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Biomedical & TCM Study of
Dysphagia
ATD II
AOMA Winter 2014
Swallowing, also known as
deglutition, is the process of passing
something from the mouth, into the esophagus by way of the pharynx, while
shutting the epiglottis. Swallowing is controlled by the the swallowing reflex
which can be disrupted by various conditions. When there is difficulty
swallowing it is referred to as dysphagia. Dysphagia may affect the oral
preparatory, oral propulsive, pharyngeal and/or esophageal phases of swallowing
(Palmer et al., 2000). Dysphagia can occur in any age group, often resulting
from structural damage, congenital abnormalities and/or medical conditions
(Logemann, 1998). It is a symptom with many different causes, such as cancer,
neurologic disease, stroke, and gastroesophageal reflux disease (GERD). It is of primary importance that the treating
physician takes a complete history from the patient in case the underlying
cause may be treated. Though swallowing disorders can occur at any age, they
are most prevalent among the elderly (Shamburek & Farrar, 1990).
Deglutition is a multi-step process
that involves the coordinated activity of the mouth, pharynx, larynx and
esophagus. It includes four main phases: oral preparatory, oral propulsive,
pharyngeal and esophageal. The first two phases take place in the oral cavity.
The preparatory phase involves the creation of a “swallowable” bolus, while the
propulsive phase propels the bolus into the oropharynx. When drinking liquid
only the pharyngeal phase immediately follows, with solid food there may be a
delay while the bolus accumulates into a full “swallows worth.”
Whatever
the food consistency, the pharyngeal phase involves a rapid sequence of
overlapping events. The soft palate elevates. The hyoid bone and larynx move
upward and forward. The vocal folds move to the midline, and the epiglottis
folds backward to protect the airway. The tongue pushes backward and downward
into the pharynx to propel the bolus down. It is assisted by the pharyngeal
walls, which move inward with a progressive wave of contraction from top to
bottom. The upper esophageal sphincter relaxes during the pharyngeal phase of
swallowing and is pulled open by the forward movement of the hyoid bone and
larynx (Palmer, Drennan & Baba, 2000).
In
the final esophageal phase, peristaltic waves move the bolus downward and
triggers the esophageal sphincter to relax allowing the bolus to enter the
stomach. Once the bolus enters the stomach the esophageal sphincter closes,
preventing gastroesophageal reflux (Palmer, Drennan & Baba, 2000).
Any step of deglutition can be
disrupted and may lead to dysphagia, therefore it is categorized according to
the swallowing phase that is affected. Disorders affecting the oral phase may
include the preparatory and propulsive phases and usually result from impaired
control of the tongue. When there is dysfunction of the pharyngeal phase bolus
transport to the esophagus may be impaired. This results in the bolus remaining
in the pharynx after a swallow (Palmer, Drennan & Baba, 2000). Often in
young patients, oropharyngeal dysphagia is caused by inflammatory muscle
diseases, webs, and rings. Oropharyngeal dysphagia in the elder population is
usually caused by central nervous system disorders, such as dementia, stroke,
Parkinson’s disease, or Myasthenia gravis (Malagelada et al., 2007).
Esophageal dysphagia, also known as
“low dysphagia” results in a retention of food and liquid and may result from a
motility disorder, mechanical obstruction, or impaired opening of the lower
esophageal sphincter. A web, tumor or stricture may be obstructing the
esophagus,
overactivity
of the musculature may result in spasms or weakness could lead to a reduction
propulsory force. As stated before, patients with GERD are at higher risk for
reflux esophagitis and peptic strictures which can result in esophageal
dysphagia (Palmer, Drennan & Baba, 2000). When esophageal dysphagia only
occurs with solids but never liquids it points to the possibility of a mechanical
obstruction such as a peptic stricture or carcinoma (Malagelada et al., 2007).
To diagnose dysphagia one of the
easiest and most inexpensive methods is a simple water or pudding swallow in
which the practitioner observes and records how much and how quickly the
patient can swallow (Malagelada et al., 2007). Though the water swallow is an
accurate test the gold standard for diagnosis is a modified barium swallow
study, also known as a video-fluoroscopy study. Using these techniques
physicians can view bolus transport, consistency and how head positioning
effects a patients swallowing function depending on anatomy and
physiology. An upper endoscopy, a useful
and minimally invasive tool, can be used as a follow up diagnostic technique
when structural causes are suspected (Palmer, Drennan & Baba, 2000).
If possible, the underlying disorder causing
the dysphagia should be treated. However, many of the disorders which cause it,
such as stroke, cannot be. A full history should be taken along with the patient's
current medications, especially psychotropic medications which can exacerbate
dysphagia (Palmer, Drennan & Baba, 2000). When taking the history special
interest should be taken to check for signs of malignancy such as acute onset,
weight loss, and dysphagia more for solids (Malagelada et al., 2007). Treatment
is individualized based on the functional and structural abnormalities present.
