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Dysphagia () is a medical term defined as "difficulty swallowing." It derives from the Greek root ''dys'' meaning difficulty or disordered, and ''phagia'' meaning "to eat". It is a sensation that suggests difficulty in the passage of solids or liquids from the Mouth to the Stomach . Sleisinger and Fordtran's Gastrointestinal and Liver Disease, 7th edition, Chapter 6, p. 63 Dysphagia is distinguished from similar symptoms including Odynophagia , which is defined as painful swallowing, and Globus , which is the sensation of a lump in the throat. A psychogenic dysphagia is known as Phagophobia . It is also worthwhile to refer to the Physiology Of Swallowing in understanding dysphagia. EPIDEMIOLOGY Swallowing disorders can occur in all age groups, resulting from congenital abnormalities, structural damage, and/or medical conditions.1 Swallowing problems are a common or Chronic Care facilities. Other causes of dysphagia include Head And Neck Cancer and progressive neurologic diseases like Parkinson's Disease , Multiple Sclerosis , or Amyotrophic Lateral Sclerosis . Dysphagia is a symptom of many different causes, which can usually be elicited by a careful History by the treating Physician . Schatzki R. Panel discussion on diseases of the esophagus. Am J Gastro. 31:117 (1959). It should be noted that some patients with dysphagia are not aware of the problem. Dysphagia is classified into two major types: oropharyngeal dysphagia (or '''transfer''' dysphagia) and '''esophageal''' dysphagia. In some patients, no organic cause for dysphagia can be found, and these patients are defined as having '''functional''' dysphagia. OROPHARYNGEAL DYSPHAGIA Arises from abnormalities of the upper esophagus, pharynx, and oral cavity. Signs and symptoms Some signs and symptoms of swallowing difficulties or dysphagia include the inability to recognize food and taste it, difficulty placing food in the mouth, inability to control food or saliva in the mouth, difficulty initiating a swallow, coughing, choking, frequent Pneumonia , unexplained weight loss, gurgly or wet voice after swallowing, nasal regurgitation, and patient complaint of swallowing difficulty. When asked where the food is getting stuck patients will often point to the Cervical (neck) region as the site of the obstruction. However, this may be misleading due to patients' inaccurate sensation of the site of obstruction (with obstructions / dysmotilities lower in the esophagus being common). Complications If left untreated, dysphagia can potentially cause Aspiration Pneumonia , Malnutrition , or Dehydration , all of which can be symptoms of dysphagia as well. Etiology and Differential Diagnosis (causes)
Assessment of adults A Speech Language Pathologist is most often the first person called upon to evaluate a patient with suspected dysphagia. During this informal examination, medical history is obtained, the Mini-mental State Examination is administered, and oral and facial sensorimotor function, speech, and swallowing are evaluated non-instrumentally. A patient needing further investigation will most likely receive a Modified Barium Swallow (MBS). Different consistencies of liquid and food mixed with Barium sulfate are fed to the patient by spoon, cup or syringe, and x-rayed using videofluoroscopy. A patient's swallowing then can be evaluated and described. Some clinicians might choose to describe the swallow in detail, making mention of any delays or deviations from the norm. Others might choose to use a rating scale such as the Penetration Aspiration Scale. The scale was developed to describe the disordered physiology of a person's swallow using the numbers 1-8.Rosenbek, J. C., Robbins J. A., Roecker, E. B., Coyle, J. L., & Wood, J. L. (1996). A penetration aspiration scale. "Dysphagia, 11," 93-98. Other scales also exist for this purpose. A patient can also be assessed using videoendoscopy, also known as flexible fiberoptic endoscopic examination of swallowing (FEES). The instrument, is placed into the nose until the clinician can view the Pharynx and then he or she examines the pharynx and Larynx before and after swallowing. During the actual swallow, the camera is blocked from viewing the anatomical structures. A rigid scope, placed into the oral cavity to view the structures of the pharynx and larynx, can also be used, however; the patient cannot swallow. Other less frequently used assessments of swallowing are imaging studies, Ultrasound and Scintigraphy and nonimaging studies, Electromyography (EMG), electroglottography (EGG)(records vocal fold movement), cervical Auscultation , and pharyngeal Manometry . Treatment After assessment, a Speech Language Pathologist will determine the safety of the patient's swallow and recommend treatment accordingly. The Speech Language Pathologist will also advise staff/caregivers and give information about what signs to look for to know if the client is aspirating (e.g. coughing, choking, voice quality becoming 'wet' or 'gurgly', chest colds, recurrent pneumonia) and feeding instructions if required, including posture while eating, consistency of food, and size of mouthfuls. -Postural techniques.
-Swallowing Maneuvers.
-Diet modification may be warranted. Some patients require a Soft Diet that is easily chewed, and some require liquids of a thickened or thinned consistency. -Environmental modification can be suggested to assist and reduce risk factors for aspiration. For example: having the patient use a straw while drinking liquids, putting a pillow behind the patient's head during feeding, removing distractors like too many people in the room or turning off the TV during feeding, etc. -Oral sensory awareness techniques can be used with patients who have a swallow apraxia, tactile Agnosia for food, delayed onset of the oral swallow, reduced oral sensation, or delayed onset of the pharyngeal swallow.
