Dysphagia

AUTHOR: Fred F. Ferri, MD

Definition

The term “dysphagia” is derived from the Greek words dys (with difficulty) and phagia (to eat). It is characterized by abnormal transfer of food from mouth to the stomach, which may involve the oral, pharyngeal, or esophageal stages of swallowing.

ICD-10CM CODES
D50.1		Sideropenic dysphagia
I69.091		Dysphagia following nontraumatic subarachnoid hemorrhage
I69.191		Dysphagia following nontraumatic intracerebral hemorrhage
I69.291		Dysphagia following other nontraumatic intracranial hemorrhage
I69.391		Dysphagia following cerebral infarction
I69.891		Dysphagia following other cerebrovascular disease
I69.991		Dysphagia following unspecified cerebrovascular disease
R13.10		Dysphagia, unspecified
R13.11		Dysphagia, oral phase
R13.12		Dysphagia, oropharyngeal phase
R13.13		Dysphagia, pharyngeal phase
R13.14		Dysphagia, pharyngoesophageal phase
R13.19		Other dysphagia

Epidemiology & Demographics

This is seen in 10% of individuals above the age of 50 yr. Its prevalence increases with advancing age.
Nearly 12% of hospitalized patients have symptoms of dysphagia.
Up to 30% to 60% of nursing home patients have some form of dysphagia.
Special populations, including patients with head injury, stroke, or Parkinson disease, have 30% to 50% prevalence of oropharyngeal dysphagia.

Etiology (

Oropharyngeal:
1. Neuromuscular causes:
  1. Stroke
  2. Parkinson disease
  3. Multiple sclerosis
  4. Myasthenia gravis
  5. Amyotrophic lateral sclerosis
  6. CNS tumors
  7. Muscular dystrophy
  8. Thyroid dysfunction
  9. Polymyositis and dermatomyositis
  10. Sarcoidosis
  11. Cerebral palsy
  12. Head trauma
  13. Metabolic encephalopathy
  14. Dementia
  15. Bell palsy
2. Structural causes:
  1. Oropharyngeal tumors
  2. Zenker diverticulum
  3. Infection of pharynx or neck (mucositis from Candida, herpes, and CMV)
  4. Thyromegaly
  5. Prior surgery or radiotherapy
  6. Osteophytes and other spinal disorders
  7. Proximal esophageal webs
  8. Congenital anomalies (e.g., cleft palate)
  9. Poor dentition
Esophageal:
1. Neuromuscular disorders:
  1. Achalasia
  2. Diffuse esophageal spasm
  3. Nutcracker esophagus
  4. Hypertensive lower esophageal sphincter
  5. Ineffective esophageal motility
  6. Scleroderma
  7. Reflex-associated dysmotility
2. Structural disorder:
  1. Peptic stricture
  2. Esophageal rings and webs
  3. Diverticuli
  4. Carcinoma and benign tumors
  5. Foreign bodies
  6. Vascular compression
  7. Mediastinal masses
  8. Spinal osteophytes
  9. Mucosal injury (from pills, infection, gastroesophageal reflux disease [GERD], etc.)

BOX 1 Mechanical Dysphagia

Oral

Amyloidosis
Congenital abnormalities
Intraoral tumors
Lip injuries:
1. Burns
2. Trauma
Macroglossia
Scleroderma
Temporomandibular joint dysfunction
Xerostomia:
1. Sjögren syndrome

Pharyngeal

Cervical anterior osteophytes
Infection:
1. Diphtheria
Thyromegaly
Retropharyngeal abscess
Retropharyngeal tumor
Zenker diverticulum

Esophageal

Aberrant origin of right subclavian artery
Caustic injury
Esophageal carcinoma
Esophageal diverticulum
Esophageal infection:
1. Candida albicans
2. Cytomegalovirus
3. Herpes simplex virus
4. Varicella zoster virus
Esophageal intramural pseudodiverticula
Esophageal stricture
Esophageal ulceration
Esophageal webs or rings
Gastroesophageal reflux disease
Hiatal hernia
Metastatic carcinoma
Posterior mediastinal mass
Thoracic aortic aneurysm

From Jankovic J et al: Bradley and Daroff’s neurology in clinical practice, ed 8, Philadelphia, 2022, Elsevier.

