Dysphagia

Dysphagia—difficulty swallowing—is a common symptom that's usually easy to localize. It may be constant or intermittent and is classified by the phase of swallowing it affects. (See Classifying dysphagia.)

Among the factors that interfere with swallowing are severe pain, obstruction, abnormal peristalsis, an impaired gag reflex, and excessive, scanty, or thick oral secretions.

Dysphagia is the most common—and sometimes the only—symptom of esophageal disorders. However, it may also result from oropharyngeal, respiratory, neurologic, and collagen disorders or from the effects of toxins and treatments. Dysphagia increases the risk of choking and aspiration and may lead to malnutrition and dehydration.

Action stat!

If the patient suddenly complains of dysphagia and displays signs of respiratory distress, such as dyspnea and stridor, suspect an airway obstruction and quickly perform abdominal thrusts. Prepare to administer oxygen by mask or nasal cannula, or to assist with endotracheal intubation.

History and physical examination

If the patient's dysphagia doesn't suggest an airway obstruction, begin a health history. Ask the patient if swallowing is painful. If so, is the pain constant or intermittent? Have the patient point to where dysphagia feels most intense. Does eating alleviate or aggravate the symptom? Are solids or liquids more difficult to swallow? If the answer is liquids, ask if hot, cold, and lukewarm fluids affect him differently. Does the symptom disappear after he tries to swallow a few times? Is swallowing easier if he changes position? Ask if he has recently experienced vomiting, regurgitation, weight loss, anorexia, hoarseness, dyspnea, or a cough.

To evaluate the patient's swallowing reflex, place your finger along his thyroid notch and instruct him to swallow. If you feel his larynx rise, the reflex is intact. Next, have him cough to assess his cough reflex. Check his gag reflex if you're sure he has a good swallow or cough reflex. Listen closely to his speech for signs of muscle weakness. Does he have aphasia or dysarthria? Is his voice nasal, hoarse, or breathy? Assess the patient's mouth carefully. Check for dry mucous membranes and thick, sticky secretions. Observe for tongue and facial weakness and obvious obstructions (for example, enlarged tonsils). Assess the patient for disorientation, which may make him neglect to swallow.

Medical causes

Achalasia.Achalasia produces phase 3 dysphagia for solids and liquids. The dysphagia develops gradually and may be precipitated or exacerbated by stress. Occasionally, it's preceded by esophageal colic. Regurgitation of undigested food, especially at night, may cause wheezing, coughing, or choking as well as halitosis. Weight loss, cachexia, hematemesis and, possibly, heartburn are late findings.

Airway obstruction.Life-threatening upper airway obstruction is marked by signs of respiratory distress, such as crowing and stridor. Phase 2 dysphagia occurs with gagging and dysphonia. When hemorrhage obstructs the trachea, dysphagia is usually painless and rapid in onset. When inflammation causes the obstruction, dysphagia may be painful and develop slowly.

Amyotrophic lateral sclerosis (ALS).Besides dysphagia, ALS causes muscle weakness and atrophy, fasciculations, dysarthria, dyspnea, shallow respirations, tachypnea, slurred speech, hyperactive deep tendon reflexes (DTRs), and emotional lability.

Bulbar paralysis.Phase 1 dysphagia occurs along with drooling, difficulty chewing, dysarthria, and nasal regurgitation. Dysphagia for solids and liquids is painful and progressive. Accompanying features may include arm and leg spasticity, hyperreflexia, and emotional lability.

Esophageal cancer.Phases 2 and 3 dysphagia is the earliest and most common symptom of esophageal cancer. Typically, this painless, progressive symptom is accompanied by rapid weight loss. As the cancer advances, dysphagia becomes painful and constant. In addition, the patient complains of steady chest pain, a cough with hemoptysis, hoarseness, and a sore throat. He may also develop nausea and vomiting, a fever, hiccups, hematemesis, melena, and halitosis.

Esophageal compression (external).Usually caused by a dilated carotid or aortic aneurysm, esophageal compression—a rare condition—causes phase 3 dysphagia as the primary symptom. Other features depend on the cause of the compression.

Esophageal diverticulum.Esopha-geal diverticulum causes phase 3 dysphagia when the enlarged diverticulum obstructs the esophagus. Associated signs and symptoms include food regurgitation, a chronic cough, hoarseness, chest pain, and halitosis.

Esophageal obstruction by foreign body.Sudden onset of phase 2 or 3 dysphagia, gagging, coughing, and esophageal pain characterize this potentially life-threatening condition. Dyspnea may occur if the obstruction compresses the trachea.

Esophageal spasm.The most striking symptoms of esophageal spasm are phase 2 dysphagia for solids and liquids and a dull or squeezing substernal chest pain. The pain may last up to an hour and may radiate to the neck, arm, back, or jaw; however, it may be relieved by drinking a glass of water. Bradycardia may also occur.

Esophageal stricture.Usually caused by a chemical ingestion or scar tissue, esophageal stricture causes phase 3 dysphagia. Drooling, tachypnea, and gagging may also be evident.

Esophagitis.Corrosive esophagitis, resulting from ingestion of alkali or acids, causes severe phase 3 dysphagia. Accompanying it are marked salivation, hematemesis, tachypnea, a fever, and intense pain in the mouth and anterior chest that's aggravated by swallowing. Signs of shock, such as hypotension and tachycardia, may also occur.

