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dysphagia (swallowing disorder)

Difficulty swallowing. Classification: - oropharyngeal dysphagia - esophageal dysphafia [4] Etiology: 1) oropharyngeal dysphagia (transfer dysphagia) a) oral causes - stomatitis - tongue ulcer - cleft palate - vitamin deficiency - Sjogren's syndrome - poor salivation - sicca syndrome - large hook-like epiglottis (common in elderly) b) nervous system disorders - cerebrovascular accident - especially brainstem stroke - pseudobulbar palsy - Parkinson's disease - multiple sclerosis - amyotrophic lateral sclerosis - Huntington's disease - brain tumors - especially brainstem tumors - dementia [4] - peripheral neuropathy - diabetes mellitus - lead poisoning - alcoholism - hypercalcemia - recurrent laryngeal nerve damage c) infection &/or inflammation - pharyngitis - retropharyngeal abscess - botulism - poliomyelitis - rabies - tetanus d) structural lesions - oropharyngeal tumor - pharyngeal webs, cricoid webs - extrinsic compression - vertebral osteophyte - thyromegaly (goiter) - diverticula - Zenker's diverticulum e) myopathies (see below) 2) esophageal dysphagia a) structural lesions - benign esophageal strictures - peptic, corrosive, inflammatory, radiation - eosinophilic esophagitis - neoplasm - esophageal carcinoma - squamous cell carcinoma - adenocarcinoma - dysphagia progressing from solids alone to both solids & liquids suggests malignancy - esophageal webs - esophageal rings - Schatzki's ring - external compression - thyroid - bronchogenic cyst - mediastinal mass - left atrial enlargement - aortic aneurysm - epiphrenic diverticula, traction diverticulum [4] - dysphagia lusoria (vascular dysphagia) b) esophageal motility disorders - primary - achalasia - esophageal spasm, diffuse - lower esophageal sphincter dysfunction - hypertonic - upper esophageal sphincter dysfunction - secondary - gastroesophageal reflux disease (GERD) - scleroderma - Chagas' disease - Herpesvirus - Candida - cytomegalovirus 3) muscular disorders (myopathy) a) myasthenia gravis b) muscular dystrophy c) polymyositis/dermatomyositis d) metabolic myopathy - myxedema (hypothyroidism) 4) other a) radiation therapy b) sodium fluoride poisoning c) Plummer-Vinson syndrome (women) - dysphagia resolves with correction of anemia Clinical manifestations: 1) patients may present with coughing, choking, changes in speech (nasal voice), repeated aspirations, nasopharyngeal regurgitation -> oropharyngeal dysphagia 2) oropharyngeal dysphagia occurs immediately with swallowing 3) esophageal dysphagia usually occurs after initiation of swallowing 4) difficulties with only solid foods suggests a mechanical narrowing of the esophagus 5) dysphagia related to both liquids & solid food or liquids alone suggests a disorder of esophageal motility 6) intermittent dysphagia suggests a ring, web or motility disorder 7) progressive dysphagia for solid foods suggests peptic stricture or carcinoma [4] 8) weight loss may be only clue to presence of dysphagia 9) evidence of acute or chronic aspiration 10) presence or absence of a gag reflex has no bearing on ability to swallow 12) evidence of psychosocial dysfunction may be present 12) globus may be noted patients with emotional disorders or GERD 13) other signs associated with dysphagia may be present a) poor awareness or control of saliva b) infrequent swallowing of saliva c) continuous copius chest secretions 14) specific findings for specific etiologies Special laboratory: 1) modified barium swallow with video esophagography (videofluoroscopy) [4] a) includes pre-esophageal component of swallowing b) 1st line for oropharyngeal dysphagia [4] c) images [12] 2) upper GI endoscopy a) all patients with dysphagia for solid foods [4] - barium swallow 1st test for suspected Zenker's diverticulum [1] b) procedure of choice for esophageal dysphagia, including suspected mass lesion or malignancy [4] c) allows for direct visual inspection, esophageal biopsy & dilation [4] d) may be diagnostic & therapeutic for esophageal dysphagia [4] e) narrowing of the lower esophageal sphincter suggests Schatzki's ring [15] 3) manometric & motility studies Radiology: - barium swallow - 1st test for suspected Zenker's diverticulum [4] - modified barium swallow for oropharyngeal dysphagia [4] - chest X-ray may show aspiration of barium (image) [12] - swallowing dynamic computed tomography [14] Differential diagnosis: - odynophagia [6] - cardiac causes of chest pain need to be ruled out [4] - dysphagia progressing from occurrence with solids alone to both solids & liquids suggests malignancy Management: 1) general measures a) speech therapy: functional & behavioral techniques for oropharyngeal dysphagia - food consistency - unclear whether thickened liquid diet benefits patients with Alzheimer's disease & related dementias & dysphagia [16] - sensory stimulation - motor retraining - controlled breathing - coughing - head positioning b) gastrostomy or jejunostomy c) parenteral feedings 2) specific measures for specific etiologies - dysphagia due to stroke: - nearly 1/2 of patients recover effective swallowing within 7 days [5] - recovery of swallowing may take up to a year - prophylactic antibiotics do not prevent pneumonia & may result in harm [11] - surgery for external compression on the esophagus (bronchogenic cyst) 3) multidisciplinary team approach, consisting of: a) ENT specialist b) gastroenterologist c) speech pathologist d) dietician e) primary care physician

