Causes of Oculopharyngeal Muscular Dystrophy
List of causes of Oculopharyngeal Muscular Dystrophy
Following is a list of causes or underlying conditions
(see also Misdiagnosis of underlying causes of Oculopharyngeal Muscular Dystrophy)
that could possibly cause Oculopharyngeal Muscular Dystrophy includes:
- The condition is inherited
Oculopharyngeal Muscular Dystrophy Causes: Book Excerpts
Related information on causes of Oculopharyngeal Muscular Dystrophy:
As with all medical conditions,
there may be many causal factors.
Further relevant information on causes of Oculopharyngeal Muscular Dystrophy may be found in:
Causes of Oculopharyngeal Muscular Dystrophy: Online Medical Books
16 MEDICAL BOOKS ONLINE!
Review excerpts from medical books online, free, without registration,
for more information about the causes of Oculopharyngeal Muscular Dystrophy.
Dysphagia:
Differential Diagnosis
(In a Page: Signs and Symptoms)
- Intrinsic esophageal lesions
–Gastric acid reflux
–Esophageal webs and rings
–Radiation-induced inflammation and
stricture formation
–Trauma
–Esophageal perforation
–Diverticula
–Malignancy
–Postsurgical
–Foreign body retention
- Extrinsic lesions
–Anterior cervical osteophyte
–Mediastinal mass (e.g., thymoma, teratoma, lymphoma, carotid/aortic aneurysm)
–Post-thoracic surgery or anterior cervical
discectomy
–Enlarged thyroid
–Thyroglossal duct cyst
- Aberrant motility
–Hypertensive lower esophageal sphincter
–Nutcracker esophagus
–Scleroderma
–Achalasia
–Diffuse esophageal spasm (DES)
- Neurological causes
–Myopathies (e.g., polymyositis, inherited)
–Neuromuscular junction disorders (e.g., myasthenia gravis, botulism)
–Polyneuropathies (e.g., diabetic,
Guillain-Barré syndrome, toxin-related)
–Brainstem stroke
–ALS
- Less common etiologies (“zebras”) include globus hystericus (psychogenic dysphagia), anxiety disorders, hypothyroidism, amyloidosis, dysphagia lusoria (extrinsic esophageal compression due to aortic arch anomalies), left atrial enlargement, and Chagas’ disease
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Source: In a Page: Signs and Symptoms, 2004
Ptosis:
Differential Diagnosis
(In a Page: Signs and Symptoms)
-
Differentiate from lid edema (e.g., post-trauma), pseudoptosis/dermatochalasis (excess skin of upper lids), enophthalmos (narrowed palpebral fissure), hypotropia, contralateral eyelid retraction causing asymmetry, small eye (phthisis bulbi, microphthalmia, anophthalmia)
-
Acquired -
Aponeurotic or senile ptosis
–Most common type of ptosis
–Caused by disinsertion or dehiscence of the levator aponeurosis
–Normal levator function, high lid crease
–May be exacerbated by any ocular surgery -
Mechanical
–Caused by mass effect of tumor or edema or by tethering by scar (cicatricial)
-
Myogenic
–Poor levator or Müller's muscle function
–Myasthenia gravis (variable ptosis)
–CPEO
–Myotonic dystrophy - Neurogenic
–Third nerve palsy [associated supraduction deficit; may also have adduction or infraduction deficit, eye may be down and out; mydriasis]
–Horner's syndrome [associated with miosis (1–2 mm pupil), “reverse ptosis” (lower lid higher), and often anhidrosis]; due to many etiologies, including Pancoast tumor and neuroblastoma
Congenital
-
Simple congenital (myopathic) ptosis
–Poor levator function, lid lag in downgaze
–Subset of blepharophimosis syndrome
(bilateral ptosis, horizontal shortened palpebral fissures, and telecanthus with dominant inheritance)
-
Congenital Horner's syndrome (associated with vertebral anomalies)
-
Marcus Gunn jaw-winking syndrome (unilateral ptosis at rest; when chewing or opening mouth the ptotic lid raises up)
-
Mitochondrial myopathies
» READ BOOK EXCERPT ONLINE »
Source: In a Page: Signs and Symptoms, 2004
Dysphagia:
Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)
-
A problem with any phase of swallowing may cause dysphagia
Oral preparatory phase
-
Decreased salivation
-
Nasal obstruction: Inability to breathe through nose may cause problems with swallowing in neonates and young infants
Oral phase
- Cleft palate and velopharyngeal insufficiency: Inability to separate the nose/nasopharynx from the mouth may lead to nasal regurgitation during swallowing
–Hypertrophic tonsils: Mechanical obstruction to swallowing
–Neuromuscular problems: Prematurity, cerebral palsy, Duchenne muscular dystrophy, Guillain-Barré syndrome, Riley-Day syndrome all lead to poor coordination of swallow
Pharyngeal phase
-
Congenital defects such as vallecular cysts or laryngeal cleft
–Inflammatory response; e.g., GERD
–Infectious processes
–Viral and bacterial pharyngitis
–Mass effect from deep neck space abscess
-
Tumors: lymphangiomas, hemangiomas, respiratory papillomas, ranulas
–Trauma caused by foreign body or caustic ingestion
Esophageal phase
-
Congenital lesions such as vascular lesions, webs, or rings
-
Inflammatory/infectious
–Esophagitis (may be from GERD, allergy,
Candida, or HSV)
–Chagas disease
-
Esophageal dysmotility
–Cricopharyngeal or lower esophageal sphincter achalasia
–Esophageal spasm
-
Systemic
–Diabetes mellitus, thyroid disease
–Scleroderma, polymyositis, dermatomyositis
-
Psychological: Globus hystericus
» READ BOOK EXCERPT ONLINE »
Source: In A Page: Pediatric Signs and Symptoms, 2007
Ptosis:
Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)
-
Must differentiate true ptosis from lid retraction, which occurs primarily from chemical stimulation (phenylephrine) or thyroid disease
-
Of all cases of ptosis, 60% are believed to be congenital; may be exacerbated with fatigue and age
-
Dermatochalasis (drooping tissue) may simulate ptosis
-
Lid conditions such as hordeola, chalazia, and lid cellulitis may present as ptosis
-
Previous lid or ocular surgery
-
Traumatic ptosis
-
Marcus Gunn (also called jaw-winking) syndrome
-
Myasthenia gravis
-
Third nerve palsy from hypertension, diabetes, aneurysm
-
Horner syndrome
–Sympathetic lesion causing partial ptosis, miosis, and anhidrosis
–Caused by tumors, aneurysms, inflammatory processes, injuries, or chest surgery
-
Acquired myogenic ptosis from local or diffuse muscular disease, such as muscular dystrophy, chronic progressive external ophthalmoplegia, or oculopharyngeal dystrophy
-
Chromosomal disorders
–Turner syndrome, trisomy 18, 4p-, 18p
-
Fetal drug exposure
–Alcohol, hydantoin, trimethadione
-
Inherited syndromes
–Noonan, Smith-Lemli-Opitz, Aarskog
-
Migraine
-
Botulism
-
Poisoning
–Lead, arsenicals, carbon monoxide
-
Thiamine deficiency
-
Carnitine deficiency
-
Vitamin E deficiency
-
Tangier disease
-
Hydrocephalus
» READ BOOK EXCERPT ONLINE »
Source: In A Page: Pediatric Signs and Symptoms, 2007
Dysphagia:
Medical causes
(Handbook of Signs & Symptoms (Third Edition))
Achalasia
Most common in patients ages 20 to 40, achalasia produces phase 3 dysphagia for solids and liquids. The dysphagia develops gradually and may be precipitated or exacerbated by stress. Occasionally, it's preceded by esophageal colic. Regurgitation of undigested food, especially at night, may cause wheezing, coughing, or choking as well as halitosis. Weight loss, cachexia, hematemesis and, possibly, heartburn are late findings.
Airway obstruction
Life-threatening upper airway obstruction is marked by signs of respiratory distress, such as crowing and stridor. Phase 2 dysphagia occurs with gagging and dysphonia. When hemorrhage obstructs the trachea, dysphagia is usually painless and rapid in onset. When inflammation causes the obstruction, dysphagia may be painful and develop slowly.
Amyotrophic lateral sclerosis (ALS)
Besides dysphagia, ALS causes muscle weakness and atrophy, fasciculations, dysarthria, dyspnea, shallow respirations, tachypnea, slurred speech, hyperactive deep tendon reflexes (DTRs), and emotional lability.
