visits at 1- to 3-month intervals for up to 12 months. RESULTS: Of the 125 patients complaining of swallowing difficulties, 6 (5%) were diagnosed as having oropharyngeal dysphagia and 119 (95%) had esophageal dysphagia. Of the patients with esophageal dysphagia, 84 (67%) had nonobstructive dysphagia. A total of 30 patients participated in the study. Seventeen patients were randomized to the study group and 13 were randomized to the control group. The baseline dysphagia, diet, and quality-of-life scores were comparable between groups. Dysphagia in both groups improved after dilation compared with baseline; however, the difference in the degree of improvement between the two groups was not significant. In addition, there was no significant difference in improvement of the quality of life between the two groups. CONCLUSION: Most patients with esophageal dysphagia have a nonobstructing esophageal lumen. Our prospective, randomized, controlled study does not support the practice of empiric esophageal dilation for patients with nonobstructive esophageal dysphagia. Improvement in both groups suggests the possibility that it occurred due to proton pump inhibitor therapy, lending credence to the hypothesis that esophageal hypersensitivity to acid contributes to symptoms in most patients with nonobstructive esophageal dysphagia, which is the predominant category of dysphagia.     

Inappropriate ADH secretion in tetanus

Of 99 patients with adult tetanus, 7 developed the clinical and biochemical features of the syndrome of inappropriate antidiuretic hormone secretion (SIADH). The diagnosis for these 7 patients was severe tetanus (dysphagia with frequent severe spasms); 5/7 patients had evidence of autonomic overactivity (tachycardia, sweating, cardiovascular lability, and hypersalivation). They all responded favorably to fluid restriction, SIADH was self-limited and resolved as the disease regressed.     

Severe Dysphagia after botulinum toxin B injection to the lower limbs and lumbar paraspinal muscles

We report a case of severe dysphagia in a 29-yr-old woman with cerebral palsy after she was injected with botulinum toxin B to her lower limbs and lumbar paraspinal muscles. Four days after the treatment, she developed difficulty swallowing, more severe for solid foods than for liquids, accompanied by dry mouth, blurred vision, and voice hoarseness. Fifteen days after the injection, with worsening of her dysphagia, she was hospitalized. A laryngoscopic evaluation revealed bilateral vocal cord paresis, and a modified barium swallow test demonstrated delayed oral initiation, upper airway penetration, and no reflexive cough. In the following days, she improved spontaneously and was discharged 12 days later when she re-acquired the ability to swallow solid foods. Her symptoms resolved completely only 75 days after the injection. Although dysphagia is a common side effect of botulinum injection in the neck, to our knowledge, this is the first reported case of severe dysphagia after injection in a distant anatomic site.     

“Discphagia”: A case report

An anterior herniated intervertebral disc at the low cervical level caused dysphagia and an extrinsic impression on the esophagus seen on barium swallow. This entity should be added to the differential diagnosis of extrinsic esophageal defects.     

Solid-state computerized manometry improves diagnostic yield in pharyngeal dysphagia: simultaneous videoradiography and manometry in dysphagia patients with normal barium swallows

Objective:

Dynamic barium radiology with cine- or video recording has been the most frequently used technique for assessing patients with pharyngeal dysphagia. Although the diagnostic yield of the barium swallow has been high, many patients with pharyngeal dysphagia have normal dynamic barium radiology and remain a diagnostic dilemma. Could manometry add important diagnostic information in these patients?

Material and methods:

We examined 19 patients (12 men and 7 women, mean age 47 years, range 19–69 years) with pharyngeal dysphagia but a normal barium swallow with simultaneous videoradiography and pharyngeal manometry and compared their manometry to that found in 24 normal volunteers (11 men and 13 women, mean age 37 years, range 23–59 years).

Results:

Comparing mean values, the patient group showed statistically significant differences from the control group for eight of 10 manometric parameters. Fourteen of 19 patients showed at least one (five patients) and in most cases multiple (nine patients) manometric abnormalities (values exceeding normal mean by ±2SD) which might have contributed to their dysphagia: five patients with high upper esophageal sphincter (UES) resting pressures, five with high LIES residual pressures, three with weak pharyngeal contractions, three with pharyngeal “spasms,” seven with prolonged contraction/relaxation times, five with reduced compliance, and seven with UES/P incoordination.

Conclusions:

Solid-state computerized manometry is a useful adjunct to videoradiography and can provide potentially important additional information in the diagnosis of dysphagia patients.     

Dysphagia. Diagnostic pitfalls and how to avoid them

Oropharyngeal and esophageal dysphagia involve different phases of swallowing, have different causes, and can usually be distinguished by a thorough patient history. Initial evaluation of patients with suspected oropharyngeal dysphagia includes patient history, physical and neurologic examination, and careful videofluoroscopic study of pharyngeal dynamics. Initial evaluation of patients with suspected esophageal dysphagia includes patient history and barium swallow with esophagography. Lesions such as Schatzki's ring or peptic stricture may not be detected unless the esophagus is sufficiently distended and the patient is given a bolus challenge.     

