BASICS
Difficulty transmitting the alimentary bolus from the mouth to stomach
DESCRIPTION
- Oropharyngeal dysphagia: difficulty transferring food bolus from oropharynx to proximal esophagus
- Esophageal dysphagia: difficulty moving food bolus through the body of the esophagus to the pylorus
EPIDEMIOLOGY
10% of individuals >50 years of age
Prevalence
- Common primary care complaint
- Rates of impaired swallowing in nursing home residents range from 29 to 32%.
ETIOLOGY AND PATHOPHYSIOLOGY
- Oropharyngeal (transfer dysphagia):
- Mechanical causes: pharyngeal and laryngeal cancer, acute epiglottitis, carotid body tumor, pharyngitis, tonsillitis, strep throat, lymphoid hyperplasia of lingual tonsil, lateral pharyngeal pouch, hypopharyngeal diverticulum
- Esophageal:
- Esophageal mechanical lesions: carcinomas, esophageal diverticula, esophageal webs, Schatzki ring, structures (peptic, chemical, trauma, radiation), foreign body
- Extrinsic mechanical lesions: peritonsillar abscess, thyroid disorders, tumors, mediastinal compression, vascular compression (enlarged left atrium, aberrant subclavius, aortic aneurysm), osteoarthritis cervical spine, adenopathy, esophageal duplication cyst
- Neuromuscular: achalasia, diffuse esophageal spasm, hypertonic lower esophageal sphincter, scleroderma, nutcracker esophagus, CVA, Alzheimer disease, Huntington chorea, Parkinson disease, multiple sclerosis, skeletal muscle disease (polymyositis, dermatomyositis), neuromuscular junction disease (myasthenia gravis, Lambert-Eaton syndrome, botulism), hyper- and hypothyroidism, Guillain-Barr © syndrome, systemic lupus erythematous, acute lymphoblastic leukemia, amyloidosis, diabetic neuropathy, brainstem tumors, Chagas disease
- Infection: diphtheria, chronic meningitis, tertiary syphilis, Lyme disease, rabies, poliomyelitis, CMV, esophagitis (Candida, herpetic)
- Globus phenomenon
RISK FACTORS
- Children: hereditary and/or congenital malformations
- Adults: age >50 years. Elderly: GERD, stroke, COPD, chronic pain
- Smoking, excess alcohol intake, obesity
- Medications: quinine, potassium chloride, vitamin C, tetracycline, Bactrim, clindamycin, NSAIDs, procainamide, anticholinergics, bisphosphates
- Neurologic events or diseases: CVA, myasthenia gravis, multiple sclerosis, Parkinson disease, amyotrophic lateral sclerosis (ALS), Huntington chorea
- HIV patients with CD4 cell count <100 cells/mm3
- Trauma or irradiation of head, neck, and chest; mechanical lesions
- Extrinsic mechanical lesions: lung, thyroid tumors, lymphoma, metastasis
- Iron deficiency
- Anterior cervical spine surgery (up to 71% in the first 2 weeks postop; 12-14% at 1 year postop)
- Dysphagia lusoria (vascular abnormalities causing dysphagia): complete vascular ring, double aortic arch, right aortic arch with retroesophageal left subclavian artery and left ligamentum arteriosum, and right aortic arch with mirrow-image branching and left ligamentum arteriousum
GENERAL PREVENTION
- Correct poorly fitting dentures in older patients.
- Educate patients on prolonged chewing and drinking large volumes of water to accompany meals.
- Liquid and soft food diet in appropriate patients
- Avoid alcohol with meals.
- Prophylactic swallowing exercises in patients with head and neck cancer undergoing chemoradiation
COMMONLY ASSOCIATED CONDITIONS
Peptic structure, esophageal webs and rings, carcinoma; history of stroke, dementia, pneumonia
DIAGNOSIS
HISTORY
- Dysphagia to both solids and liquids from the onset of deglutition is likely an esophageal motility disorder.
- Oropharyngeal dysphagia presents as difficulty in initiating the swallowing process.
- Dysphagia for solids that later progresses to involve liquids more likely reflects mechanical obstruction.
- Progressive dysphagia is usually caused by cancer or a peptic stricture. Intermittent dysphagia is most often related to a lower esophageal ring.
- Inquire about heartburn, weight loss, hematemesis, coffee ground emesis, anemia, regurgitation of undigested food particles, and respiratory symptoms.
- Inquire about regurgitation, aspiration, or drooling immediately after swallowing
- May represent oropharyngeal dysphagia
- Does the food bolus feel stuck?
- Upper sternum or back of throat may represent oropharyngeal dysphagia, whereas sensation over the lower sternum is typical of esophageal dysphagia.
- Is odynophagia present?
- May represent inflammation, achalasia, diffuse esophageal spasm, esophagitis, pharyngitis, pill-induced esophagitis, cancer
- Globus sensation ("lump in the throat")?
- Indicates cricopharyngeal or laryngeal disorders
- History of sour taste in the back of the throat or history of chronic heartburn suggests GERD.
- Inquire about alcohol and/or tobacco use.
- Are there associated symptoms such as weight loss or chest pain?