Bulbar paralysis
Phase 1 dysphagia occurs along with drooling, difficulty chewing, dysarthria, and nasal regurgitation. Dysphagia for solids and liquids is painful and progressive. Accompanying features may include arm and leg spasticity, hyperreflexia, and emotional lability.
Esophageal cancer
Phases 2 and 3 dysphagia is the earliest and most common symptom of esophageal cancer. Typically, this painless, progressive symptom is accompanied by rapid weight loss. As the cancer advances, dysphagia becomes painful and constant. In addition, the patient complains of steady chest pain, a cough with hemoptysis, hoarseness, and a sore throat. He may also develop nausea and vomiting, a fever, hiccups, hematemesis, melena, and halitosis.
Esophageal compression (external)
Usually caused by a dilated carotid or aortic aneurysm, esophageal compression — a rare condition — causes phase 3 dysphagia as the primary symptom. Other features depend on the cause of the compression.
Esophageal diverticulum
Esophageal diverticulum causes phase 3 dysphagia when the enlarged diverticulum obstructs the esophagus. Associated signs and symptoms include food regurgitation, a chronic cough, hoarseness, chest pain, and halitosis.
Esophageal obstruction by foreign body.
Sudden onset of phase 2 or 3 dysphagia, gagging, coughing, and esophageal pain characterize this potentially life-threatening condition. Dyspnea may occur if the obstruction compresses the trachea.
Esophageal spasm.
The most striking symptoms of esophageal spasm are phase 2 dysphagia for solids and liquids and a dull or squeezing substernal chest pain. The pain may last up to an hour and may radiate to the neck, arm, back, or jaw; however, it may be relieved by drinking a glass of water. Bradycardia may also occur.
Esophageal stricture.
Usually caused by a chemical ingestion or scar tissue, esophageal stricture causes phase 3 dysphagia. Drooling, tachypnea, and gagging may also be evident.
Esophagitis.
Corrosive esophagitis, resulting from ingestion of alkali or acids, causes severe phase 3 dysphagia. Accompanying it are marked salivation, hematemesis, tachypnea, a fever, and intense pain in the mouth and anterior chest that's aggravated by swallowing. Signs of shock, such as hypotension and tachycardia, may also occur.
Candidal esophagitis causes phase 2 dysphagia, a sore throat and, possibly, retrosternal pain on swallowing. With reflux esophagitis, phase 3 dysphagia is a late symptom that usually accompanies stricture development. The patient complains of heartburn, which is aggravated by strenuous exercise, bending over, or lying down and is relieved by sitting up or taking an antacid.
Other features include regurgitation; frequent, effortless vomiting; a dry, nocturnal cough; and substernal chest pain that may mimic angina pectoris. If the esophagus ulcerates, signs of bleeding, such as melena and hematemesis, may occur along with weakness and fatigue.
Gastric carcinoma
Infiltration of the cardia or esophagus by gastric carcinoma causes phase 3 dysphagia along with nausea, vomiting, and pain that may radiate to the neck, back, or retrosternum. In addition, perforation causes massive bleeding with coffee-ground vomitus or melena.
Laryngeal cancer (extrinsic)
Phase 2 dysphagia and dyspnea develop late in laryngeal cancer. Accompanying features include a muffled voice, stridor, pain, halitosis, weight loss, ipsilateral otalgia, a chronic cough, and cachexia. Palpation reveals enlarged cervical nodes.
Lead poisoning
Painless, progressive dysphagia may result from lead poisoning. Related findings include a lead line on the gums, a metallic taste, papilledema, ocular palsy, footdrop or wristdrop, and signs of hemolytic anemia, such as abdominal pain and a fever. The patient may be depressed and display severe mental impairment and seizures.
Myasthenia gravis
Fatigue and progressive muscle weakness characterize myasthenia gravis and account for painless phase 1 dysphagia and possibly choking. Typically, dysphagia follows ptosis and diplopia. Other features include masklike facies, a nasal voice, frequent nasal regurgitation, and head bobbing. Shallow respirations and dyspnea may occur with respiratory muscle weakness. Signs and symptoms worsen during menses and with exposure to stress, cold, or infection.
Oral cavity tumor
Painful phase 1 dysphagia develops along with hoarseness and ulcerating lesions.
Plummer-Vinson syndrome
Plummer-Vinsonsyndrome causes phase 3 dysphagia for solids in some women with severe iron deficiency anemia. Related features include upper esophageal pain; atrophy of the oral or pharyngeal mucous membranes; tooth loss; a smooth, red, sore tongue; a dry mouth; chills; inflamed lips; spoon-shaped nails; pallor; and splenomegaly.
Rabies.
Severe phase 2 dysphagia for liquids results from painful pharyngeal muscle spasms occurring late in this rare, life-threatening disorder. In fact, the patient may become dehydrated and possibly apneic. Dysphagia also causes drooling, and in 50% of cases it's responsible for hydrophobia. Eventually, rabies causes progressive flaccid paralysis that leads to peripheral vascular collapse, coma, and death.
Systemic lupus erythematosus (SLE).
SLE may cause progressive phase 2 dysphagia. However, its primary signs and symptoms include nondeforming arthritis, a characteristic butterfly rash, and photosensitivity.
Tetanus
Phase 1 dysphagia usually develops about 1 week after the patient receives a puncture wound. Other characteristics include marked muscle hypertonicity, hyperactive DTRs, tachycardia, diaphoresis, drooling, and a low-grade fever. Painful, involuntary muscle spasms account for lockjaw (trismus), risus sardonicus, opisthotonos, boardlike abdominal rigidity, and intermittent tonic seizures.
Other causes
Procedures
Recent tracheostomy or repeated or prolonged intubation may cause temporary dysphagia.
Radiation therapy
When directed against oral cancer, this therapy may cause scant salivation and temporary dysphagia.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Signs & Symptoms (Third Edition), 2006
Ptosis:
Medical causes
(Handbook of Signs & Symptoms (Third Edition))
Botulism
Acute cranial nerve dysfunction as a result of botulism infection causes hallmark signs of ptosis, dysarthria, dysphagia, and diplopia. Other findings include a dry mouth, a sore throat, weakness, vomiting, diarrhea, hyporeflexia, and dyspnea.
Cerebral aneurysm
An aneurysm that compresses the oculomotor nerve can cause sudden ptosis, along with diplopia, a dilated pupil, and an inability to rotate the eye. These may be the first signs of this life-threatening disorder. A ruptured aneurysm typically produces a sudden severe headache, nausea, vomiting, and a decreased level of consciousness (LOC). Other findings include nuchal rigidity, back and leg pain, a fever, restlessness, irritability, occasional seizures, blurred vision, hemiparesis, sensory deficits, dysphagia, and visual defects.
Lacrimal gland tumor
A lacrimal gland tumor commonly produces mild to severe ptosis, depending on the tumor’s size and location. It may also cause brow elevation, exophthalmos, eye deviation and, possibly, eye pain.
Myasthenia gravis
Commonly the first sign of myasthenia gravis, gradual bilateral ptosis may be mild to severe and is accompanied by weak eye closure and diplopia. Other characteristics include muscle weakness and fatigue, which eventually may lead to paralysis. Depending on the muscles affected, other findings may include masklike facies, difficulty chewing or swallowing, dyspnea, and cyanosis.
Ocular muscle dystrophy
With ocular muscle dystrophy, bilateral ptosis progresses slowly to complete eyelid closure. Related signs and symptoms include progressive external ophthalmoplegia and muscle weakness and atrophy of the upper face, neck, trunk, and limbs.
Ocular trauma
Trauma to the nerve or muscles that control the eyelids can cause mild to severe ptosis. Depending on the damage, eye pain, lid swelling, ecchymosis, and decreased visual acuity may also occur.
Parry-Romberg syndrome
Unilateral ptosis and facial hemiatrophy occur with Parry-Romberg syndrome. Other signs include miosis, sluggish pupil reaction to light, enophthalmos, different-colored irises, ocular muscle paralysis, nystagmus, and neck, shoulder, trunk, and extremity atrophy.
Other causes
Drugs
Vinca alkaloids can produce ptosis.
Lead poisoning
With lead poisoning, ptosis usually develops over 3 to 6 months. Other findings include anorexia, nausea, vomiting, diarrhea, colicky abdominal pain, a lead line in the gums, a decreased LOC, tachycardia, hypotension and, possibly, irritability and peripheral nerve weakness.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Signs & Symptoms (Third Edition), 2006
Muscular dystrophy:
Causes and incidence
(Professional Guide to Diseases (Eighth Edition))
Muscular dystrophy is caused by various genetic mechanisms. Duchenne’s and Becker’s muscular dystrophies are X-linked recessive disorders. Both result from defects in the gene coding for the muscle protein dystrophin; the gene has been mapped to the Xp21 locus.
