Dysphagia

Dysphagia is defined as difficulty swallowing. It may occur during any phase of the swallowing mechanism. Prompt diagnosis is important, because delays may lead to pulmonary infection (secondary to aspiration) and failure to thrive.

Differential Diagnosis

• A problem with any phase of swallowing may cause dysphagia

Oral preparatory phase
• Decreased salivation
• Nasal obstruction: Inability to breathe through nose may cause problems with swallowing in neonates and young infants

• Cleft palate and velopharyngeal insufficiency: Inability to separate the nose/nasopharynx from the mouth may lead to nasal regurgitation during swallowing
  –Hypertrophic tonsils: Mechanical obstruction to swallowing
  –Neuromuscular problems: Prematurity, cerebral palsy, Duchenne muscular dystrophy, Guillain-Barré syndrome, Riley-Day syndrome all lead to poor coordination of swallow
  Pharyngeal phase

• Congenital defects such as vallecular cysts or laryngeal cleft
  –Inflammatory response; e.g., GERD
  –Infectious processes
  –Viral and bacterial pharyngitis
  –Mass effect from deep neck space abscess
• Tumors: lymphangiomas, hemangiomas, respiratory papillomas, ranulas
  –Trauma caused by foreign body or caustic ingestion

Esophageal phase
• Congenital lesions such as vascular lesions, webs, or rings
• Inflammatory/infectious
  –Esophagitis (may be from GERD, allergy, Candida, or HSV)
  –Chagas disease
• Esophageal dysmotility
  –Cricopharyngeal or lower esophageal sphincter achalasia
  –Esophageal spasm
• Systemic
  –Diabetes mellitus, thyroid disease
  –Scleroderma, polymyositis, dermatomyositis
• Psychological: Globus hystericus

Workup and Diagnosis

• History
  –Fever, duration, onset, severity, frequency, odynophagia, drooling; vomiting of solids, liquids, or secretions
  –Voice changes, aspiration, weight loss or failure to thrive, foreign body ingestion, trauma, caustic ingestion
  –Liquids are least affected by obstructive lesions and first affected by neurologic disorders
  –Prenatal history: Polyhydramnios, esophageal anomalies

• Physical exam
  –Craniofacial anomalies/defects in facial anatomy
  –Nasal exam: Mass or obstruction (6 Fr catheter should pass through in healthy newborn)
  –Mouth: Pooled secretions, mass, tonsil size, palatal motion
  –Neck: Neck mass, thyromegaly

• Workup
  –Modified barium swallow evaluates all phases of swallowing and esophageal function
  –Flexible fiberoptic exam assesses dynamic problems
  –Rigid endoscopy: Allows for controlled airway, better optics, and removal of foreign body
  –Functional endoscopic evaluation of swallow (FEES): Evaluates pharyngeal phase, limited in children because of poor patient cooperation

Treatment

• Important to assess for adequate nutritional intake and safety of swallow without aspiration
• Underlying inflammatory disorders are addressed
• The modified barium swallow study may provide guidance and the speech pathologist may provide recommendations regarding position during feeds, consistency, size limitations, temperature of food, appropriate bottles or utensils, bolus size
• Total oral feeding may not be possible for all children; options include naso- or orogastric feeding or gastrotomy tube feeding
• Surgery
  –Dysphagia associated with tonsillar hypertrophy may require tonsillectomy
  –Pharyngeal and esophageal tumors may require resection

Book Source Details

• Book Title: In A Page: Pediatric Signs and Symptoms
• Author(s): Jonathan E. Teitelbaum, Kathleen O. Deantonis, Scott Kahan
• Year of Publication: 2007
• Copyright Details: In A Page: Pediatric Signs and Symptoms, Copyright © 2007 Lippincott Williams & Wilkins.

Other Book Chapters Related to Swallowing symptoms

Read excerpts from these other book chapters related to Swallowing symptoms:

Copyright Details: In A Page: Pediatric Signs and Symptoms, Copyright © 2008 Williams & Wilkins.

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• Back to symptom: Swallowing symptoms: Introduction (review 469 causes)
• Next Book Extract About Swallowing symptoms: DIFFICULTY SWALLOWING (DYSPHAGIA) (Differential Diagnosis in Primary Care)
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More About This Book: Title: In A Page: Pediatric Signs and Symptoms Authors: Jonathan E. Teitelbaum, Kathleen O. Deantonis, Scott Kahan Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 1-4051-0427-9