- Double aortic arch, right aortic arch with retroesophageal left subclavian artery and left ligamentum arteriosum
- Anticholinergics, antihistamines, and some antihypertensives can decrease salivary production.
- Halitosis: Rule out diverticulitis.
- Prior history of a connective tissue disorder
- Changes in speech, hoarseness, weak cough, dysphonia? Rule out neuromuscular dysfunction.
PHYSICAL EXAM
- General: vital signs
- Skin:
- Telangiectasia, sclerodactyly, calcinosis (r/o autoimmune disease); Reynaud phenomenon, sclerodactyly may be found in CREST syndrome or systemic scleroderma; stigmata of alcohol abuse (palmar erythema; telangiectasia)
- Head, eye, ear, nose, throat (HEENT):
- Oropharyngeal:
- Pharyngeal erythema/edema, tonsillitis, pharyngeal ulcers or thrush, odynophagia (bacterial, viral, fungal infections)
- Tongue fasciculations (ALS)
- Neck:
- Neck masses, lymphadenopathy, neck tenderness, goiter
- Neck tenderness: acute thyroiditis
- Neurologic:
- Cranial nerve exam:
- Sensory: cranial nerves V, IX, and X
- Motor: cranial nerves V, VII, X, XI, and XII
- CNS, mental status exam, strength testing, Horner syndrome, ataxia, cogwheel rigidity (CVA, dementia, Parkinson disease, Alzheimer disease)
- Eye position, extraocular motility
- Informal bedside swallowing evaluation:
- Observe level of consciousness, postural control-upright position, oral hygiene, mobilization of oral secretions.
DIFFERENTIAL DIAGNOSIS
See "Etiology and Pathophysiology."
DIAGNOSTIC TESTS & INTERPRETATION
Adults: (1)[C]
- Barium swallow
- Fiberoptic endoscopic examination of swallowing (FEES)
- Gastroesophageal endoscopy
- Barium cine/video esophagogram
- Ambulatory 24-hour pH testing
- Esophageal manometry
- Videofluoroscopic swallowing study (VFSS): oropharyngeal dysphagia
Initial Tests (lab, imaging)
- Guided by diagnostic considerations (2)[C]
- CBC (infection and inflammation)
- Serum protein and albumin levels for nutritional assessment
- Thyroid function studies to detect dysphagia associated with hypothyroidism or hyperthyroidism, cobalamin levels
- Antiacetylcholine antibodies (myasthenia)
- Barium swallow: detects strictures or stenosis
Follow-Up Tests & Special Considerations
- CT scan of chest
- MRI of brain and cervical spine
- Videofluoroscopic swallowing function study (VSFS) (lips, tongue, palate, pharynx, larynx, proximal esophagus)
- Fiberoptic endoscopy and videofluoroscopy are similar in terms of diagnostic sensitivity (3)[C].
Diagnostic Procedures/Other
Endoscopy with biopsy; esophageal manometry; esophageal pH monitoring
Test Interpretation
- Squamous cell or adenocarcinoma
- Barrett metaplasia
- Fibrous tissue of a ring, web, or stricture
- Loss of smooth muscle (scleroderma)
TREATMENT
GENERAL MEASURES
Exclude cardiac disease. Ensure airway patency and adequate pulmonary function. Assess nutritional status. Speech therapy evaluation is helpful.
MEDICATION
First Line
- For esophageal spasms: calcium channel blockers: nifedipine 10 to 30 mg TID; imipramine 50 mg at bedtime; sildenafil 50 mg/day PRN
- For esophagitis:
- Antacids: Tums, Mylanta, Maalox
- H2 blockers:
- Cimetidine: up to 1,600 mg orally per day in 2 or 4 divided doses for 12 weeks
- Ranitidine: initial 150 mg orally 4 times daily and maintenance 150 mg orally twice daily
- Nizatidine: 150 mg orally twice daily for 12 weeks
- Famotidine: 20 to 40 mg orally twice daily for 12 weeks
- Proton pump inhibitors:
- Omeprazole: 20 mg once daily for 4 to 8 weeks
- Lansoprazole: 30 mg once daily for up to 8 weeks
- Rabeprazole: 20 mg orally once daily for 4 to 8 weeks
- Esomeprazole: 20 to 40 mg orally once daily for 4 to 8 weeks
- Pantoprazole: 40 mg orally once daily for up to 8 weeks
- Prokinetic agents: rarely used
- Precautions: may need to use liquid forms of medications because patients might have difficulty swallowing pills
ISSUES FOR REFERRAL
- Gastroenterology: endoscopy, refractory symptoms
- Surgery: dilation, esophageal myotomy, biopsy
ADDITIONAL THERAPIES
Speech therapy to assess swallowing; nutritional evaluation for dietary and positioning recommendations; physical therapy for muscle-strengthening exercise; no eating at bedtime; remaining upright after eating
- Self-expanded metal stent is safe, effective, and quicker in palliating dysphagia compared to other modalities.