The incidence muscular dystrophy is about 1 in 651,450 persons in the United States. Duchenne’s and Becker’s muscular dystrophies affect males almost exclusively.
Facioscapulohumeral dystrophy is an autosomal dominant disorder. Limb-girdle dystrophy is usually autosomal recessive. These two types affect both sexes about equally.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Diseases (Eighth Edition), 2005
Ptosis:
Causes and incidence
(Professional Guide to Diseases (Eighth Edition))
Congenital ptosis is transmitted as an autosomal dominant trait or results from a congenital anomaly in which the levator muscles of the eyelids fail to develop. This condition is usually unilateral.
Acquired ptosis may result from any of the following:
❑ advanced age (involutional ptosis, the most common form, usually seen in older patients following cataract surgery)
❑ mechanical factors that make the eyelid heavy, such as swelling caused by a foreign body on the palpebral surface of the eyelid or by edema, inflammation produced by a tumor or pseudotumor, or an extra fatty fold
❑ myogenic factors, such as muscular dystrophy or myasthenia gravis (in which the defect appears to be in humoral transmission at the myoneural junction)
❑ neurogenic (paralytic) factors from interference in innervation of the eyelid by the oculomotor nerve (cranial nerve III), most commonly due to trauma, diabetes, or carotid aneurysm
❑ nutritional factors, such as thiamine deficiency in chronic alcoholism, hyperemesis gravidarum, and other malnutrition-producing states.
Risk factors for ptosis include aging, diabetes, stroke, Horner’s syndrome, myasthenia gravis, and cancer that affects nerve or muscle response.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Diseases (Eighth Edition), 2005
Lid lag [Graefe's sign]:
Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))
Thyrotoxicosis
This disorder may produce bilateral lid lag and other ocular effects, including exophthalmos, infrequent blinking, eye dryness and discomfort, conjunctival injection, and a characteristic stare. (Thyrotoxicosis is the most common cause of unilateral and bilateral exophthalmos in adults and children.) Restricted eye movement may produce diplopia. Other effects include an enlarged thyroid, nervousness, heat intolerance, weight loss despite increased appetite, diaphoresis, diarrhea, tremors, palpitations, widened pulse pressure, and silken-smooth skin texture.
Because thyrotoxicosis affects virtually every body system, it can produce many other findings. For example, central nervous system effects include clumsiness, shaky handwriting, and emotional lability. Integumentary effects include smooth, warm, flushed, and thickened skin with itchy patches; fine, soft hair with premature graying and increased loss; friable nails; and onycholysis.
Cardiopulmonary involvement causes constant dyspnea; tachycardia; full, bounding pulse; widened pulse pressure; visible point of maximal impulse; and, occasionally, systolic murmur.
Besides nausea and vomiting, GI findings include anorexia, diarrhea, and hepatomegaly. Musculoskeletal findings include weakness, fatigue, and atrophy, along with paralysis and, occasionally, acropachy. Women may report oligomenorrhea or amenorrhea; men may develop gynecomastia; both sexes may experience decreased libido.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Dysphagia:
Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))
Achalasia
Most common in patients ages 20 to 40, this disorder produces phase 3 dysphagia for solids and liquids. The dysphagia develops gradually and may be precipitated or exacerbated by stress. Occasionally, it’s preceded by esophageal colic. Regurgitation of undigested food, especially at night, may cause wheezing, coughing, or choking as well as halitosis. Weight loss, cachexia, hematemesis and, possibly, heartburn are late findings.
Airway obstruction
Life-threatening upper airway obstruction is marked by signs of respiratory distress, such as crowing and stridor. Phase 2 dysphagia occurs with gagging and dysphonia. When hemorrhage obstructs the trachea, dysphagia is usually painless and rapid in onset. When inflammation causes the obstruction, dysphagia may be painful and develop slowly.
Amyotrophic lateral sclerosis
Besides dysphagia, this disorder causes muscle weakness and atrophy, fasciculations, dysarthria, dyspnea, shallow respirations, tachypnea, slurred speech, hyperactive deep tendon reflexes, and emotional lability.
Botulism
This type of food poisoning causes phase 1 dysphagia and dysuria, usually within 36 hours of toxin ingestion. Other early findings include blurred or double vision, dry mouth, sore throat, nausea, vomiting, and diarrhea. Symmetrical descending weakness or paralysis occurs gradually.
Bulbar paralysis
Phase 1 dysphagia occurs along with drooling, difficulty chewing, dysarthria, and nasal regurgitation in this disorder. Dysphagia for both solids and liquids is painful and progressive. Accompanying features may include arm and leg spasticity, hyperreflexia, and emotional lability.
Dysphagia lusoria
This disorder is caused by compression of the esophagus by a congenital vascular abnormality (usually an aberrant right subclavian artery arising from the left side of the aortic arch). Phase 3 dysphagia symptoms may start in childhood or may develop later from changes in the aberrant vessel such as arteriosclerosis.
Esophageal cancer
Phase 2 or 3 dysphagia is the earliest and most common symptom of esophageal cancer. Typically, this painless, progressive symptom is accompanied by rapid weight loss. As the cancer advances, dysphagia becomes painful and constant. In addition, the patient complains of steady chest pain, cough with hemoptysis, hoarseness, and sore throat. He may also develop nausea and vomiting, fever, hiccups, hematemesis, melena, and halitosis.
Esophageal compression (external)
Usually caused by a dilated carotid or aortic aneurysm, this rare condition causes phase 3 dysphagia as the primary symptom. Other features depend on the cause of the compression.
Esophageal diverticulum
This disorder causes phase 3 dysphagia when the enlarged diverticulum obstructs the esophagus. Associated signs and symptoms include food regurgitation, chronic cough, hoarseness, chest pain, and halitosis.
Esophageal leiomyoma
A relatively rare benign tumor, esophageal leiomyoma may cause phase 3 dysphagia along with retrosternal pain or discomfort. In addition, the patient experiences weight loss and a feeling of fullness.
Esophageal obstruction by foreign body
Sudden onset of phase 2 or 3 dysphagia, gagging, coughing, and esophageal pain characterize this potentially life-threatening condition. Dyspnea may occur if the obstruction compresses the trachea.
Esophageal spasm
The most striking symptoms of this disorder are phase 2 dysphagia for solids and liquids and dull or squeezing substernal chest pain. The pain may last up to an hour and may radiate to the neck, arm, back, or jaw; however, it may be relieved by drinking a glass of water. Bradycardia may also occur.
Esophageal stricture
Usually caused by scar tissue or ingestion of a chemical, this condition causes phase 3 dysphagia. Drooling, tachypnea, and gagging may also be evident.
Esophagitis
Corrosive esophagitis, resulting from ingestion of alkalies or acids, causes severe phase 3 dysphagia. Accompanying it are marked salivation, hematemesis, tachypnea, fever, and intense pain in the mouth and anterior chest that’s aggravated by swallowing. Signs of shock, such as hypotension and tachycardia, may also occur.
Candidal esophagitis causes phase 2 dysphagia, sore throat and, possibly, retrosternal pain on swallowing. In reflux esophagitis, phase 3 dysphagia is a late symptom that usually accompanies stricture development. The patient complains of heartburn, which is aggravated by strenuous exercise, bending over, or lying down and is relieved by sitting up or taking an antacid.
Other features include regurgitation; frequent, effortless vomiting; a dry, nocturnal cough; and substernal chest pain that may mimic angina pectoris. If the esophagus ulcerates, signs of bleeding, such as melena and hematemesis, may occur along with weakness and fatigue.
Gastric carcinoma
Infiltration of the cardia or esophagus by gastric carcinoma causes phase 3 dysphagia along with nausea, vomiting, and pain that may radiate to the neck, back, or retrosternum. In addition, perforation causes massive bleeding with coffee-ground vomitus or melena.
Hypocalcemia
Although tetany is its primary sign, severe hypocalcemia may cause neuromuscular irritability, producing phase 1 dysphagia associated with numbness and tingling in the nose, ears, fingertips, and toes and around the mouth. Carpopedal spasms, muscle twitching, and laryngeal spasms may also occur.
