Dysphagia: A Merck Manual of Patient Symptoms podcast

Dysphagia is difficulty swallowing. The condition results from impeded transport of liquids, solids, or both from the pharynx to the stomach. Dysphagia should not be confused with globus sensation (see Symptoms of GI Disorders: Lump in Throat), a feeling of having a lump in the throat, which is unrelated to swallowing and occurs without impaired transport.

Complications

Dysphagia can lead to tracheal aspiration of ingested material, oral secretions, or both. Aspiration can cause acute pneumonia; recurrent aspiration may eventually lead to chronic lung disease. Prolonged dysphagia often leads to inadequate nutrition and weight loss.

Etiology

Dysphagia is classified as oropharyngeal or esophageal, depending on where it occurs.

Oropharyngeal dysphagia

Oropharyngeal dysphagia is difficulty emptying material from the oropharynx into the esophagus; it results from abnormal function proximal to the esophagus. Patients complain of difficulty initiating swallowing, nasal regurgitation, and tracheal aspiration followed by coughing.

Most often, oropharyngeal dysphagia occurs in patients with neurologic conditions or muscular disorders that affect skeletal muscles (see Table 1: Esophageal and Swallowing Disorders: Some Causes of Oropharyngeal Dysphagia).

Table 1
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Some Causes of Oropharyngeal Dysphagia Mechanism Examples Neurologic Stroke Parkinson's disease Multiple sclerosis Some motor neuron disorders (amyotrophic lateral sclerosis, progressive bulbar palsy, pseudobulbar palsy) Bulbar poliomyelitis Muscular Myasthenia gravis Dermatomyositis Muscular dystrophy Cricopharyngeal incoordination

Esophageal dysphagia

Esophageal dysphagia is difficulty passing food down the esophagus. It results from either a motility disorder or a mechanical obstruction (see Table 2: Esophageal and Swallowing Disorders: Some Causes of Esophageal Dysphagia).

Table 2
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Some Causes of Esophageal Dysphagia Mechanism Examples Motility disorder Achalasia Diffuse esophageal spasm Systemic sclerosis Eosinophilic esophagitis Mechanical obstruction Peptic stricture Esophageal cancer Lower esophageal rings Extrinsic compression (eg, caused by an enlarged left atrium, an aortic aneurysm, an aberrant subclavian artery [termed dysphagia lusoria], a substernal thyroid, a cervical bony exostosis, or a thoracic tumor) Caustic ingestion

Evaluation

History

History of present illness begins with duration of symptoms and acuity of onset. Patients should describe what substances cause difficulty and where they feel the disturbance is located. Specific concerns include whether patients have difficulty swallowing solids, liquids, or both; whether food comes out their nose; whether they drool or have food spill from their mouth; and whether they cough or choke while eating.

Review of symptoms should focus on symptoms suggestive of neuromuscular, GI, and connective tissue disorders and on the presence of complications. Important neuromuscular symptoms include weakness and easy fatigability, gait or balance disturbance, tremor, and difficulty speaking. Important GI symptoms include heartburn or other chest discomfort suggestive of reflux. Symptoms of connective tissue disorders include muscle and joint pain, Raynaud's phenomenon, and skin changes (eg, rash, swelling, thickening).

Past medical history should ascertain known diseases that may cause dysphagia (see Table 1: Esophageal and Swallowing Disorders: Some Causes of Oropharyngeal Dysphagia and Table 2: Esophageal and Swallowing Disorders: Some Causes of Esophageal Dysphagia).

Physical examination

Examination focuses on findings suggestive of neuromuscular, GI, and connective tissue disorders and on the presence of complications.

General examination should evaluate nutritional status (including body weight). A complete neurologic examination is essential, with attention to any resting tremor, the cranial nerves (note the gag reflex may normally be absent; this absence is thus not a good marker of swallowing dysfunction), and muscle strength. Patients who describe easy fatigability should be observed performing a repetitive action (eg, blinking, counting aloud) for a rapid decrement in performance. The patient's gait should be observed, and balance should be tested. Skin is examined for rash and thickening or texture changes, particularly on the fingertips. Muscles are inspected for wasting and fasciculations and are palpated for tenderness. The neck is evaluated for thyromegaly or other mass.

Red flags

Any dysphagia is of concern, but certain findings are more urgent:

• Symptoms of complete obstruction (eg, drooling, inability to swallow anything)
• Dysphagia resulting in weight loss
• New focal neurologic deficit, particularly any objective weakness

Interpretation of findings

Dysphagia that occurs in conjunction with an acute neurologic event is likely the result of that event; new dysphagia in a patient with a stable, long-standing neurologic disorder may have another etiology. Dysphagia for solids alone suggests mechanical obstruction; however, a problem with both solids and liquids is nonspecific. Drooling and spilling food from the mouth while eating or nasal regurgitation suggests an oropharyngeal disorder. Regurgitation of a small amount of food on lateral compression of the neck is virtually diagnostic of pharyngeal diverticulum.