Interactions

disease interactions

Related

causes of dysphagia odynophagia (swallowing pain) screening for dysphagia swallowing (deglutition)

Specific

vascular dysphagia; dysphagia lusoria

General

sign/symptom

References

  1. nlmpubs.nlm.nih.gov/hstat/ahcpr/
  2. Guide to Physical Examination & History Taking, 6th edition, Bates B, JB Lippincott, Philadelphia, 1995, pg 42
  3. Mayo Internal Medicine Board Review, 1998-99, Prakash UBS (ed) Lippincott-Raven, Philadelphia, 1998, pg 279-82
  4. Medical Knowledge Self Assessment Program (MKSAP) 11, 15, 16, 17, 18. American College of Physicians, Philadelphia 1998, 2009, 2012, 2015, 2018. - Medical Knowledge Self Assessment Program (MKSAP) 19 Board Basics. An Enhancement to MKSAP19. American College of Physicians, Philadelphia 2022
  5. Geriatrics Review Syllabus, American Geriatrics Society, 5th edition, 2002-2004; 7th edition 2010
  6. Holt PR, Annals of Long-Term Care suppl, Feb 2004
  7. Mary Johnson, Speech Pathology, VAMC, Sacramento CA
  8. Cook IJ. Diagnostic evaluation of dysphagia. Nat Clin Pract Gastroenterol Hepatol. 2008 Jul;5(7):393-403 PMID: 18542115 - Cook IJ Oropharyngeal dysphagia. Gastroenterol Clin North Am. 2009 Sep;38(3):411-31. Review. PMID: 19699405
  9. Hill M, Hughes T, Milford C. Treatment for swallowing difficulties (dysphagia) in chronic muscle disease. Cochrane Database Syst Rev. 2004;(2):CD004303. Review. PMID: 15106246
  10. Rofes L, Arreola V, Almirall J et al Diagnosis and management of oropharyngeal Dysphagia and its nutritional and respiratory complications in the elderly. Gastroenterol Res Pract. 2011;2011 PMID: 20811545
  11. Kalra L et al. Prophylactic antibiotics after acute stroke for reducing pneumonia in patients with dysphagia (STROKE-INF): A prospective, cluster-randomised, open-label, masked endpoint, controlled clinical trial. Lancet 2015 Sep 3; PMID: 26343840 - Meisel A and Smith CJ. Prevention of stroke-associated pneumonia: Where next? Lancet 2015 Sep 3 PMID: 26343837
  12. Paik NJ, Lorenzo CT (images) Medscape: Dysphagia http://emedicine.medscape.com/article/2212409-overview
  13. Sura L, Madhavan A, Carnaby G, Crary MA. Dysphagia in the elderly: management and nutritional considerations. Clin Interv Aging. 2012;7:287-98. Review. PMID: 22956864 Free PMC Article
  14. Inamoto Y, Gonzalez-Fernandez M, Saitoh E. 3D-CT Evaluation of Swallowing: Metrics of the Swallowing Response Using Swallowing CT. Dysphagia. 2021 Apr 5 PMID: 33818630 Review.
  15. NEJM Knowledge+ Gastroenterology
  16. Makhnevich A et al. Thick liquids and clinical outcomes in hospitalized patients with Alzheimer disease and related dementias and dysphagia. JAMA Intern Med 2024 May 6; [e-pub]. PMID: 38709510 PMCID: PMC11074929 (available on 2025-05-06) https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2818195
  17. National Institute on Deafness and Other Communication Disorders (HIDCD) Dysphagia https://www.nidcd.nih.gov/health/dysphagia