Laryngeal cancer (extrinsic)
Phase 2 dysphagia and dyspnea develop late in this disorder. Accompanying features include muffled voice, stridor, pain, halitosis, weight loss, ipsilateral otalgia, chronic cough, and cachexia. Palpation reveals enlarged cervical nodes.
Laryngeal nerve damage
Commonly the result of radical neck surgery, superior laryngeal nerve damage may produce painless phase 2 dysphagia.
Lower esophageal ring
Narrowing of the lower esophagus can cause an attack of phase 3 dysphagia that may recur several weeks or months later. During the attack, the patient complains of a foreign body sensation in the lower esophagus, which may be relieved by drinking water or vomiting. Esophageal rupture produces severe lower chest pain followed by a feeling of something giving way.
Mediastinitis
Varying with the extent of esophageal perforation, mediastinitis can cause insidious or rapid onset of phase 3 dysphagia. The patient displays chills, fever, and severe retrosternal chest pain that may radiate to the epigastrium, back, or shoulder. The pain may be aggravated by breathing, coughing, or sneezing. Other findings include tachycardia, subcutaneous crepitation in the suprasternal notch, and falling blood pressure.
Myasthenia gravis
Fatigue and progressive muscle weakness characterize this disorder and account for painless phase 1 dysphagia and possibly choking. Typically, dysphagia follows ptosis and diplopia. Other features include masklike facies, nasal voice, frequent nasal regurgitation, and head bobbing. Shallow respirations and dyspnea may occur with respiratory muscle weakness. Signs and symptoms worsen during menses and with exposure to stress, cold, or infection.
Oral cavity tumor
Painful phase 1 dysphagia is accompanied by hoarseness and ulcerating lesions in patients with this type of tumor.
Parkinson’s disease
Usually a late symptom, phase 1 dysphagia is painless but progressive and may cause choking. Other signs and symptoms include bradykinesia, tremors, muscle rigidity, dysarthria, masklike facies, muffled voice, increased salivation and lacrimation, constipation, stooped posture, a propulsive gait, incontinence, and sexual dysfunction.
Pharyngitis (chronic)
This condition causes painful phase 2 dysphagia for solids and liquids. Rarely serious, it’s accompanied by a dry, sore throat; a cough; and thick mucus in the throat.
Plummer-Vinson syndrome
This syndrome causes phase 3 dysphagia for solids in some women with severe iron deficiency anemia. Related features include upper esophageal pain; atrophy of the oral or pharyngeal mucous membranes; tooth loss; a smooth, red, sore tongue; dry mouth; chills; inflamed lips; spoon-shaped nails; pallor; and splenomegaly.
Rabies
Severe phase 2 dysphagia for liquids results from painful pharyngeal muscle spasms occurring late in this rare, life-threatening disorder. In fact, the patient may become dehydrated and possibly apneic. Dysphagia also causes drooling and, in 50% of patients, hydrophobia. Eventually, rabies causes progressive flaccid paralysis that leads to peripheral vascular collapse, coma, and death.
Scleroderma (progressive systemic sclerosis)
Typically, dysphagia is preceded by Raynaud’s phenomenon in patients with this disorder. The dysphagia may be mild at first and described as a feeling of food sticking behind the breastbone. The patient also complains of heartburn after meals that’s aggravated by lying down. As the disease progresses, dysphagia worsens until only liquids can be swallowed. It may be accompanied by other GI effects, including weight loss, abdominal distention, diarrhea, and malodorous, floating stools. Other characteristic late features include joint pain and stiffness, masklike facies, and thick, taut, shiny skin.
Syphilis
Rarely, tertiary-stage syphilis causes ulceration and stricture of the upper esophagus, resulting in phase 3 dysphagia. The dysphagia may be accompanied by regurgitation after meals and heartburn that’s aggravated by lying down or bending over.
Systemic lupus erythematosus
This disorder may cause progressive phase 2 dysphagia. However, its primary signs and symptoms include nondeforming arthritis, a characteristic butterfly rash, and photosensitivity.
Tetanus
Phase 1 dysphagia usually develops about 1 week after the patient receives a puncture wound. Other characteristics include marked muscle hypertonicity, hyperactive deep tendon reflexes, tachycardia, diaphoresis, drooling, and low-grade fever. Painful, involuntary muscle spasms account for lockjaw (trismus), risus sardonicus, opisthotonos, boardlike abdominal rigidity, and intermittent tonic seizures.
Other causes
Lead poisoning
Painless, progressive dysphagia may result from lead poisoning. Related findings include a lead line on the gums, metallic taste, papilledema, ocular palsy, footdrop or wristdrop, and signs of hemolytic anemia, such as abdominal pain and fever. The patient may be depressed and display severe mental impairment and seizures.
Procedures
A recent tracheostomy or repeated or prolonged intubation may cause temporary dysphagia.
Radiation therapy
When usd to treat oral cancer, radiation therapy may cause scant salivation and temporary dysphagia.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Ptosis:
Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))
Alcoholism
Long-term alcohol abuse can cause ptosis and such complications as severe weight loss, jaundice, ascites, and mental disturbances.
Botulism
Acute cranial nerve dysfunction causes hallmark signs of ptosis, dysarthria, dysphagia, and diplopia. Other findings include dry mouth, sore throat, weakness, vomiting, diarrhea, hyporeflexia, and dyspnea.
Cerebral aneurysm
An aneurysm that compresses the oculomotor nerve can cause sudden ptosis, along with diplopia, a dilated pupil, and inability to rotate the eye. These may be the first signs of this life-threatening disorder. A ruptured aneurysm typically produces sudden severe headache, nausea, vomiting, and decreased level of consciousness (LOC). Other findings include nuchal rigidity, back and leg pain, fever, restlessness, irritability, occasional seizures, blurred vision, hemiparesis, sensory deficits, dysphagia, and visual defects.
Dacryoadenitis
Ptosis may accompany unilateral exophthalmos, limited extraocular movements, eyelid edema and erythema, conjunctival injection, eye pain, and diplopia.
Hemangioma
This orbital tumor can produce ptosis, exophthalmos, limited extraocular movement, and blurred vision.
Horner’s syndrome
This disorder causes moderate unilateral ptosis that almost disappears when the patient opens his eyes widely. Common accompanying findings include unilateral miosis and ipsilateral anhidrosis of the face and neck, which may spread to the entire body. Other signs and symptoms include transient conjunctival injection, vascular headache on the affected side, and vertigo.
Lacrimal gland tumor
This disorder commonly produces mild to severe ptosis, depending on the tumor’s size and location. It may also cause brow elevation, exophthalmos, eye deviation and, possibly, eye pain.
Levator muscle maldevelopment
Ptosis from maldevelopment of the levator muscle of the upper eyelid—formerly classified as true congenital ptosis—is the result of an isolated dystrophy of the levator muscle affecting its contraction and relaxation. Lid lag on downgaze is an important clue to diagnosis.
Myasthenia gravis
Commonly the first sign of this disorder, gradual bilateral ptosis may be mild to severe and is accompanied by weak eye closure and diplopia. Other characteristics include muscle weakness and fatigue, which eventually may lead to paralysis. Depending on the muscles affected, other findings may include masklike facies, difficulty chewing or swallowing, dyspnea, cyanosis, and others.
Myotonic dystrophy
This disorder may cause mild to severe bilateral ptosis. Distinctive cataracts with iridescent dots in the cortex, miosis, diplopia, decreased tearing, and muscular and testicular atrophy may also occur.
Ocular muscle dystrophy
With this disorder, bilateral ptosis progresses slowly to complete eyelid closure. Related signs and symptoms include progressive external ophthalmoplegia and muscle weakness and atrophy of the upper face, neck, trunk, and limbs.
Ocular trauma
Trauma to the nerve or muscles that control the eyelids can cause mild to severe ptosis. Depending on the damage, eye pain, lid swelling, ecchymosis, and decreased visual acuity may also occur.
Parinaud’s syndrome
This form of ophthalmoplegia can cause ptosis, enophthalmos, nystagmus, lid retraction, dilated pupils with absent or poor light response, and papilledema. The patient’s ocular muscles fail to move voluntarily.
Parry-Romberg syndrome
Unilateral ptosis and facial hemiatrophy occur with this disorder. Other signs include miosis, sluggish pupil reaction to light, enophthalmos, different-colored irises, ocular muscle paralysis, nystagmus, and neck, shoulder, trunk, and extremity atrophy.
Subdural hematoma (chronic)
Ptosis may be a late sign, along with unilateral pupillary dilation and sluggishness. Headache, behavioral changes, and decreased LOC commonly occur.
