Dysphagia

Michael R. Spieker

Dysphagia (difficult swallowing) is a common diagnosis, ranking in frequency alongside other complaints such as pneumonia, bronchitis, and otitis media (1). At least 7% to 10% of adults aged more than 50 years experience dysphagia and up to 25% of hospitalized patients and 30% to 40% of nursing home patients experience swallowing problems (2). Aspiration is the most serious potential complication.

Approach

Initially, categorize complaints as due to obstructive or neuromuscular causes (Table 9.3). Further categorize the dysphagia as occurring in the oropharyngeal or esophageal stages of swallowing (3).

 A. Differential diagnosis of dysphagia. Stroke and neuromuscular disease affect older patients. Drug-induced esophagitis is most common with patients taking alendronate (Fosamax), nonsteroidal antiinflammatory drugs, and slow release potassium chloride. α-Adrenergic blockers can cause xerostomia (dry mouth). Younger patients can have strictures secondary to gastric reflux associated with tobacco and alcohol use. Rapid progression of dysphagia associated with weight loss is considered a malignancy until proved otherwise (Chapter 2.13).

 B. Other considerations. True dysphagia must be distinguished from other esophageal complaints that do not cause difficulty with the swallowing mechanism. Odynophagia (painful swallowing) and globus (the sensation of a lump in the throat without organic defect) are separate symptoms from dysphagia. Up to 28% of patients with noncardiac chest pain can have abnormal esophageal motility disorders (Chapter 7.1).

History

 More than 80% of the causes of dysphagia can be identified by history alone. Is there difficulty initiating the swallow or a sensation of the food bolus getting stuck in the chest? Oropharyngeal dysphagias cause difficulty initiating a swallow and have associated coughing, choking, or nasal regurgitation. The patient’s speech quality may have a nasal tone. Esophageal dysphagias cause patients to complain of food sticking in their throat or chest.

 A. Chronology and progression of the dysphagia. Has the dysphagia acutely progressed or has it gradually worsened over a long time? A progressively rapid course can represent mechanical obstruction secondary to tumors, other mediastinal masses, and esophageal webs or rings. Gradual dysphagias requiring progressive, forceful swallows and the Valsalva maneuver are indicative of neuromuscular motor disease. Acute dysphagia suggests infection, irritation, or food bolus impaction.

 B. Solid or liquid dysphagia. Does the patient have dysphagia for solids, liquids, or both? Solid food dysphagia and weight loss indicate mechanical obstruction; difficulty with both liquids and solids suggests neuromuscular disease. Cold foods and beverages can exacerbate neuromuscular dysphagia.

 C. Social history. Does the patient use tobacco, alcohol, or any over-the-counter (OTC) or prescription medications? Smoking causes chest malignancies, including esophageal carcinoma. Alcohol and many OTC and prescription medications decrease esophageal motility, relax the lower esophageal sphincter, or induce esophagitis directly (4).

 D. Associated symptoms. Pain with swallowing can be associated with achalasia or spasm. Pain on swallowing saliva alone suggests mucosal inflammation from infection. Heartburn and dysphagia for solids indicate distal esophageal stricture from reflux. Are there associated neurologic symptoms consistent with a stroke (Chapter 4.8)?

 E. Evidence of aspiration. Does the patient cough when swallowing? Does the cough occur in the oropharyngeal stage or esophageal stage of swallowing? Pneumonia or other chest infection without a cough can indicate silent aspiration.

Physical examination

A general physical examination and focused organ- or symptom-specific examinations based on the history often confirm the cause of the patient’s dysphagia.

 A. Focused examination. Assess mental status, motor and sensory functioning, deep tendon reflexes, cerebellar function, and cranial nerves. Focus special attention on the cranial nerves (CN) associated with swallowing (CN IX, X). A decreased gag reflex is associated with an increased risk of aspiration. Inspect the oropharynx and note the patients’speech. A widened anteroposterior chest diameter and distant breath sounds are signs of chronic obstructive lung disease and may indicate chronic aspiration.

 B. The swallow. Observe the patient swallowing a variety of liquids and solids. Can the patient chew, mix, and propel a food bolus to the posterior pharynx without choking or coughing? When in the swallowing sequence does the patient complain of difficulty?

