Approach to dysphagia:
- Oropharyngeal vs esophageal? (ask patient if they can tell where food gets stuck)
- Oropharyngeal: think about neuromuscular disease, myopathies, structural lesions, metabolic (eg thyroid), infections (eg CMV, candida esophagitis), iatrogenic (eg radiation, meds)
- Esophageal: motility vs obstructive (ask patient if it’s solids, liquids, or both)
- Motility (solids + liq): neuromuscular (eg achalasia, diffuse esophageal spasm, scleroderma, Chagas)
- Structural (solids>liquids): intrinsic (tumors, strictures, webs, rings) vs extrinsic (left atrial/aortic enlargement, mediastinal mass, etc)
- Most common oropharyngeal cause = neurogenic/myogenic, most common esophageal cause = mechanical/motility issue
Management of acute inspiratory stridor – Remember your ABCs! worry about upper airway obstruction and impending respiratory compromise!
- Intubate if needed (will need to be intubated under direct visualization) (NIPPV is probably not helpful in these patients)
- If lesion is above the vocal cords and hard to intubate, consider cricothyrotomy or tracheostomy
- Urgent ENT eval for direct visualization/tx
- Racemic epi to acutely reduce edema if that is the cause
- Heliox may help reduce turbulent flow across obstruction but not routinely used
Manifestations of rheumatoid arthritis:
- Symmetric synovitis is characteristic! Esp of small joints of the hands (PCP and PIP, not DIP!), wrist, and forefoot. Can lead to reduced grip strength!
- Axial involvement – rare, except cervical (20-50%) – remember atlantoaxial (C1-C2) involvement! Rarely, can cause spinal cord compression
- Cricoarytenoid joint – involved in 30%! Symptoms include hoarseness and inspiratory stridor!
- Can’t be diagnosed with imaging! Need direct visualization with ENT (just like how you can see synovitis on exam of other joints!)
- Great article from rheum of 3 cases of RA manifested as acute stridor: Peters JE et al., Clin Rheumatol 2011; 30(5): 723-7 (attached here!)
- Other joints: Acromioclavicular, sternoclavicular, temporomandibular
Ddx for bilateral vocal cord paralysis – a short list, thanks to Anna!
- Infiltrative – amyloid/sarcoid
- Infectious – TB
- Malignancy – esp SCC
- Postsurgical/postprocedural – post-intubation, post-thyroidectomy
- Neuro – myasthenia gravis, motor neuro diseases like ALS
Bonus #1: Ortner’s syndrome: hoarseness from massively dilated left atrium or left pulmonary artery leading to compression of left recurrent laryngeal nerve
Bonus #2: a nice diagram of flow loops on spirometry depending on where you have obstruction (upper airway vs COPD) and a few other scenarios 🙂