Other causes
Drugs
Vinca alkaloids can produce ptosis.
Lead poisoning
With this disorder, ptosis usually develops over 3 to 6 months. Other findings include anorexia, nausea, vomiting, diarrhea, colicky abdominal pain, a lead line in the gums, decreased LOC, tachycardia, hypotension and, possibly, irritability and peripheral nerve weakness.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
dysphagia/Heartburn:
Differential Overview
(Field Guide to Bedside Diagnosis)
Dysphagia
❑ Infectious esophagitis
❑ Reflux stricture
❑ Zenker diverticulum
❑ Transfer dysphagia
❑ Diffuse esophageal spasm
❑ Foreign body
❑ Esophageal cancer
❑ Achalasia
❑ External compression
❑ Scleroderma
❑ Myasthenia gravis
❑ Radiation injury
❑ Globus hystericus
❑ Esophageal web
❑ Botulism
Heartburn
❑ Reflux esophagitis
❑ Drugs
❑ Gastritis
❑ Pregnancy
❑ Aerophagia
❑ Infectious esophagitis
❑ Scleroderma
» READ BOOK EXCERPT ONLINE »
Source: Field Guide to Bedside Diagnosis, 2007
Ptosis:
Differential Overview
(Field Guide to Bedside Diagnosis)
❑ Horner syndrome
❑ Diabetic mononeuritis
❑ Eyelid edema
❑ Myasthenia gravis
❑ Posterior communicating artery aneurysm
» READ BOOK EXCERPT ONLINE »
Source: Field Guide to Bedside Diagnosis, 2007
Dysphagia:
Medical causes
(Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)
Achalasia
Most common in patients ages 20 to 40, achalasia produces phase 3 dysphagia for solids and liquids. The dysphagia develops gradually and may be precipitated or exacerbated by stress. Occasionally, it’s preceded by esophageal colic. Regurgitation of undigested food, especially at night, may cause wheezing, coughing, or choking as well as halitosis. Weight loss, cachexia, hematemesis and, possibly, heartburn are late findings.
Airway obstruction
Life-threatening upper airway obstruction is marked by signs of respiratory distress, such as crowing and stridor. Phase 2 dysphagia occurs with gagging and dysphonia. When hemorrhage obstructs the trachea, dysphagia is usually painless and rapid in onset. When inflammation causes the obstruction, dysphagia may be painful and develop slowly.
Amyotrophic lateral sclerosis (ALS)
Besides dysphagia, ALS causes muscle weakness and atrophy, fasciculations, dysarthria, dyspnea, shallow respirations, tachypnea, slurred speech, hyperactive deep tendon reflexes, and emotional lability.
Botulism
Botulism causes phase 1 dysphagia and dysuria, usually within 36 hours of toxin ingestion. Other early findings include blurred or double vision, dry mouth, sore throat, nausea, vomiting, and diarrhea. Symmetrical descending weakness or paralysis occurs gradually.
Bulbar paralysis
Phase 1 dysphagia occurs along with drooling, difficulty chewing, dysarthria, and nasal regurgitation. Dysphagia for both solids and liquids is painful and progressive. Accompanying features may include arm and leg spasticity, hyperreflexia, and emotional lability.
Dysphagia lusoria
Dysphagia lusoria is caused by compression of the esophagus by a congenital vascular abnormality (usually an aberrant right subclavian artery arising from the left side of the aortic arch). Phase 3 dysphagia symptoms may occur in childhood or develop later from changes in the aberrant vessel such as arteriosclerosis.
Esophageal cancer
Phases 2 and 3 dysphagia is the earliest and most common symptom of esophageal cancer. Typically, this painless, progressive symptom is accompanied by rapid weight loss. As the cancer advances, dysphagia becomes painful and constant. In addition, the patient complains of steady chest pain, cough with hemoptysis, hoarseness, and sore throat. He may also develop nausea and vomiting, fever, hiccups, hematemesis, melena, and halitosis.
Esophageal compression (external)
Usually caused by a dilated carotid or aortic aneurysm, external esophageal compression — a rare condition — causes phase 3 dysphagia as the primary symptom. Other features depend on the cause of the compression.
Esophageal diverticulum
. Esophageal diverticulum causes phase 3 dysphagia when the enlarged diverticulum obstructs the esophagus. Associated signs and symptoms include food regurgitation, chronic cough, hoarseness, chest pain, and halitosis.
Esophageal leiomyoma
A relatively rare benign tumor, esophageal leiomyoma may cause phase 3 dysphagia along with retrosternal pain or discomfort. In addition, the patient experiences weight loss and a feeling of fullness.
Esophageal obstruction by foreign body
Sudden onset of phase 2 or 3 dysphagia, gagging, coughing, and esophageal pain characterize esophageal obstruction by foreign body — a potentially life-threatening condition. Dyspnea may occur if the obstruction compresses the trachea.
Esophageal spasm
The most striking symptoms of esophageal spasm are phase 2 dysphagia for solids and liquids and dull or squeezing substernal chest pain. The pain may last up to an hour and may radiate to the neck, arm, back, or jaw; however, it may be relieved by drinking a glass of water. Bradycardia may also occur.
Esophageal stricture
Usually caused by a chemical ingestion or scar tissue, esophageal stricture causes phase 3 dysphagia. Drooling, tachypnea, and gagging may also be evident.
Esophagitis
Corrosive esophagitis, resulting from ingestion of alkalies or acids, causes severe phase 3 dysphagia. Accompanying it are marked salivation, hematemesis, tachypnea, fever, and intense pain in the mouth and anterior chest that’s aggravated by swallowing. Signs of shock, such as hypotension and tachycardia, may also occur.
Candidal esophagitis causes phase 2 dysphagia, sore throat and, possibly, retrosternal pain on swallowing. With reflux esophagitis, phase 3 dysphagia is a late symptom that usually accompanies stricture development. The patient complains of heartburn, which is aggravated by strenuous exercise, bending over, or lying down and is relieved by sitting up or taking an antacid.
Other features include regurgitation; frequent, effortless vomiting; a dry, nocturnal cough; and substernal chest pain that may mimic angina pectoris. If the esophagus ulcerates, signs of bleeding, such as melena and hematemesis, may occur along with weakness and fatigue.
Gastric carcinoma
Infiltration of the cardia or esophagus by gastric carcinoma causes phase 3 dysphagia along with nausea, vomiting, and pain that may radiate to the neck, back, or retrosternum. In addition, perforation causes massive bleeding with coffee-ground vomitus or melena.
Hypocalcemia
Although tetany is its primary sign, severe hypocalcemia may cause neuromuscular irritability, producing phase 1 dysphagia associated with numbness and tingling in the nose, ears, fingertips, and toes and around the mouth. Carpopedal spasms, muscle twitching, and laryngeal spasms may also occur.
Laryngeal cancer (extrinsic)
Phase 2 dysphagia and dyspnea develop late in extrinsic laryngeal cancer. Accompanying features include muffled voice, stridor, pain, halitosis, weight loss, ipsilateral otalgia, chronic cough, and cachexia. Palpation reveals enlarged cervical nodes.
Laryngeal nerve damage
Commonly the result of radical neck surgery, superior laryngeal nerve damage may produce painless phase 2 dysphagia.
Lead poisoning
Painless, progressive dysphagia may result from lead poisoning. Related findings include a lead line on the gums, metallic taste, papilledema, ocular palsy, footdrop or wristdrop, and signs of hemolytic anemia, such as abdominal pain and fever. The patient may be depressed and display severe mental impairment and seizures.
Lower esophageal ring
Narrowing of the lower esophagus can cause an attack of phase 3 dysphagia that may recur several weeks or months later. During the attack, the patient complains of a foreign body in the lower esophagus, a sensation that may be relieved by drinking water or vomiting. Esophageal rupture produces severe lower chest pain followed by a feeling of something giving way.
Mediastinitis
Varying with the extent of esophageal perforation, mediastinitis can cause insidious or rapid onset of phase 3 dysphagia. The patient displays chills, fever, and severe retrosternal chest pain that may radiate to the epigastrium, back, or shoulder. The pain may be aggravated by breathing, coughing, or sneezing. Other findings include tachycardia, subcutaneous crepitation in the suprasternal notch, and falling blood pressure.
Myasthenia gravis
Fatigue and progressive muscle weakness characterize myasthenia gravis and account for painless phase 1 dysphagia and possibly choking. Typically, dysphagia follows ptosis and diplopia. Other features include masklike facies, nasal voice, frequent nasal regurgitation, and head bobbing. Shallow respirations and dyspnea may occur with respiratory muscle weakness. Signs and symptoms worsen during menses and with exposure to stress, cold, or infection.
