(See also Overview of Esophageal and Swallowing Disorders Overview of Esophageal and Swallowing Disorders The swallowing apparatus consists of the pharynx, upper esophageal (cricopharyngeal) sphincter, the body of the esophagus, and the lower esophageal sphincter (LES). The upper third of the esophagus... read more .)
The swallowing apparatus consists of the pharynx, upper esophageal (cricopharyngeal) sphincter, the body of the esophagus, and the lower esophageal sphincter (LES). The upper third of the esophagus and the structures proximal to it are composed of skeletal muscle; the distal esophagus and LES are composed of smooth muscle. These components work as an integrated system that transports material from the mouth to the stomach and prevents its reflux into the esophagus. Physical obstruction or disorders that interfere with motor function (esophageal motility disorders Esophageal Motility Disorders Esophageal motility disorders involve dysfunction of the esophagus that causes symptoms such as dysphagia, heartburn, and chest pain. (See also Overview of Esophageal and Swallowing Disorders... read more ) can affect the system.
Etiology of Dysphagia
Dysphagia is classified as oropharyngeal or esophageal, depending on where it occurs.
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.
Some Causes of Oropharyngeal Dysphagia
Esophageal dysphagia is difficulty passing food down the esophagus. It results from either a motility disorder or a mechanical obstruction.
Some Causes of Esophageal Dysphagia
Oropharyngeal dysphagia can lead to tracheal aspiration of ingested material, oral secretions, or both. Aspiration can cause acute pneumonia Aspiration Pneumonitis and Pneumonia Aspiration pneumonitis and pneumonia are caused by inhaling toxic and/or irritant substances, usually gastric contents, into the lungs. Chemical pneumonitis, bacterial pneumonia, or airway obstruction... read more ; recurrent aspiration may eventually lead to chronic lung disease. Prolonged dysphagia often leads to inadequate nutrition and weight loss.
Esophageal dysphagia can lead to weight loss, malnutrition, tracheal aspiration of ingested material, and in severe cases food impaction. Food impaction puts patients at risk of spontaneous esophageal perforation, which can lead to sepsis and even death.
Evaluation of Dysphagia
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; whether they have had food impaction; and whether they cough or choke while eating.
Review of symptoms should focus on symptoms suggestive of neuromuscular, gastrointestinal (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 phenomenon, and skin changes (eg, rash, swelling, thickening).
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 suggestive of myasthenia gravis Myasthenia Gravis Myasthenia gravis is characterized by episodic muscle weakness and easy fatigability caused by autoantibody- and cell-mediated destruction of acetylcholine receptors. It is more common among... read more . 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.
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
Recurrent aspiration pneumonia
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: Some Helpful Findings in Dysphagia 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.
Patients with dysphagia should always have upper endoscopy, which is extremely important to rule out cancer. During endoscopy, esophageal biopsies should also be done to look for eosinophilic esophagitis.
A barium swallow (with a solid bolus, usually a marshmallow or tablet) can be done if the patient is unable to undergo an upper endoscopy, or if upper endoscopy with biopsy does not identify a cause.
If the barium swallow is negative and the upper endoscopy is normal, esophageal motility studies should be done. Other tests for specific causes are done as suggested by findings.
Impedance planimetry Impedance Planimetry (See also Manometry.) Impedance planimetry provides real-time assessment of luminal distensibility and geometric changes in response to applied pressure in various parts of the gastrointestinal... read more is a new technology that simultaneously measures the area across the inside of the esophagus and the pressure inside in the lumen. This procedure allows measurements of esophageal distensibility and may be helpful in the evaluation of patients with dysphagia.
Treatment of Dysphagia
Treatment of dysphagia 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 done. 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: Dysphagia
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 Diabetic Neuropathy In patients with diabetes mellitus, years of poorly controlled hyperglycemia lead to multiple, primarily vascular, complications that affect small vessels (microvascular), large vessels (macrovascular)... read more , stroke Overview of Stroke Strokes are a heterogeneous group of disorders involving sudden, focal interruption of cerebral blood flow that causes neurologic deficit. Strokes can be Ischemic (80%), typically resulting... read more , Parkinson disease Parkinson Disease Parkinson disease is a slowly progressive, degenerative disorder characterized by resting tremor, stiffness (rigidity), slow and decreased movement (bradykinesia), and eventually gait and/or... read more , amyotrophic lateral sclerosis Amyotrophic Lateral Sclerosis (ALS) and Other Motor Neuron Diseases (MNDs) Amyotrophic lateral sclerosis and other motor neuron diseases are characterized by steady, relentless, progressive degeneration of corticospinal tracts, anterior horn cells, bulbar motor nuclei... read more , multiple sclerosis Multiple Sclerosis (MS) Multiple sclerosis (MS) is characterized by disseminated patches of demyelination in the brain and spinal cord. Common symptoms include visual and oculomotor abnormalities, paresthesias, weakness... read more ). 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.
All patients complaining of dysphagia should undergo upper endoscopy to rule out cancer.
If the upper endoscopy does not reveal structural causes for symptoms, biopsies should be obtained to rule out eosinophilic esophagitis.
Treatment of dysphagia is geared toward the cause.