BOX 2 Neurogenic Dysphagia

Oropharyngeal

Arnold-Chiari malformation
Basal ganglia disease:
1. Biotin responsive
2. Corticobasal degeneration
3. DLB
4. HD
5. Multiple system atrophy
6. Neuroacanthocytosis
7. PD
8. PSP
9. WD
Central pontine myelinolysis
Cerebral palsy
Drug related:
1. Cyclosporine
2. Tardive dyskinesia
3. Vincristine
Infectious:
1. Brainstem encephalitis
2. Diphtheria
3. Epstein-Barr virus
4. Listeria
5. Poliomyelitis
6. Progressive multifocal leukoencephalopathy
7. Rabies
Mass lesions:
1. Abscess
2. Hemorrhage
3. Metastatic tumor
4. Primary tumor
Motor neuron diseases:
1. ALS
2. MS
Peripheral neuropathic processes:
1. Charcot-Marie-Tooth disease
2. Guillain-Barré syndrome (Miller Fisher variant)
Spinocerebellar ataxias
1. Stroke
2. Syringobulbia

Esophageal

Achalasia
Autonomic neuropathies:
1. Diabetes mellitus
2. Familial dysautonomia
3. Paraneoplastic syndromes
Basal ganglia disorders:
1. PD
Chagas disease
Esophageal motility disorders
Scleroderma

From Jankovic J et al: Bradley and Daroff’s neurology in clinical practice, ed 8, Philadelphia, 2022, Elsevier.

Pathogenesis

The inability to swallow is caused either by a problem in strength or coordination of the muscles required to move material from the mouth to stomach or by a fixed obstruction somewhere between the mouth and the stomach.

Clinical Features

Oropharyngeal dysphagia (transfer dysphagia):

The patient is unable to transfer the food bolus from the mouth to the upper esophagus. Problem arises within 2 sec of initiating the voluntary phase of swallowing.
Typical symptoms include drooling, spillage of food, postnasal regurgitation, difficulty in initiation of swallowing, sialorrhea, sensation of food stuck in the neck, coughing or choking during swallowing, the need to swallow repeatedly to clear food or fluid from the pharynx, dysphonia, nasal speech, hoarseness of voice, and dysarthria.
A thorough physical examination including that of the nervous system, oral cavity, and the head/neck is very important in patients with oropharyngeal dysphagia.

Esophageal dysphagia:

Problem usually arises several seconds after swallowing.
Patients often complain of food being stuck in lower substernal area.
Dysphagia to solids suggests mechanical obstruction whereas dysphagia with liquids or combination of solids and liquids favors a motility disorder.
Neuromuscular causes result in dysphagia to both solids and liquids. Particularly, patients with achalasia tend to drink a lot of fluids while eating or apply maneuvers such as straightening the back, raising their arms over their heads, or standing to increase intraesophageal pressure to facilitate the emptying of food into the stomach.
Oftentimes, ingestion of very cold or very hot foods precipitates the dysphagia associated with neuromuscular disorder.
Delayed regurgitation of food, heartburn, and chest pain are usually present.
Weight loss is usually associated with malignancy or achalasia.
Symptoms are intermittent in patients with esophageal dysphagia from benign causes of structural obstruction or diffuse esophageal spasm. However, it is progressive in patients with peptic stricture, esophageal carcinoma, scleroderma, and achalasia.
In patients with structural obstruction, when the luminal diameter is more than 18 to 20 mm, they are rarely symptomatic, whereas those with a diameter of less than 13 mm are nearly always symptomatic.
These patients with esophageal dysphagia usually do not have any characteristic physical findings.

Diagnosis ⬆ ⬇

Workup

Box 3 summarizes pertinent questions in a comprehensive swallowing history.
Important physical examination findings potentially related to dysphagia are described in Tables 1 and 2.
Fig. 1 illustrates an algorithm for the evaluation of dysphagia.