Oral cavity tumor
Painful phase 1 dysphagia develops along with hoarseness and ulcerating lesions.
Parkinson’s disease
Usually a late symptom, phase 1 dysphagia is painless but progressive and may cause choking. Other signs and symptoms include bradykinesia, tremors, muscle rigidity, dysarthria, masklike facies, muffled voice, increased salivation and lacrimation, constipation, stooped posture, propulsive gait, incontinence, and sexual dysfunction.
Pharyngitis (chronic)
Chronic pharyngitis causes painful phase 2 dysphagia for solids and liquids. Rarely serious, it’s accompanied by a dry, sore throat; a cough; and thick mucus in the throat.
Plummer-Vinson syndrome
Plummer-Vinson syndrome causes phase 3 dysphagia for solids in some females with severe iron deficiency anemia. Related features include upper esophageal pain; atrophy of the oral or pharyngeal mucous membranes; tooth loss; smooth, red, sore tongue; dry mouth; chills; inflamed lips; spoon-shaped nails; pallor; and splenomegaly.
Progressive systemic sclerosis
Typically, dysphagia is preceded by Raynaud’s phenomenon in patients with progressive systemic sclerosis. The dysphagia may be mild at first and described as a feeling of food sticking behind the breastbone. The patient also complains of heartburn after meals that’s aggravated by lying down. As the disease progresses, dysphagia worsens until only liquids can be swallowed. It may be accompanied by other GI effects, including weight loss, abdominal distention, diarrhea, and malodorous, floating stools. Other characteristic late features include joint pain and stiffness and thickening of the skin that progresses to taut, shiny skin. The patient usually has masklike facies.
Rabies
Severe phase 2 dysphagia for liquids results from painful pharyngeal muscle spasms occurring late in rabies — a rare, life-threatening disorder. In fact, the patient may become dehydrated and possibly apneic. Dysphagia also causes drooling, and in 50% of patients it’s responsible for hydrophobia. Eventually, rabies causes progressive flaccid paralysis that leads to peripheral vascular collapse, coma, and death.
Syphilis
Rarely, tertiary-stage syphilis causes ulceration and stricture of the upper esophagus, resulting in phase 3 dysphagia. The dysphagia may be accompanied by regurgitation after meals and heartburn that’s aggravated by lying down or bending over.
Systemic lupus erythematosus (SLE)
SLE may cause progressive phase 2 dysphagia. However, its primary signs and symptoms include nondeforming arthritis, a characteristic butterfly rash, and photosensitivity.
Tetanus
Phase 1 dysphagia usually develops about 1 week after the patient receives a puncture wound. Other characteristics include marked muscle hypertonicity, hyperactive deep tendon reflexes, tachycardia, diaphoresis, drooling, and low-grade fever. Painful, involuntary muscle spasms account for lockjaw (trismus), risus sardonicus, opisthotonos, boardlike abdominal rigidity, and intermittent tonic seizures.
Other causes
Medical procedures
Recent tracheostomy or repeated or prolonged intubation may cause temporary dysphagia.
Radiation therapy
When directed against oral cancer, this therapy may cause scant salivation and temporary dysphagia.
» READ BOOK EXCERPT ONLINE »
Source: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, 2007
Dysphagia:
Medical causes
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
Achalasia
Most common in patients ages 20 to 40, achalasia produces phase 3 dysphagia for solids and liquids. The dysphagia develops gradually and may be precipitated or exacerbated by stress. Occasionally, it’s preceded by esophageal colic. Regurgitation of undigested food, especially at night, may cause wheezing, coughing, or choking as well as halitosis. Weight loss, cachexia, hematemesis and, possibly, heartburn are late findings.
Airway obstruction
Life-threatening upper airway obstruction is marked by signs of respiratory distress, such as crowing and stridor. Phase 2 dysphagia occurs with gagging and dysphonia. When hemorrhage obstructs the trachea, dysphagia is usually painless and rapid in onset. When inflammation causes the obstruction, dysphagia may be painful and develop slowly.
Amyotrophic lateral sclerosis
In addition to dysphagia, amyotrophic lateral sclerosis (ALS), which is also known as Lou Gehrig disease, causes muscle weakness and atrophy, fasciculations, dysarthria, dyspnea, shallow respirations, tachypnea, slurred speech, hyperactive deep tendon reflexes, and emotional lability.
Botulism
Botulism causes phase 1 dysphagia and dysuria, usually within 36 hours of toxin ingestion. Other early findings include blurred or double vision, dry mouth, sore throat, nausea, vomiting, and diarrhea. Symmetrical descending weakness or paralysis occurs gradually.
Bulbar paralysis
In bulbar paralysis, phase 1 dysphagia occurs along with drooling, difficulty chewing, dysarthria, and nasal regurgitation. Dysphagia for solids and liquids is painful and progressive. Accompanying features may include arm and leg spasticity, hyperreflexia, and emotional lability.
Esophageal cancer
Dysphagia (phases 2 and 3) is the earliest and most common symptom of esophageal cancer. Typically, this painless, progressive symptom is accompanied by rapid weight loss. As the cancer advances, dysphagia becomes painful and constant. In addition, the patient complains of steady chest pain, cough with hemoptysis, hoarseness, and sore throat. He may also develop nausea and vomiting, fever, hiccups, hematemesis, melena, and halitosis.
Esophageal diverticulum
Esophageal diverticulum causes phase 3 dysphagia when the enlarged diverticulum obstructs the esophagus. Associated signs and symptoms include food regurgitation, chronic cough, hoarseness, chest pain, and halitosis.
Esophageal obstruction by foreign body
Esophageal obstruction by foreign body is characterized by sudden onset of dysphagia (phase 2 or 3) as well as gagging, coughing, and esophageal pain. Dyspnea may occur if the obstruction compresses the trachea.
Esophageal spasm
The most striking symptoms of esophageal spasm are phase 2 dysphagia for solids and liquids and dull or squeezing substernal chest pain. The pain may last up to 1 hour; radiate to the neck, arm, back, or jaw; and be relieved by drinking a glass of water. Bradycardia may also occur.
Esophageal stricture
Usually caused by a chemical ingestion or scar tissue, esophageal stricture causes phase 3 dysphagia. Drooling, tachypnea, and gagging also may be evident. In chemical ingestion, dysphagia may be accompanied by burns, ulcers, or erythema of the lips and mouth.
Esophagitis
Corrosive esophagitis, resulting from ingestion of alkalies or acids, causes severe phase 3 dysphagia. Dysphagia is accompanied by marked salivation, hematemesis, tachypnea, fever, and intense pain in the mouth and anterior chest that’s aggravated by swallowing. Signs of shock, such as hypotension and tachycardia, may also occur.
Candidal esophagitis causes phase 2 dysphagia, sore throat and, possibly, retrosternal pain on swallowing.
With reflux esophagitis, phase 3 dysphagia is a late symptom that usually accompanies stricture development. The patient complains of heartburn, which is aggravated by strenuous exercise, bending over, or lying down and is relieved by sitting up or taking an antacid. Other features include regurgitation; frequent, effortless vomiting; a dry, nocturnal cough; and substernal chest pain that may mimic angina pectoris. If the esophagus ulcerates, signs of bleeding, such as melena and hematemesis, may occur along with weakness and fatigue.
Hypocalcemia
Although tetany is its primary sign, severe hypocalcemia may cause neuromuscular irritability, producing phase 1 dysphagia associated with numbness and tingling in the nose, ears, fingertips, and toes and around the mouth. Carpopedal spasms, muscle twitching, and laryngeal spasms also may occur.
Laryngeal cancer (extrinsic)
Phase 2 dysphagia and dyspnea develop late in laryngeal cancer. Accompanying features include muffled voice, stridor, pain, halitosis, weight loss, ipsilateral otalgia, chronic cough, and cachexia. Palpation reveals enlarged cervical lymph nodes.
Lead poisoning
Painless, progressive dysphagia may result from lead poisoning. Related findings include a lead line on the gums, metallic taste, papilledema, ocular palsy, footdrop or wristdrop, and signs of hemolytic anemia, such as abdominal pain and fever. The patient may be depressed and display severe mental impairment and seizures.
Lower esophageal ring
Narrowing of the lower esophagus can cause an attack of phase 3 dysphagia that may recur several weeks or months later. During the attack, the patient complains of a foreign body in the lower esophagus, a sensation that may be relieved by drinking water or vomiting. Esophageal rupture produces severe lower chest pain followed by a feeling of something giving way.
