Basics
Description
- Difficulty swallowing
- Can be neuromuscular or mechanical
Etiology
- Oropharyngeal (transfer) dysphagia:
- Difficulty transferring from the mouth to the proximal esophagus (difficulty initiating a swallow)
- Easier to swallow solids vs. liquids
- Immediate, within seconds of swallowing
- Associated with nasal or oral regurgitation, coughing, or choking
- Usually a neuromuscular disorder resulting in bulbar muscle weakness or impaired coordination
- Esophageal (transport) dysphagia:
- Failure of normal transit through the esophagus
- Retrosternal sticking sensation seconds after swallowing
- Nocturnal regurgitation/aspiration
- Drooling or regurgitation of undigested food and liquid (characteristic of esophageal obstruction)
- Motility disorder vs. mechanical obstruction
- Functional dysphagia:
- Diagnosis of exclusion
- Full workup without evidence of mechanical or neuromuscular pathology
- Symptoms >12 wk
- Odynophagia:
- Pain with swallowing
- Separate, but often related, entity
- Pain pattern:
- Overall poor ability to localize pain with dysphagia, although oropharyngeal source is better
- Somatic nerve fibers in the upper esophagus; better pain localization
- Visceral pain from the lower esophagus is poorly localized and may be difficult to distinguish from that of acute coronary syndrome.
- Pediatric dysphagia:
- Common causes in infants/newborns include prematurity, congenital malformations, neuromuscular disease, infection (e.g., candidiasis), inflammation
- Always consider foreign body aspiration in a child presenting with dysphagia
- Other common causes in children include caustic ingestions, infections, and neurologic disorders including sequelae from head injury
- Acquired tracheoesophageal fistula in children may result from ingestions (disk battery, caustic ingestions) or prior surgery
- Other life-threatening causes of dysphagia include epiglottitis, retropharyngeal abscess, CNS infection, botulism, esophageal perforation, diphtheria
Diagnosis
Signs and Symptoms
- Difficulty initiating swallowing
- Sensation of food stuck after swallowing
- Cough/choke after eating
- Impairment of gag reflex and ability to clear bolus
- Voice change/dysphonia
- Drooling
- Dysarthria
- Chest pain
History
- Is there difficulty swallowing solids, liquids, or both?
- Solids and liquids suggest a neuromuscular disorder.
- Solids only or progression from solids to liquids suggests a mechanical abnormality.
- How long after swallowing do symptoms occur?
- Immediate onset of symptoms suggests oropharyngeal cause
- Delay (seconds after swallowing) suggests esophageal cause
- Are symptoms intermittent or progressive?
- Intermittent symptoms suggest rings or webs.
- Progressive symptoms suggest peptic or malignant strictures.
- Motility disorders can be intermittent or progressive.
- How long have the symptoms been present?
- Acute onset is more concerning for acutely life-threatening etiology
- Food impaction is the most common cause of acute-onset dysphagia
- Malignancy may also progressive relatively quickly
- Are there other associated symptoms?
- e.g., nasal regurgitation, choking, heartburn, weight loss
Physical Exam
- Often unremarkable
- Oropharyngeal inspection
- Pulmonary and cardiac auscultation
- Neurologic exam with emphasis on cranial nerves (esp. V, VII, IX, X, XII)
Essential Workup
- Adequate airway evaluation
- Thorough neurologic exam
Diagnosis Tests & Interpretation
EKG:
- Consider cardiac etiology for chest discomfort
Lab
No specific studies are indicated.