Figure 1 Assessment of dysphagia.

From Jankovic J et al: Bradley and Daroff’s neurology in clinical practice, ed 8, Philadelphia, 2022, Elsevier.

TABLE 1 Important Physical Examination Findings Potentially Related to Dysphagia

Lips: Mass, weakness, oral competence (ability to form seal), presence of drooling
Teeth: Presence or absence of teeth; condition of teeth; missing, broken, ill-fitting or unused dentures
Oral cavity: Masses, xerostomia
Tongue: Weakness, deviation, fasciculation, defect (postsurgical changes)
Palate: Asymmetry, velopharyngeal insufficiency (leads to nasal regurgitation)
Larynx: Unilateral or bilateral vocal fold paralysis, decreased sensation

From Broaddus VC et al: Murray & Nadel’s textbook of respiratory medicine, ed 7, Philadelphia, 2022, Elsevier.

TABLE 2 Clues to Dysphagia

Clue		Cause of Dysphagia
Difficulty initiating swallowing		Oropharyngeal dysfunction
Repetitive swallowing		Oropharyngeal dysfunction
Retrosternal “hanging-up” sensation		Esophageal dysfunction
Difficulty with solids but not liquids		Mechanical obstruction
Difficulty with both solids and liquids		Esophageal dysmotility
Regurgitation of undigested food		Zenker diverticulum
Halitosis		Zenker diverticulum

From Jankovic J et al: Bradley and Daroff’s neurology in clinical practice, ed 8, Philadelphia, 2022, Elsevier.

BOX 3 Pertinent Questions in Comprehensive Swallowing History

How is your swallowing?

What are you eating these days?

For instance, regular diet, soft foods only, liquids only

Are you avoiding any particular types of foods?

For instance, bread, meat, crackers, nuts

Have you had to change how you eat/drink?

For instance, adding more sauces/gravy, cutting food into smaller pieces, taking pills one (instead of a handful) at a time, taking pills with applesauce instead of water, sipping liquids instead of gulping/chugging

How long does it take you to eat a meal?

Are you coughing or choking with liquids?

Does it take effort to swallow?

Does it hurt to swallow?

Do you feel as if food/liquids/pills get “stuck”? If so, can you point to where you feel this?

Has your weight changed lately? How do your clothes fit?

Have you had pneumonia recently?

Have you ever needed the Heimlich maneuver?

Do you regurgitate? If so, is the material digested or undigested?

Do you experience heartburn, reflux, or indigestion?

What makes your swallowing worse?

What makes your swallowing better?

From Broaddus VC et al: Murray & Nadel’s textbook of respiratory medicine, ed 7, Philadelphia, 2022, Elsevier.

Laboratory Evaluation:

CBC
Thyroid studies
Nutritional assessment by checking serum protein and albumin levels
Other studies based on specific clinical conditions

Special studies (Boxes 4 and 5):

Oropharyngeal dysphagia
1. Videofluoroscopy is the first test often ordered in evaluation of patients with oropharyngeal dysphagia
2. Double contrast modified barium swallow study (Fig. 2)
3. Fiberoptic flexible nasopharyngeal laryngoscopy is mandatory in all cases when a structural lesion, particularly malignancy, is suspected
4. Pharyngeal and upper esophageal manometry (Fig. 3) is occasionally of value to predict which patients will have a favorable outcome from cricopharyngeal myotomy or dilation
5. Radiography of head and neck when indicated
Esophageal dysphagia
1. Barium esophagography should precede upper endoscopies to identify patients at risk from potential perforation with an endoscopy and to help plan fluoroscopically guided dilation. It is often the first step in evaluating patients with dysphagia, especially if an obstructive lesion is suspected
2. EGD
3. Esophageal manometry is indicated if no abnormality is identified by barium study or EGD
4. Esophageal pH monitoring in patients with suspected reflux disease
5. Endoscopic ultrasonography
6. Radiograph, CT, and MRI of chest

Figure 2 Barium Swallow Demonstrating a Benign Peptic Stricture in a Patient with Gastroesophageal Reflux Disease and Dysphagia

From Talley NJ, Martin C: Clinical gastroenterology: a practical problem-based approach, ed 2, Sydney, 2006, Churchill Livingstone.