Mediastinitis
Varying with the extent of esophageal perforation, mediastinitis can cause insidious or rapid onset of phase 3 dysphagia. The patient displays chills, fever, and severe retrosternal chest pain that may radiate to the epigastrium, back, or shoulder. The pain may be aggravated by breathing, coughing, or sneezing. Other findings include tachycardia, subcutaneous crepitation in the suprasternal notch, and falling blood pressure.
Myasthenia gravis
Fatigue and progressive muscle weakness characterize myasthenia gravis and account for painless phase 1 dysphagia and possibly choking. Typically, dysphagia follows ptosis and diplopia. Other features include masklike facies, nasal voice, frequent nasal regurgitation, and head bobbing. Shallow respirations and dyspnea may occur with respiratory muscle weakness. Signs and symptoms worsen during menses and with exposure to stress, cold, or infection.
Oral cavity tumor
With an oral cavity tumor, painful phase 1 dysphagia develops along with hoarseness and ulcerating lesions. The patient may report an abnormal taste in the mouth, abnormal bleeding from the mouth, or a feeling that dentures no longer fit properly.
Parkinson’s disease
Usually a late symptom of Parkinson’s disease, phase 1 dysphagia is painless but progressive and may cause choking. Other signs and symptoms include bradykinesia, tremors, muscle rigidity, dysarthria, masklike facies, muffled voice, increased salivation and lacrimation, constipation, stooped posture, propulsive gait, incontinence, and sexual dysfunction.
Pharyngitis (chronic)
Pharyngitis causes painful phase 2 dysphagia of solids and liquids. Rarely serious, it’s accompanied by a dry, sore throat; a cough; and thick mucus in the throat. The patient may report the sensation of a lump in his throat.
Progressive systemic sclerosis
Typically, dysphagia is preceded by Raynaud’s phenomenon in patients with progressive systemic sclerosis. The dysphagia may be mild at first and described as a feeling of food sticking behind the breastbone. The patient also complains of heartburn after meals that’s aggravated by lying down. As the disease progresses, dysphagia worsens until only liquids can be swallowed. It may be accompanied by other GI effects, including weight loss, abdominal distention, diarrhea, and malodorous, floating stools. Other characteristic late features include joint pain and stiffness and thickening of the skin that progresses to taut, shiny skin. The patient usually has masklike facies.
Rabies
Severe phase 2 dysphagia of liquids results from painful pharyngeal muscle spasms occurring late in this rare, life-threatening disorder. In fact, the patient may become dehydrated and possibly apneic. Dysphagia also causes drooling, and in 50% of patients it’s responsible for hydrophobia. Eventually, rabies causes progressive flaccid paralysis that leads to peripheral vascular collapse, coma, and death.
Tetanus
Phase 1 dysphagia usually develops about 1 week after the patient receives a puncture wound. Other characteristics of tetanus include marked muscle hypertonicity, hyperactive deep tendon reflexes, tachycardia, diaphoresis, drooling, and low-grade fever. Painful, involuntary muscle spasms account for lockjaw (trismus), risus sardonicus, opisthotonos, boardlike abdominal rigidity, and intermittent tonic seizures.
Other causes
Procedures
Recent tracheostomy or repeated or prolonged intubation may cause temporary dysphagia.
Radiation therapy
When directed against oral cancer, radiation therapy may cause scant salivation and temporary dysphagia.
» READ BOOK EXCERPT ONLINE »
Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Ptosis:
Medical causes
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
Alcoholism
Long-term alcohol abuse can cause ptosis and such complications as severe weight loss, jaundice, ascites, and mental disturbances. It may also result in signs and symptoms of withdrawal when drinking is stopped.
Botulism
With botulism, acute cranial nerve dysfunction causes the hallmark signs of ptosis, dysarthria, dysphagia, and diplopia. Other findings include dry mouth, sore throat, weakness, vomiting, diarrhea, hyporeflexia, and dyspnea.
Cerebral aneurysm
A cerebral aneurysm that compresses the oculomotor nerve can cause sudden ptosis, along with diplopia, a dilated pupil, and inability to rotate the eye. These may be the first signs of this life-threatening disorder. A ruptured aneurysm typically produces sudden severe headache, nausea, vomiting, and decreased level of consciousness (LOC). Other findings include nuchal rigidity, back and leg pain, fever, restlessness, irritability, occasional seizures, blurred vision, hemiparesis, sensory deficits, dysphagia, and visual defects.
Hemangioma
Hemangioma is an orbital tumor that can produce ptosis, exophthalmos, limited extraocular movement, and blurred vision. Periorbital tissues may become swollen.
Levator muscle maldevelopment
Ptosis from maldevelopment of the levator muscle of the upper eyelid — formerly classified as true congenital ptosis — is the result of an isolated dystrophy of the levator muscle affecting its contraction and relaxation. Lid lag on downgaze is an important clue to diagnosis.
Myasthenia gravis
Commonly the first sign of myasthenia gravis, gradual bilateral ptosis may be mild to severe and is accompanied by weak eye closure and diplopia. Other characteristics include muscle weakness and fatigue, which eventually may lead to paralysis. Depending on the muscles affected, other findings may include masklike facies, difficulty chewing or swallowing, dyspnea, cyanosis, and others.
Myotonic dystrophy
Myotonic dystrophy may cause mild to severe bilateral ptosis. Distinctive cataracts with iridescent dots in the cortex, miosis, diplopia, decreased tearing, and muscular and testicular atrophy may also occur.
Ocular muscle dystrophy
With ocular muscle dystrophy, bilateral ptosis progresses slowly to complete eyelid closure. Related signs and symptoms include progressive external ophthalmoplegia and muscle weakness and atrophy of the upper face, neck, trunk, and limbs.
Ocular trauma
Trauma to the nerve or muscles that control the eyelids can cause mild to severe ptosis. Depending on the damage, eye pain, lid swelling, ecchymosis, and decreased visual acuity may also occur.
Parinaud’s syndrome
Parinaud’s syndrome, a form of ophthalmoplegia, can cause ptosis, enophthalmos, nystagmus, lid retraction, dilated pupils with absent or poor light response, and papilledema. The patient’s ocular muscles fail to move voluntarily.
Subdural hematoma (chronic)
Ptosis may be a late sign of a chronic subdural hematoma, along with unilateral pupillary dilation and sluggishness. Headache, behavioral changes, and decreased LOC commonly occur. Specific neurologic signs depend on the hematoma’s location and size.
Other causes
Drugs
Vinca alkaloids can produce ptosis.
Lead poisoning
With lead poisoning, ptosis usually develops over 3 to 6 months. Other findings include anorexia, nausea, vomiting, diarrhea, colicky abdominal pain, a lead line in the gums, decreased LOC, tachycardia, hypotension and, possibly, irritability and peripheral nerve weakness.
» READ BOOK EXCERPT ONLINE »
Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Ptosis:
Principal Causes of Ptosis
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)
- Defectivedevelopment of the levator palpebrae muscle
- Trauma
- Neurologic disorders
- Oculomotornerve palsy
- Ophthalmoplegic migraine
- Horner syndrome
- Neuromuscular junction disorders
- Myastheniagravis
- Muscle disorders
- Neoplasm
- Marcus Gunn phenomenon
» READ BOOK EXCERPT ONLINE »
Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006
Dysphagia:
Medical causes
(Nursing: Interpreting Signs and Symptoms)
Achalasia.Achalasia produces phase 3 dysphagia for solids and liquids. The dysphagia develops gradually and may be precipitated or exacerbated by stress. Occasionally, it's preceded by esophageal colic. Regurgitation of undigested food, especially at night, may cause wheezing, coughing, or choking as well as halitosis. Weight loss, cachexia, hematemesis and, possibly, heartburn are late findings.
Airway obstruction.Life-threatening upper airway obstruction is marked by signs of respiratory distress, such as crowing and stridor. Phase 2 dysphagia occurs with gagging and dysphonia. When hemorrhage obstructs the trachea, dysphagia is usually painless and rapid in onset. When inflammation causes the obstruction, dysphagia may be painful and develop slowly.
Amyotrophic lateral sclerosis (ALS).Besides dysphagia, ALS causes muscle weakness and atrophy, fasciculations, dysarthria, dyspnea, shallow respirations, tachypnea, slurred speech, hyperactive deep tendon reflexes (DTRs), and emotional lability.