Imaging
- CXR:
- Achalasia food dilating the esophagus may be seen as widened mediastinum, air-fluid level in posterior mediastinum
- Aspiration pneumonitis
- Extrinsic compressing mass
- Soft tissue lateral neck radiograph
- Modified barium swallow (with solid bolus) or videofluoroscopy:
- Defines esophageal anatomy
- Assesses function
- Do not perform if endoscopy anticipated
- CT/MRI of the head:
- Indicated for new-onset neuromuscular dysphagia
Diagnostic Procedures/Surgery
- Often performed in the outpatient setting
- Upper endoscopy:
- Indicated to relieve obstruction and inspect the esophageal anatomy
- Biopsy possible if indicated
- Esophageal manometry
- Fiberoptic nasopharyngeal laryngoscopy
Differential Diagnosis
- Oropharyngeal:
- Infectious:
- Botulism
- CNS infections
- Mucositis
- Lyme disease
- Mechanical:
- Congenital
- Malignancy
- Pharyngeal pouch
- Medications:
- Antibiotics (especially doxycycline)
- Aspirin and NSAIDs
- Bisphosphonates
- Ferrous sulfate
- Potassium chloride
- Quinidine
- Neuromuscular:
- Amyotrophic lateral sclerosis
- Cerebrovascular accident
- Guillain-Barr © syndrome
- Cranial nerve palsy
- Huntington chorea
- Multiple sclerosis
- Myasthenia gravis
- Parkinson disease
- Traumatic brain injury
- Psychological/behavioral
- Esophageal:
- Mechanical:
- Diverticula
- Esophageal webs
- Foreign body
- Neoplasm
- Peptic esophageal stricture
- Postsurgical (laryngeal, spinal)
- Radiation injury
- Schatzki ring
- Motor:
- Achalasia
- Chagas
- Cushing syndrome
- Diffuse esophageal spasm
- Hyperthyroidism/hypothyroidism
- Nutcracker esophagus
- Scleroderma
- Vitamin B12 deficiency
- Inflammatory:
- Eosinophilic esophagitis
- Pill esophagitis
- Extrinsic:
- Cardiovascular abnormalities (vascular rings, thoracic aneurysm, left atrial enlargement, aberrant subclavian artery)
- Cervical osteophytes
- Mediastinal mass
Treatment
Pre-Hospital
- Vigilant airway attention
- Position of comfort with suction available
Initial Stabilization/Therapy
- Vigilant airway attention
- Position of comfort with suction available
- NPO
- 0.9% NS 500 mL (peds: 20 mL/kg) IV fluid bolus for significant dehydration
- Evaluate for life-threatening causes of dysphagia including
- Retropharyngeal hematoma/abscess
- Epiglottitis
- Foreign body
- Upper airway obstruction
- Cardiovascular causes (thoracic aortic aneurysm)
Ed Treatment/Procedures
- Nitroglycerin for esophageal spasm
- Glucagon for impacted foreign body
- Treat complications:
- Airway obstruction
- Aspiration, pneumonia, lung abscess
- Dehydration, malnutrition
- Endoscopy
- Dietary modifications:
- Thickened liquids for neuromuscular disorder
- Thin liquids for mechanical disorders
Medication
First Line
- Glucagon for food impaction: 1 mg IV followed by 2nd dose of 1 mg after 5 min if there is no improvement in symptoms (0.02-0.03 mg/kg in children, not to exceed 0.5 mg):
- Success rates vary from 12-50%, which may not be better than spontaneous passage.
Second Line
Calcium channel blockers and nitrates may be used in motility disorders (e.g., achalasia and nutcracker esophagus)
Follow-Up
Disposition
Admission Criteria
- Esophageal obstruction persists despite treatment
- Compromised fluid or nutrition status
- Inability to protect airway
- Unable to tolerate own secretions
Discharge Criteria
- Well-hydrated patient
- Urgent neurology, otolaryngology, or gastroenterology referral arranged for further evaluation and treatment
Issues for Referral
Next day follow-up with PCP or ENT/GI
Follow-Up Recommendations
- Clear liquid diet prior to ENT follow-up
- Return if SOB, chest pain, or unable to tolerate own secretions.
Pearls and Pitfalls
- Consider foreign-body aspiration in children presenting with dysphagia.
- Dysphagia is a common presentation in stroke.
- Consider in patients with recurrent pneumonia.
- Assess for life-threatening causes of dysphagia before deferring definitive diagnosis to outpatient setting.
Additional Reading
- Fass R. Evaluation of dysphagia in adults. Cited from UpToDate.com. Accessed February 22, 2013.
- Furnival RA, Woodward GA. Pain-dysphagia. In: Fleisher GR, Ludwig S, Henretig FM, eds. Textbook of Pediatric Emergency Medicine. 5th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2006.
- Seamens CS, Brywczynski. Esophageal disorders. In: Harwood Nuss' Clinical Practice of Emergency Medicine. 5th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2010.
- Smith Hammond CA, Goldstein LB. Cough and aspiration of food and liquids due to oral-pharyngeal dysphagia: ACCP evidence-based clinical practice guidelines. Chest. 2006;129:154S-168S.
- Yal §in Åž, Ciftci AO, Karnak I, et al. Management of acquired tracheoesophageal fistula with various clinical presentations. J Pediatr Surg. 2011; 46(10):1887-1892.
See Also (Topic, Algorithm, Electronic Media Element)
Stroke
Codes
ICD9
- 787.20 Dysphagia, unspecified
- 787.22 Dysphagia, oropharyngeal phase
- 787.24 Dysphagia, pharyngoesophageal phase
- 787.29 Other dysphagia
- 787.21 Dysphagia, oral phase
- 787.23 Dysphagia, pharyngeal phase
- 787.2 Dysphagia
ICD10
- R13.10 Dysphagia, unspecified
- R13.12 Dysphagia, oropharyngeal phase
- R13.14 Dysphagia, pharyngoesophageal phase
- R13.19 Other dysphagia
- R13.11 Dysphagia, oral phase
- R13.13 Dysphagia, pharyngeal phase
- R13.1 Dysphagia
SNOMED
- 40739000 Dysphagia (disorder)
- 71457002 Oropharyngeal dysphagia (disorder)
- 40890009 Esophageal dysphagia (disorder)
- 249485007 Food sticks on swallowing (disorder)
- 429975007 Oral phase dysphagia