Dietary modifications are a common treatment therapy, as the patients ability
to swallow thin or thick liquids vary.
Most
patients with significant dysphagia are unable to eat meats or similarly tough
foods safely. Hence, they require a mechanical soft diet. A pureed diet is
recommended for patients who exhibit difficulties with the oral preparatory phase
of swallowing, who “pocket” food in the buccal recesses (between the teeth and
cheek) or who have significant
pharyngeal retention of chewed solid foods (Palmer, Drennan & Baba, 2000).
Swallow
therapy is another common form of treatment. There are three main kinds of
swallow therapy: exercises to perform while swallowing, postural maneuvers, and
exercises to generally strengthen swallowing muscles. Surgery is not a primary
option but may be necessary in extreme cases. Also, in cases of esophageal strictures
dilation may be required. Another treatment, enteral feeding, is rare but can
be used in patients who’s oral cavity and pharynx need to be bypassed. Enteral
feeding is founds to be necessary when a patient is unable to adequately
achieve hydration and alimentation by mouth (Palmer, Drennan & Baba, 2000).
Depending on the underlying cause of
the patients dysphagia the TCM mechanism may vary. When the underlying cause is
a more excess type pattern, in the case of GERD, it often begins with a liver Qi
stagnation which can quickly progress to the liver overacting on the stomach.
When the stomach is overacted on, the stomach Qi rebels upward causing acid
reflux (Flaws & Sionneau, 2001). Over time the continued burning of the
esophagus with heat from the stomach leads to the weakening of the local
muscles, sinews and bones. This alone can cause dysphagia but it can also lead
to local Qi and blood stagnation, like strictures, webs and tumors. For a case
of dysphagia caused by an underlying disease like GERD, subdue the rebellious
liver Qi and tonify the stomach. Points to use: LV14 to harmonize the liver and
stomach, GB34 harmonize
the liver, Ren10 and 13 to subdue the rebellious stomach Qi and stimulate it to
descend, also ST19 and 21 to descend the stomach Qi (Maciocia, 2005).
When the underlying cause is a more
deficient type pattern, in the case of stroke, Parkinson’s disease or ASL, it
often begins with a liver and kidney yin deficiency. When the liver and kidney
are deficient, the bones and sinews of the body become weak. This would lead to
difficulty swallowing due to weakness in the musculature, sinews and bones of
the oropharynx and esophagus. For a case of dysphagia caused by an underlying
disease like stroke, nourish the liver and kidney yin. Points to use: KD3, 6 to
tonify kidney yin, LV8 tonify liver blood and yin, Ren4 and SP6 to nourish and
tonify liver and kidney yin (Maciocia, 2005).
An underlying Qi and/or blood
deficiency could allow for external evils to invade into the skin, muscles,
sinews and bones locally as with a tumor. When there is a yin, Qi or blood
deficiency it is also easier for wind evil to invade internally. An inner wind
could cause neuromuscular disturbances leading to some of the underlying causes
mentioned before such as stroke, Parkinson’s disease, MS, and ALS. When there
is inner wind present remove it with Du16, 20, GB20 and 4 gates.
When you are treating a patient with
dysphagia it is important to remember to treat the symptom itself as well as
the underlying disease. Sky window points are particularly good because they
are local to the symptom but also because they “regulate the ascending and
descending of Qi between head and body”(Maciocia, 2005). Points to use: Ren22,
23, ST9, LI18, LU7 and KD6 to open
the Ren. It may also be helpful to add points which treat diseases of the
throat and diaphragm such as, LU7 and KD6 (Wu & Yip, 2004).
Flaws,
B., & Sionneau, P. (2001). The
treatment of modern western medical disease with Chinese medicine. (1st ed.). Boulder, CO: Blue
Poppy Press.
Logemann, J.A.
(1998). Evaluation and treatment of swallowing disorders. (2. ed.) Austin,
Tex.: PRO-ED.
Maciocia,
G. (2008). The
foundations of Chinese medicine.
(2nd ed.). Elsevier Churchill Livingstone.
Malagelada,
J., Bazzoli, F., Elewaut, A., Fried, M., Krabshuis, J., Lindberg, G.,
Malfertheiner, P., & Sharma, P. (2007). Dysphagia. World Gastroenterology Organization.
Palmer,
J., Drennan, J., & Baba, M. (2000). Evaluation and treatment of swallowing
impairments. American
Family Physician, 15(61), 2453-2462.
(Palmer,
Drennan & Baba, 2000)
Shamburek,
R., & Farrar, J. (1990). Disorders of the digestive system in the elderly. New England Journal of
Medicine, (322),
438-443. Organisation: 10.1056/NEJM199002153220705
Wu,
J., & Yip, F. (2004). Acupuncture
treatment of disease.
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