电视透视下吞咽能力检查在口咽期吞咽障碍中的应用

目的 分析吞咽障碍患者电视透视下吞咽能力检查(VFSS)结果.方法 16例知情同意吞咽障碍患者接受VFSS检查.分别采用稀钡餐(50％ w/v)、稠钡餐(270％ w/v)、饼干沾稠钡餐进行咀嚼测试.一口量为10 ml.采用正位、侧位动态造影测试,依次观察双侧梨状窝对称情况、口期时长、咽期起始时间、咽期时长、滞留、误吸及其时间、剂量等.结果5例为口期吞咽障碍;3例为咽期吞咽障碍,显示存在咽期起始迟缓,并且有1例表现为吞咽后误吸;8例为口咽期吞咽障碍,其中5例不伴误吸,3例伴有误吸,其中2例为安静误吸,1例表现为吞咽前误吸,1例表现为吞咽后误吸(梨状窝滞留引起),1例无法判断误吸时间.4例误吸患者中,3例存在钡剂25％以上的重度误吸,1例存在5％的轻度误吸,同时配合吞咽康复治疗.结论VFSS检测可为制订吞咽障碍的康复方案提供参考.     

The effect of nasogastric tubes on swallowing function in persons with dysphagia following stroke

OBJECTIVE: To determine whether the use of a nasogastric tube influences swallowing function in stroke patients with dysphagia. DESIGN: Before-after trial. SETTING: Primary care center. PARTICIPANTS: A total of 22 patients with stroke (12 men, 10 women; mean age, 69.7 y; range, 19-85 y) participated in the study. Time from onset of stroke to time of assessment averaged 20.3 days (range, 14-38 d). All participants continued to use a nasogastric tube for nutrition supply and had either minor or no aspiration of barium on videofluoroscopic examination of swallowing (VFES). INTERVENTION: The swallowing function was evaluated by VFES with thin and thick bariums (5 mL each) as a contrast medium. MAIN OUTCOME MEASURES: The oral transit, swallowing trigger, and pharyngeal transit times were measured and compared before and after the removal of the nasogastric tube. The patients were also observed for changes in velopharyngeal closure, pharyngeal contraction, epiglottic tilt, valleculae stasis, pyriform sinus stasis, penetration, and aspiration. RESULTS: Transit times were reduced by 0.2 to 0.6 seconds after removal of the nasogastric tube, but the reduction was not statistically significant. These transit times were slightly longer with thick barium than with thin barium, but were without statistical significance. Similarly, most of the patients had no change in nontemporal assessment of swallowing function after the tube was removed. CONCLUSIONS: The placement of a nasogastric tube did not affect temporal and nontemporal measurement of swallowing in stroke patients with dysphagia with or without minor aspiration.     

Endoscopic and radiological features of intramural esophageal dissection

A 41-year-old woman was admitted to our hospital complaining of chest pain, dysphagia, and odynophagia after an upper respiratory tract infection and nasogastric tube insertion. An upper endoscopy showed a large submucosal bulge along the posterior wall from the upper esophagus with mucosal tears and bridge formation, extending down to the lower esophagus. A barium esophagogram revealed a "double-barreled" esophagus, and chest computed tomography (CT) scan showed eccentric thickening of the esophageal wall. The diagnosis of intramural esophageal dissection (IED) was made and the patient was managed conservatively with nothing by mouth and intravenous hydration. The clinical course was uneventful; the patient was discharged later and up to the time of writing has been completely asymptomatic, with normal swallowing function.     

Videofluoroscopic evaluation of HIV/AIDS patients with swallowing dysfunction

Background: We investigated the association of abnormalities of the swallowing mechanism in the oral and pharyngeal phases of swallowing with symptoms of dysphagia and painful swallowing in patients with human immunodeficiency virus (HIV). Methods: Seventeen patients, two with HIV and 15 with acquired immunodeficiency syndrome (AIDS), with symptoms of dysphagia or pain on swallowing for routine barium esophagograms were studied prospectively by videofluoroscopic examination of the oropharynx in addition to a routine biphasic esophagogram. The videofluoroscopic studies were performed in conjunction with a speech pathologist. Results: All 17 patients demonstrated abnormalities in the oral, pharyngeal, or esophageal phase of swallowing. Eight patients aspirated, six of whom did not exhibit a cough reflex and were classified as silent aspirators. Seven of the eight patients who aspirated had chest radiographs consistent with aspiration pneumonia. Conclusion: A significant number of HIV-positive and AIDS patients with dysphagia or pain on swallowing have dysfunction of the swallowing mechanism and are at risk for aspiration.     

Evaluating dysphagia

Dysphagia is a problem that commonly affects patients cared for by family physicians in the office, as hospital inpatients and as nursing home residents. Familiar medical problems, including cerebrovascular accidents, gastroesophageal reflux disease and medication-related side effects, often lead to complaints of dysphagia. Stroke patients are at particular risk of aspiration because of dysphagia. Classifying dysphagia as oropharyngeal, esophageal and obstructive, or neuromuscular symptom complexes leads to a successful diagnosis in 80 to 85 percent of patients. Based on the patient history and physical examination, barium esophagram and/or gastroesophageal endoscopy can confirm the diagnosis. Special studies and consultation with subspecialists can confirm difficult diagnoses and help guide treatment strategies.