SURGERY/OTHER PROCEDURES
- Esophageal dilatation (pneumatic or bougie)
- Esophageal stent; laser for cancer palliation (4)[A]
- Treatment for underlying problem (e.g., thyroid goiter, vascular ring, esophageal atresia)
- Nd:YAG laser incision of lower esophageal rings refractory to dilation
- Photodynamic therapy (cancer) (4)[C]
- Cricopharyngeal myotomy (oropharyngeal dysphagia)
- Surgery for Zenker diverticulum, refractory strictures, or myotomy (for achalasia)
- Percutaneous endoscopic gastrostomy (PEG) decreases risk of dysphagia when compared with nasogastric tube.
COMPLEMENTARY & ALTERNATIVE MEDICINE
- Acupuncture has been used for neurogenic dysphagia.
- Electroacupuncture combined with dilating granule has been used in the treatment of GERD.
- Insufficient evidence for routine use of botulinum toxin
INPATIENT CONSIDERATIONS
Admission Criteria/Initial Stabilization
- Complete or partial esophageal obstruction with malnutrition or hypovolemia/dehydration
- Comorbid conditions complicating dysphagia
- Need for enteral feeding
- Outpatient for conditions where patient is able to maintain nutrition and has little risk of complications.
- Hospitalization may be required for adults when dysphagia is associated with total or near-total obstruction of esophageal lumen.
- Hospitalization may be needed for endoscopy and/or esophageal dilation and is generally indicated for diagnostic or therapeutic surgical procedures.
IV Fluids
For dehydrated, hypovolemic patients, and patients with impaired consciousness
Discharge Criteria
Tolerating adequate diet without nausea/pain
ONGOING CARE
DIET
See "General Prevention."
PATIENT EDUCATION
Dietary modification; no eating at bedtime; remaining upright after eating; smoking cessation
PROGNOSIS
Vary with specific diagnosis.
COMPLICATIONS
- Oropharyngeal: pneumonia, lung abscess, aspiration, airway obstruction
- Malnutrition and dehydration
REFERENCES
11 American College of Radiology. ACR appropriateness criteria for dysphagia. National Guideline Clearinghouse. https://www.guidelinecentral.com/summaries/acr-appropriateness-criteria-dysphagia/. Accessed 2014.22 Al-Hussaini A, Latif EH, Singh V. 12-minute consultation: an evidence-based approach to the management of dysphagia. Clin Otolaryngol. 2013;38(3):237-243.33 ASGE Standards of Practice Committee, Pasha SF, Acosta RD, et al. The role of endoscopy in the evaluation and management of dysphagia. Gastrointest Endosc. 2014;79(2):191-201.44 Dai Y, Li C, Xie Y, et al. Interventions for dysphagia in oesophageal cancer. Cochrane Database Syst Rev. 2014;(10):CD005048.
ADDITIONAL READING
- Anderson U, Beck A, Kjaersgaard A, et al. Systematic review and evidence based recommendations on texture modified foods and thickened fluids for adults (≥18 years) with oropharyngeal dysphagia. e-SPEN Journal. 2013;8(4):e127-e134.
- Cho SK, Lu Y, Lee DH. Dysphagia following anterior cervical spinal surgery: a systematic review. Bone Joint J. 2013;95-B(7):868-873.
- Geeganage C, Beavan J, Ellender S, et al. Interventions for dysphagia and nutritional support in acute and subacute stroke. Cochrane Database Syst Rev. 2012;(10):CD000323.
- Regan J, Murphy A, Chiang M, et al. Botulinum toxin for upper oesophageal sphincter dysfunction in neurological swallowing disorders. Cochrane Database Syst Rev. 2014;(5):CD009968.
CODES
ICD10
- R13.10 Dysphagia, unspecified
- R13.12 Dysphagia, oropharyngeal phase
- R13.14 Dysphagia, pharyngoesophageal phase
- Q39.3 Congenital stenosis and stricture of esophagus
- R13.19 Other dysphagia
- R13.13 Dysphagia, pharyngeal phase
- R13.11 Dysphagia, oral phase
ICD9
- 787.20 Dysphagia, unspecified
- 787.22 Dysphagia, oropharyngeal phase
- 787.24 Dysphagia, pharyngoesophageal phase
- 750.3 Tracheoesophageal fistula, esophageal atresia and stenosis
- 787.23 Dysphagia, pharyngeal phase
- 787.29 Other dysphagia
- 787.21 Dysphagia, oral phase
- 530.3 Stricture and stenosis of esophagus
SNOMED
- 40739000 Dysphagia (disorder)
- 71457002 Oropharyngeal dysphagia (disorder)
- 40890009 Esophageal dysphagia (disorder)
- 253760004 Congenital stenosis of esophagus
- 429975007 Oral phase dysphagia
CLINICAL PEARLS
- Preventing aspiration is a priority.
- Swallow therapy is recommended in patients with oropharyngeal dysphagia following a stroke, head or neck trauma, surgery, or degenerative neurologic diseases.
- Patients with oropharyngeal dysphagia usually report feeling an obstruction in the neck and point to this area when asked to identify the site of their symptoms.
- Weight loss is usually associated with malignancy or achalasia.
- Most patients with Sj ¶gren syndrome have associated dysphagia.