Candidal esophagitis causes phase 2 dysphagia, a sore throat and, possibly, retrosternal pain on swallowing. With reflux esophagitis, phase 3 dysphagia is a late symptom that usually accompanies stricture development. The patient complains of heartburn, which is aggravated by strenuous exercise, bending over, or lying down and is relieved by sitting up or taking an antacid.

Other features of esophagitis include regurgitation; frequent, effortless vomiting; a dry, nocturnal cough; and substernal chest pain that may mimic angina pectoris. If the esophagus ulcerates, signs of bleeding, such as melena and hematemesis, may occur along with weakness and fatigue.

Gastric carcinoma.Infiltration of the cardia or esophagus by gastric carcinoma causes phase 3 dysphagia along with nausea, vomiting, and pain that may radiate to the neck, back, or retrosternum. In addition, perforation causes massive bleeding with coffee-ground vomitus or melena.

Laryngeal cancer (extrinsic).Phase 2 dysphagia and dyspnea develop late in laryngeal cancer. Accompanying features include a muffled voice, stridor, pain, halitosis, weight loss, ipsilateral otalgia, a chronic cough, and cachexia. Palpation reveals enlarged cervical nodes.

Lead poisoning.Painless, progressive dysphagia may result from lead poisoning. Related findings include a lead line on the gums, a metallic taste, papilledema, ocular palsy, footdrop or wristdrop, and signs of hemolytic anemia, such as abdominal pain and a fever. The patient may be depressed and display severe mental impairment and seizures.

Myasthenia gravis.Fatigue and progressive muscle weakness characterize myasthenia gravis and account for painless phase 1 dysphagia and possibly choking. Typically, dysphagia follows ptosis and diplopia. Other features include masklike facies, a nasal voice, frequent nasal regurgitation, and head bobbing. Shallow respirations and dyspnea may occur with respiratory muscle weakness. Signs and symptoms worsen during menses and with exposure to stress, cold, or infection.

Oral cavity tumor.Painful phase 1 dysphagia develops along with hoarseness and ulcerating lesions.

Plummer-Vinson syndrome.Plummer-Vinson syndrome causes phase 3 dysphagia for solids in some women with severe iron deficiency anemia. Related features include upper esophageal pain; atrophy of the oral or pharyngeal mucous membranes; tooth loss; a smooth, red, sore tongue; a dry mouth; chills; inflamed lips; spoon-shaped nails; pallor; and splenomegaly.

Rabies.Severe phase 2 dysphagia for liquids results from painful pharyngeal muscle spasms occurring late in this rare, life-threatening disorder. In fact, the patient may become dehydrated and possibly apneic. Dysphagia also causes drooling, and in 50% of cases it's responsible for hydrophobia. Eventually, rabies causes progressive flaccid paralysis that leads to peripheral vascular collapse, coma, and death.

Systemic lupus erythematosus (SLE).SLE may cause progressive phase 2 dysphagia. However, its primary signs and symptoms include nondeforming arthritis, a characteristic butterfly rash, and photosensitivity.

Tetanus.Phase 1 dysphagia usually develops about 1 week after the patient receives a puncture wound. Other characteristics include marked muscle hypertonicity, hyperactive DTRs, tachycardia, diaphoresis, drooling, and a low-grade fever. Painful, involuntary muscle spasms account for lockjaw (trismus), risus sardonicus, opisthotonos, boardlike abdominal rigidity, and intermittent tonic seizures.

Other causes

Procedures.Recent tracheostomy or repeated or prolonged endotracheal intubation may cause temporary dysphagia.

Radiation therapy.When directed against oral cancer, this therapy may cause scant salivation and temporary dysphagia.

Nursing considerations

▪ Stimulate salivation by talking with the patient about food, adding a lemon slice or dill pickle to his tray, and providing mouth care before and after meals.

▪ Moisten his food with a little liquid if the patient has decreased salivation.

▪ Administer an anticholinergic or antiemetic to control excess salivation.

▪ If the patient has a weak or absent cough reflex, begin tube feedings.

▪ Consult with the dietitian to select foods with distinct temperatures and textures.

▪ Consult with a speech therapist to assess the patient for his aspiration risk and for swallowing exercises to help decrease his risk.

▪ When feeding the patient, place him in an upright position, and have him flex his neck forward slightly and keep his chin at midline.

▪ Instruct the patient to swallow multiple times before taking the next bite or sip.

▪ Separate solids from liquids, which are harder to swallow.

▪ Prepare the patient for diagnostic evaluation, including endoscopy, esophageal manometry, esophagography, and the esophageal acidity test, to pinpoint the cause of dysphagia.

Patient teaching

▪ Tell the patient which foods and textures he should avoid.

▪ Explain measures to take to reduce the risk of choking and aspiration.

▪ Explain to the patient his diagnosis and the treatment plan.

Pictures

Book Source Details

• Book Title: Nursing: Interpreting Signs and Symptoms
• Author(s): Springhouse
• Year of Publication: 2007
• Copyright Details: Nursing: Interpreting Signs and Symptoms, Copyright © 2007 Lippincott Williams & Wilkins.

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More About This Book: Title: Nursing: Interpreting Signs and Symptoms Authors: Springhouse Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 1-58255-668-7

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