Bulbar paralysis.Phase 1 dysphagia occurs along with drooling, difficulty chewing, dysarthria, and nasal regurgitation. Dysphagia for solids and liquids is painful and progressive. Accompanying features may include arm and leg spasticity, hyperreflexia, and emotional lability.
Esophageal cancer.Phases 2 and 3 dysphagia is the earliest and most common symptom of esophageal cancer. Typically, this painless, progressive symptom is accompanied by rapid weight loss. As the cancer advances, dysphagia becomes painful and constant. In addition, the patient complains of steady chest pain, a cough with hemoptysis, hoarseness, and a sore throat. He may also develop nausea and vomiting, a fever, hiccups, hematemesis, melena, and halitosis.
Esophageal compression (external).Usually caused by a dilated carotid or aortic aneurysm, esophageal compression—a rare condition—causes phase 3 dysphagia as the primary symptom. Other features depend on the cause of the compression.
Esophageal diverticulum.Esopha-geal diverticulum causes phase 3 dysphagia when the enlarged diverticulum obstructs the esophagus. Associated signs and symptoms include food regurgitation, a chronic cough, hoarseness, chest pain, and halitosis.
Esophageal obstruction by foreign body.Sudden onset of phase 2 or 3 dysphagia, gagging, coughing, and esophageal pain characterize this potentially life-threatening condition. Dyspnea may occur if the obstruction compresses the trachea.
Esophageal spasm.The most striking symptoms of esophageal spasm are phase 2 dysphagia for solids and liquids and a dull or squeezing substernal chest pain. The pain may last up to an hour and may radiate to the neck, arm, back, or jaw; however, it may be relieved by drinking a glass of water. Bradycardia may also occur.
Esophageal stricture.Usually caused by a chemical ingestion or scar tissue, esophageal stricture causes phase 3 dysphagia. Drooling, tachypnea, and gagging may also be evident.
Esophagitis.Corrosive esophagitis, resulting from ingestion of alkali or acids, causes severe phase 3 dysphagia. Accompanying it are marked salivation, hematemesis, tachypnea, a fever, and intense pain in the mouth and anterior chest that's aggravated by swallowing. Signs of shock, such as hypotension and tachycardia, may also occur.
Candidal esophagitis causes phase 2 dysphagia, a sore throat and, possibly, retrosternal pain on swallowing. With reflux esophagitis, phase 3 dysphagia is a late symptom that usually accompanies stricture development. The patient complains of heartburn, which is aggravated by strenuous exercise, bending over, or lying down and is relieved by sitting up or taking an antacid.
Other features of esophagitis include regurgitation; frequent, effortless vomiting; a dry, nocturnal cough; and substernal chest pain that may mimic angina pectoris. If the esophagus ulcerates, signs of bleeding, such as melena and hematemesis, may occur along with weakness and fatigue.
Gastric carcinoma.Infiltration of the cardia or esophagus by gastric carcinoma causes phase 3 dysphagia along with nausea, vomiting, and pain that may radiate to the neck, back, or retrosternum. In addition, perforation causes massive bleeding with coffee-ground vomitus or melena.
Laryngeal cancer (extrinsic).Phase 2 dysphagia and dyspnea develop late in laryngeal cancer. Accompanying features include a muffled voice, stridor, pain, halitosis, weight loss, ipsilateral otalgia, a chronic cough, and cachexia. Palpation reveals enlarged cervical nodes.
Lead poisoning.Painless, progressive dysphagia may result from lead poisoning. Related findings include a lead line on the gums, a metallic taste, papilledema, ocular palsy, footdrop or wristdrop, and signs of hemolytic anemia, such as abdominal pain and a fever. The patient may be depressed and display severe mental impairment and seizures.
Myasthenia gravis.Fatigue and progressive muscle weakness characterize myasthenia gravis and account for painless phase 1 dysphagia and possibly choking. Typically, dysphagia follows ptosis and diplopia. Other features include masklike facies, a nasal voice, frequent nasal regurgitation, and head bobbing. Shallow respirations and dyspnea may occur with respiratory muscle weakness. Signs and symptoms worsen during menses and with exposure to stress, cold, or infection.
Oral cavity tumor.Painful phase 1 dysphagia develops along with hoarseness and ulcerating lesions.
Plummer-Vinson syndrome.Plummer-Vinson syndrome causes phase 3 dysphagia for solids in some women with severe iron deficiency anemia. Related features include upper esophageal pain; atrophy of the oral or pharyngeal mucous membranes; tooth loss; a smooth, red, sore tongue; a dry mouth; chills; inflamed lips; spoon-shaped nails; pallor; and splenomegaly.
Rabies.Severe phase 2 dysphagia for liquids results from painful pharyngeal muscle spasms occurring late in this rare, life-threatening disorder. In fact, the patient may become dehydrated and possibly apneic. Dysphagia also causes drooling, and in 50% of cases it's responsible for hydrophobia. Eventually, rabies causes progressive flaccid paralysis that leads to peripheral vascular collapse, coma, and death.
Systemic lupus erythematosus (SLE).SLE may cause progressive phase 2 dysphagia. However, its primary signs and symptoms include nondeforming arthritis, a characteristic butterfly rash, and photosensitivity.
Tetanus.Phase 1 dysphagia usually develops about 1 week after the patient receives a puncture wound. Other characteristics include marked muscle hypertonicity, hyperactive DTRs, tachycardia, diaphoresis, drooling, and a low-grade fever. Painful, involuntary muscle spasms account for lockjaw (trismus), risus sardonicus, opisthotonos, boardlike abdominal rigidity, and intermittent tonic seizures.
Other causes
Procedures.Recent tracheostomy or repeated or prolonged endotracheal intubation may cause temporary dysphagia.
Radiation therapy.When directed against oral cancer, this therapy may cause scant salivation and temporary dysphagia.
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Source: Nursing: Interpreting Signs and Symptoms, 2007
Ptosis:
Medical causes
(Nursing: Interpreting Signs and Symptoms)
Botulism.Acute cranial nerve dysfunction as a result of botulism infection causes hallmark signs of ptosis, dysarthria, dysphagia, and diplopia. Other findings include a dry mouth, a sore throat, weakness, vomiting, diarrhea, hyporeflexia, and dyspnea.
Cerebral aneurysm.An aneurysm that compresses the oculomotor nerve can cause sudden ptosis, along with diplopia, a dilated pupil, and an inability to rotate the eye. These may be the first signs of this life-threatening disorder. A ruptured aneurysm typically produces a sudden severe headache, nausea, vomiting, and decreased level of consciousness (LOC). Other findings include nuchal rigidity, back and leg pain, fever, restlessness, irritability, occasional seizures, blurred vision, hemiparesis, sensory deficits, dysphagia, and visual defects.
Lacrimal gland tumor.A lacrimal gland tumor commonly produces mild to severe ptosis, depending on the tumor's size and location. It may also cause brow elevation, exophthalmos, eye deviation and, possibly, eye pain.
Myasthenia gravis.Commonly the first sign of myasthenia gravis, gradual bilateral ptosis may be mild to severe and is accompanied by weak eye closure and diplopia. Other characteristics include muscle weakness and fatigue, which eventually may lead to paralysis. Depending on the muscles affected, other findings may include masklike facies, difficulty chewing or swallowing, dyspnea, and cyanosis.
Ocular muscle dystrophy.With ocular muscle dystrophy, bilateral ptosis progresses slowly to complete eyelid closure. Related signs and symptoms include progressive external ophthalmoplegia and muscle weakness and atrophy of the upper face, neck, trunk, and limbs.
Ocular trauma.Trauma to the nerve or muscles that control the eyelids can cause mild to severe ptosis. Depending on the damage, eye pain, lid swelling, ecchymosis, and decreased visual acuity may also occur.
Parry-Romberg syndrome.Unilateral ptosis and facial hemiatrophy occur with Parry-Romberg syndrome. Other signs include miosis, sluggish pupil reaction to light, enophthalmos, different-colored irises, ocular muscle paralysis, nystagmus, and neck, shoulder, trunk, and extremity atrophy.
Other causes
Drugs.Vinca alkaloids can produce ptosis.
Lead poisoning.With lead poisoning, ptosis usually develops over 3 to 6 months. Other findings include anorexia, nausea, vomiting, diarrhea, colicky abdominal pain, a lead line in the gums, decreased LOC, tachycardia, hypotension and, possibly, irritability and peripheral nerve weakness.
» READ BOOK EXCERPT ONLINE »
Source: Nursing: Interpreting Signs and Symptoms, 2007
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