Patients who complain of difficulty getting food to leave the mouth or of food sticking in the lower esophagus are usually correct about the condition's location; the sensation of dysphagia in the upper esophagus is less specific.

Many findings suggest specific disorders (see Table 3: Esophageal and Swallowing Disorders: Some Helpful Findings in Dysphagia) but are of varying sensitivity and specificity and thus do not rule in or out a given cause; however, they can guide testing.

Table 3
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Some Helpful Findings in Dysphagia Finding Possible Cause Tremor, ataxia, balance disturbance Parkinson's disease Focal easy fatigability, particularly of facial muscles Myasthenia gravis Muscle fasciculation, wasting, weakness Motor neuron disease, myopathy Rapidly progressive, constant dysphagia, no neurologic findings Esophageal obstruction, probably cancer GI reflux symptoms Peptic stricture Intermittent dysphagia Lower esophageal ring or diffuse esophageal spasm Slow progression (months to years) of dysphagia to solids and liquids, sometimes with nocturnal regurgitation Achalasia Neck mass, thyromegaly Extrinsic compression Dusky, erythematous rash, muscle tenderness Dermatomyositis Raynaud's phenomenon, arthralgias, skin tightening/contractures of fingers Systemic sclerosis Cough, dyspnea, lung congestions Pulmonary aspiration Some Helpful Findings in Dysphagia Finding Possible Cause Tremor, ataxia, balance disturbance Parkinson's disease Focal easy fatigability, particularly of facial muscles Myasthenia gravis Muscle fasciculation, wasting, weakness Motor neuron disease, myopathy Rapidly progressive, constant dysphagia, no neurologic findings Esophageal obstruction, probably cancer GI reflux symptoms Peptic stricture Intermittent dysphagia Lower esophageal ring or diffuse esophageal spasm Slow progression (months to years) of dysphagia to solids and liquids, sometimes with nocturnal regurgitation Achalasia Neck mass, thyromegaly Extrinsic compression Dusky, erythematous rash, muscle tenderness Dermatomyositis Raynaud's phenomenon, arthralgias, skin tightening/contractures of fingers Systemic sclerosis Cough, dyspnea, lung congestions Pulmonary aspiration

Testing

A barium swallow (with a solid bolus, usually a marshmallow or tablet) should be done. If this test shows obstruction, endoscopy (and possibly biopsy) should be done to rule out malignancy. If the barium swallow is negative or suggestive of a motility disorder, esophageal motility studies should be done. Other tests for specific causes are done as suggested by findings.

Treatment

Treatment is directed at the specific cause. If complete obstruction occurs, emergent upper endoscopy is essential. If a stricture, ring, or web is found, careful endoscopic dilation is performed. Pending resolution, patients with oropharyngeal dysphagia may benefit from evaluation by a rehabilitation specialist. Sometimes patients benefit from changing head position while eating, retraining the swallowing muscles, doing exercises that improve the ability to accommodate a food bolus in the oral cavity, or doing strength and coordination exercises for the tongue. Patients with severe dysphagia and recurrent aspiration may require a gastrostomy tube.

Geriatrics Essentials

Chewing, swallowing, tasting, and communicating require intact, coordinated neuromuscular function in the mouth, face, and neck. Oral motor function in particular declines measurably with aging, even in healthy people. Decline in function may have many manifestations:

• Reduction in masticatory muscle strength and coordination is common, especially among patients with partial or complete dentures, and may lead to a tendency to swallow larger food particles, which can increase the risk of choking or aspiration.
• Drooping of the lower face and lips caused by decreased circumoral muscle tone and, in edentulous people, reduced bone support, is an aesthetic concern and can lead to drooling, spilling of food and liquids, and difficulty closing the lips while eating, sleeping, or resting. Sialorrhea (saliva leakage) is often the first symptom.
• Swallowing difficulties increase. It takes longer to move food from mouth to oropharynx, which increases the likelihood of aspiration.

After age-related changes, the most common causes of oral motor disorders are neuromuscular disorders (eg, cranial neuropathies caused by diabetes, stroke, Parkinson's disease, amyotrophic lateral sclerosis, multiple sclerosis). Iatrogenic causes also contribute. Drugs (eg, anticholinergics, diuretics), radiation therapy to the head and neck, and chemotherapy can greatly impair saliva production. Hyposalivation is a major cause of delayed and impaired swallowing.

Oral motor dysfunction is best managed with a multidisciplinary approach. Coordinated referrals to specialists in prosthetic dentistry, rehabilitative medicine, speech pathology, otolaryngology, and gastroenterology may be needed.

Key Points

• All patients complaining of esophageal dysphagia should undergo upper endoscopy to rule out cancer.
• If the upper endoscopy is normal, biopsies should be obtained to rule out eosinophilic esophagitis.
• Treatment is geared toward the cause.

Last full review/revision October 2007 by Michael C. DiMarino, MD