Dr. Alper is medical director of clinical reference products for EBSCO Publishing, in Ipswich, Mass., and editor-in-chief of DynaMed (www.dynamicmedical.com), a database of comprehensive updated summaries covering nearly 2,000 clinical topics. Dr. Studt is a physician in the Occupational Medicine Department, Marshfield Clinic, Eau Claire, Wis., and a reviewer for DynaMed.
- 787.2 dysphagia
- Difficulty transferring food bolus from oropharynx to proximal esophagus
- Presents as difficulty in initiating swallow
- Common causes in elderly include stroke, Parkinson disease, amyotrophic lateral sclerosis (ALS), Huntington chorea.
- Common causes in younger patients include myasthenia gravis, webs, inflammatory myopathies, Zenker’s diverticulum.
- Difficulty moving food bolus through esophagus
- Often relieved by regurgitation
- Specific causes include esophageal carcinoma, esophageal strictures and webs, achalasia, diffuse esophageal spasm, scleroderma, caustic esophagitis, infectious esophagitis.
- Oropharyngeal dysphagia
- pneumonia, lung abscess, airway obstruction
- Esophageal dysphagia
- protein-calorie malnutrition and dehydration
- Oropharyngeal dysphagia
- May present as regurgitation (of liquid through nose), aspiration, drooling, coughing, choking, occasionally sensation of food sticking at level of upper sternum or back of throat
- Symptoms develop immediately after swallowing in-gested food.
- Patients may have greater difficulty swallowing liquids than solids.
- Patient rarely describes symptoms below sternal notch.
- Esophageal dysphagia
- May present as retrosternal fullness after swallowing, sensation of food sticking at some point in esophagus
- Dysphagia for solids and liquids suggests motility disorders, neuromuscular abnormalities, or infection.
- Dysphagia for solids typical of mechanical obstruction
- Regurgitation may occur several seconds after swallow.
- Odynophagia (on or with swallowing) suggests mucosal lesion.
- Globus sensation, often described as lump-in-throat, usually indicates cricopharyngeal or laryngeal disorder.
- Identifies cause of dysphagia in 80%-85% cases
- Question caretaker
- Associated symptoms, e.g., chest pain, heartburn, odynophagia, cough, regurgitation, aspiration, wheezing, and hoarseness
- Time course of dysphagia
- Medications that may reduce salivary flow (leads to difficulty in initiating swallow) include anticholinergics, antihistamines, some antihypertensives.
- Common causes of pill-induced esophagitis include tetracycline, procainamide, quinidine, nonsteroidal anti-inflammatory drugs, potassium and iron supplements, anticholinergics.
- History of dementia, stroke, pneumonia, gastroesophageal reflux disease, head or neck irradiation (increases risk of cancer), immunocompromise, scleroderma
- Effect of symptoms on daily life, fatigue, insomnia, and anxiety
- Travel history and country of origin
- Weight loss red flag for malignancy
- Focal neurologic symptoms (dysarthria, weakness, numbness) and generalized neurologic symptoms (dementia, parkinsonism)
- Often normal, especially in esophageal dysphagia
- Fever may occur with epiglottitis (high, rapid onset), strep throat, peritonsillar abscess, thyroiditis.
- Systemic scleroderma or CREST syndrome (calcinosis, Raynaud’s phenomenon, esophageal dysmotility, sclerodactyly, telangiectasia)
- Check eye position and extraocular motility (sign of hemorrhagic stroke).
- Oropharyngeal exam important, especially for signs of infectious disease
- Tongue fasciculations suggest ALS.
- Neck masses (including thyroid enlargement) may indicate extrinsic compression.
- Cervical or supraclavicular lymphadenopathy occasionally found with metastatic esophageal malignancy
- Neck tenderness may occur with acute thyroiditis.
- Neurologic exam
- Cranial-nerve exam includes sensory (V, IX, and X) and motor (V, VII, X, XI, and XII) testing.
- Associated central nervous system deficits may suggest neuromuscular diagnosis.
- Check strength, reflexes, and sensory exam bilaterally.
Testing to consider
- Videofluoroscopic swallowing study to evaluate oropharyngeal dysphagia
- Endoscopy or barium contrast useful in diagnosing mucosal lesions
- Laryngoscopy may be sufficient for history consistent with oropharyngeal dysphagia.
- Upper GI endoscopy more sensitive in esophageal dysphagia, allows for biopsy of lesions
- Endoscopy of limited value in diagnosing motility abnormalities, submucosal or extrinsic lesions, mild strictures
- Barium studies
- Better at identifying extrinsic compression and intramural lesions not involving mucosa
- Manometry may be useful for suspected motility disorder.
- Muscle enzymes, thyroid-stimulating hormone, co-balamin levels, antiacetylcholine antibodies in selected patients
- Fecal occult blood testing
Considered safer than endoscopy for evaluation of proximal structural lesions, such as Zenker’s diverticulum or malignancies
Prognosis and treatment
- Depends on specific cause
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