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.

ICD-9 code

  • 787.2 dysphagia

Types

  • Oropharyngeal
    • 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.
  • Esophageal
    • 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.

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Complications

  • Oropharyngeal dysphagia
    • pneumonia, lung abscess, airway obstruction
  • Esophageal dysphagia
    • protein-calorie malnutrition and dehydration

Presentation

  • 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.

Detailed history

  • 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)

Physical exam

  • 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

    • Considered safer than endoscopy for evaluation of proximal structural lesions, such as Zenker’s diverticulum or malignancies

  • 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

Prognosis and treatment

  • Depends on specific cause

See www.dynamicmedical.com for references.

From the March 03, 2007 Issue of Clinical Advisor