Testing

 A. Clinical laboratory tests. Limit initial laboratory evaluations to specific studies based on the differential diagnosis generated after a complete history and physical examination. These can include thyroid function studies, erythrocyte sedimentation rate, and a complete blood count to screen for infectious or inflammatory conditions.

B. Special studies and diagnostic imaging. Additional diagnostic testing is indicated to confirm a diagnosis, to obtain biopsy specimens, or to establish the risk for aspiration. Specialists in radiology, otolaryngology, and gastroenterology will most often complete these tests.

 1. Nasopharyngoscopy. Nasopharyngoscopy assesses patients with oropharyngeal dysphagia and those at risk for aspiration. It quickly identifies structural masses and lesions and assesses laryngeal sensitivity to contact. Patients demonstrating aspiration without cough are at high risk for pulmonary complications.

2. Barium studies. Barium swallow detects obstructive lesions and assesses motility better than endoscopy, but lacks precision in identifying the nature of some obstructive lesions. It is relatively inexpensive with few complications, but can be difficult to perform on sick or uncooperative patients. Double contrast studies provide better visualization of esophageal mucosa.

 3. Upper gastrointestinal (GI) endoscopy. Patients with food impactions, esophageal mucosal symptoms, or masses identified by barium studies should undergo upper endoscopy. A consensus panel found endoscopy more sensitive (92% vs. 54%) and more specific (100% vs. 91%) than double contrast UGI in patients with dysphagia of all causes (5). Patients prefer endoscopy to UGI studies, and the higher initial cost of endoscopy may be offset by lower subsequent medical costs because of its improved diagnostic accuracy.

 4. Videoradiographic studies. Patients at risk for silent aspiration (stroke, neurologic impairment) may benefit from videoradiographic studies performed by a team composed of a radiologist, otolaryngologist, and speech pathologist with expertise in swallowing disorders. The studies are expensive and require special equipment and facilities.

 5. Other studies. Manometry detects abnormalities in only 25% of those with nonobstructive lesions. Esophageal pH monitoring is the gold standard for suspected reflux. Plain films of the chest or neck and ultrasound of the pharynx offer limited information. Computed tomography and magnetic resonance imaging scans provide excellent definition for suspected structural central nervous system abnormalities. Radionuclide studies can be used to evaluate transit function through the esophagus.

Diagnostic assessment

 A thorough history and physical examination readily identify the cause of dysphagia in most patients. Confirmatory studies are predicated on the differential diagnoses generated. Referral to other specialists is warranted when the cause is not clear or if further diagnostic or therapeutic expertise is required. Elderly patients are at highest risk for dysphagia and complications, especially silent aspiration. Aggressive early evaluation and management of stroke victims reduce symptoms and risk of aspiration.

References

1. National ambulatory medical care survey: 1993 summary. Vital and Health Statistics, series 13. Hyattsville, Maryland: US Department of Health and Human Services, 1998;136:74.

2. Lindgren S, Janzon L. Prevalence of swallowing complaints and clinical findings among 50–79-year-old men and women in an urban population. Dysphagia 1991;6:
187–192.

3. Castell DO. Approach to the patient with dysphagia. In: Yamada T, ed. Textbook of gastroenterology, 2nd ed. Philadelphia: Lippincott-Raven, 1995:638–648.

4. Boyce HW. Drug induced esophageal damage: diseases of medical progress. Gastrointest Endosc 1998;6:547–550.

5. Dooley CP, Larson AW, Stace NH, et al. Double contrast barium meal and upper gastrointestinal endoscopy: a comparative study. Ann Intern Med 1984;101:538–545.

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Book Source Details

• Book Title: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter
• Author(s): Robert B. Taylor (editor)
• Year of Publication: 2000
• Copyright Details: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, Copyright © 2000 Lippincott Williams & Wilkins.

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Copyright Details: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, Copyright © 2008 Williams & Wilkins.

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More About This Book: Title: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter Authors: Robert B. Taylor (editor) Publisher: Lippincott Williams & Wilkins Copyright: 2000 ISBN: 0-78172-094-X