- Vitalstim Therapy ( {Link without Title} ) or electrical stimulation (E-stim) is targeted for oropharyngeal dysphagia and uses electrical stimulation to retrain the muscles used in swallowing. This type of therapy being used in a clinical setting is also very controversial because it lacks evidence of effectiveness. Please see external links for more information. - Prosthetics
-Surgical treatments are usually only recommended as a last resort.
ESOPHAGEAL DYSPHAGIA Arises from the body of the esophagus, lower esophageal sphincter, or cardia of the stomach. Usually due to mechanical causes or motility problems. Symptoms, signs, and evaluation Patients usually experience food getting stuck ''several seconds'' after swallowing, and will point to the suprasternal notch or behind the sternum as the site of obstruction. If there is dysphagia to both solids and liquids, then it is most likely a motility problem. If there is dysphagia initially to solids but progresses to also involve liquids, then it is most likely a mechanical obstruction. Once a distinction has been made between a motility problem and a mechanical obstruction, it is important to note whether the dysphagia is intermittent or progressive. An intermittent motility dysphagia likely can be Diffuse Esophageal Spasm (DES) or nonspecific esophageal motility disorder (NEMD). Progressive motility dysphagia disorders include Scleroderma or Achalasia with chronic heartburn, regurgitation, respiratory problems, or weight loss. Intermittent mechanical dysphagia is likely to be an Esophageal Ring . Progressive mechanical dysphagia is most likely due to Peptic Stricture or Esophageal Cancer . =Tree diagram of esophageal dysphagia Schematically the above can be presented as a tree diagram: Etiology and Differential Diagnosis (causes) image of peptic stricture, or narrowing of the Esophagus near the junction with the Stomach . This is a complication of chronic gastroesophageal reflux disease, and can be a cause of dysphagia.]] '' Peptic Stricture '', or narrowing of the esophagus, is usually a complication of acid reflux, most commonly due to Gastroesophageal Reflux ( GERD ). These patients are usually older and have had GERD for a long time. Acid reflux can also be due to other causes, such as Zollinger-Ellison Syndrome , NG tube placement, and scleroderma. Other non-acid related causes of peptic strictures include infectious esophagitis, ingestion of chemical irritant, pill irritation, and radiation. Peptic stricture is a progressive mechanical dysphagia, meaning patients will complain of initial intolerance to solids followed by inability to tolerate liquids. Usually the threshold to solid intolerance is 13 mm of the esophageal lumen. Symptoms relating to the underlying cause of the stricture usually will also be present. See Also: peptic stricture '' Esophageal Cancer '' also presents with progressive mechanical dysphagia. Patients usually come with rapidly progressive dysphagia first with solids then with liquids, weight loss (> 10 kg), and anorexia (loss of appetite). Esophageal cancer usually affects the elderly. Esophageal cancers can be either squamous cell carcinoma or Adenocarcinoma . Adenocarcinoma is the most prevalent in the US and is associated with patients with chronic GERD who has developed Barrett's Esophagus (intestinal Metaplasia of esophageal mucosa). Squamous cell carcinoma is more prevalent in Asia and is associated with tobacco smoking and alcohol use. See Also: esophageal cancer '' Esophageal Ring s and Web s'', are actual rings and webs of tissue that may occlude the esophageal lumen.
See Also: esophageal web '' Achalasia '' is an idiopathic motility disorder characterized by failure of lower esophageal sphincter (LES) relaxation as well as loss of Peristalsis in the distal esophagus, which is mostly smooth muscle. Both of these features impair the ability of the esophagus to empty contents into the stomach. Patients usually complain of dysphagia to both solids and liquids. Dysphagia to liquids, in particular, is a characteristic of achalasia. Other symptoms of achalasia include regurgitation, night coughing, chest pain, weight loss, and heartburn. The combination of achalasia, adrenal insufficiency, and alacrima (lack of tear production) in children is known as the triple A (Allgrove) syndrome. In most cases the cause is unknown (idiopathic), but in some regions of the world, achalasia can also be caused by Chagas Disease due to infection by '' Trypanosoma Cruzi ''. See Also: achalasia '' Scleroderma '' is a disease characterized by Atrophy and Sclerosis of the gut wall, most commonly of the distal esophagus (~90%). Consequently, the lower esophageal sphincter cannot close and this can lead to severe gastroesophageal reflux disease (GERD). Patients typically present with progressive dysphagia to both solids and liquids secondary to motility problems or peptic stricture from acid reflux. See Also: scleroderma ''Spastic motility disorders'' include Diffuse Esophageal Spasm (DES), Nutcracker Esophagus , Hypertensive Lower Esophageal Sphincter , and nonspecific spastic esophageal motility disorders (NEMD).
''Rare causes of esophageal dysphagia not mentioned above''
Diagnostic tools Once esophageal dysphagia has been implicated, the next step is either a '' Barium Swallow '' or an '' Upper Endoscopy ''. If there is any suspicion of a proximal lesion such as:
a barium swallow should be performed first instead of endoscopy to prevent any perforation. If achalasia suspected on barium swallow, Manometry is performed next to confirm. If a stricture is suspected, endoscopy is performed. Any other lesions found are treated as such. If there is no suspicion of any of the above, endoscopy can be performed first. Any structural or mucosal abnormality is treated. A normal endoscopy should be followed by manometry; and if manometry is also normal, the diagnosis is Functional Dysphagia . Treatment The patient is generally sent for a GI, pulmonary, ENT, or oncology consult, depending on the suspected underlying cause. A consultation with a dietician may also be needed, as many patients may need dietary modifications. SEE ALSO
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