BOX 5 Dysphagia Testing

If Oral Phase Dysfunction Is Suspected

Screening tests:
1. Clinical examination
2. Cervical auscultation
3. 3-oz water swallow
Primary test:
1. Modified barium swallow

If Pharyngeal Phase Dysfunction Is Suspected

Screening tests:
1. Clinical examination
2. 3-oz water swallow
3. Timed swallowing
Primary test:
1. Modified barium swallow
Complementary tests:
1. Pharyngeal videoendoscopy
2. Pharyngeal manometry
3. Electromyography
4. Videomanofluorometry

If Esophageal Dysfunction Is Suspected

Primary tests:
1. Videofluoroscopy
2. Endoscopy
Complementary test:
1. Esophageal manometry

From Jankovic J et al: Bradley and Daroff’s neurology in clinical practice, ed 8, Philadelphia, 2022, Elsevier.

BOX 4 Diagnostic Tests

Oropharyngeal

Clinical examination
Cervical auscultation
Timed swallowing tests
3-oz water swallow test
Modified barium swallow test
Pharyngeal videoendoscopy
Pharyngeal manometry
Videomanofluorometry
Electromyographic recording
Dysphagia limit

Esophageal

Endoscopy
Esophageal manometry
Videofluoroscopy

From Jankovic J et al: Bradley and Daroff’s neurology in clinical practice, ed 8, Philadelphia, 2022, Elsevier.

Differential Diagnosis

Globus pharyngeus
Odynophagia
Phagophobia
GERD

Treatment ⬆ ⬇

Treatment should be approached with the help of specialists of multiple disciplines (ENT, head and neck surgeon, radiologist, speech pathologist, physical therapist, dietitian, gastroenterologist, physical medicine and rehabilitation specialist, dentist, neurologist, etc.).
Goal of therapy is airway protection and maintenance of nutrition.
Alteration of food consistency, volume, and delivery rate plays a major role.
The goal of direct therapy is to change swallowing physiology with medical treatment of primary disease, maxillofacial prosthesis, and cricopharyngeal myotomy.
Indirect therapies include exercise programs for tongue coordination and chewing under the guidance of a speech therapist.
Maintenance of oral feeding often requires compensatory techniques such as chin-tuck position, rotation of head to the affected side, tilting of head to the strong side, and lying on one’s back or on one’s side during swallowing.
Some of the voluntary maneuvers applied include supraglottic swallow, effortful swallow, Mendelson maneuver, Shaker exercise, and the Heimlich maneuver.
Placement of nasogastric tube, jejunostomy tube, or percutaneous endoscopic gastrostomy (PEG) tube is considered for enteral feeding when other measures fail and the patient remains at significant risk for aspiration or nutrition becomes compromised.
Treatment of associated GERD should not be forgotten.
Surgery for chronic aspiration may involve tracheostomy, medialization, laryngeal suspension, laryngeal closure, and/or laryngotracheal separation-diversion.
Other measures include esophageal dilation removal of foreign body, esophageal resection, chemotherapy, radiotherapy, endoscopic ablation of tumor, photodynamic therapy, esophageal prosthesis/stents, diverticulectomy, intrasphincteric injection of botulinum toxin, surgical myotomy, and others. Smooth muscle relaxants such as nitrates and calcium channel blockers have been used to effectively treat patients with diffuse esophageal spasm and nutcracker esophagus.
Several scales have been suggested to determine patients’ functional outcome. One of them is the “Swallowing Rating Scale.”

Figure 3 Combined Manometric-pH Recording System Used in the Evaluation of Esophageal Function

The Triple-Lumen Perfused Recording Catheter Measures Intraluminal Pressures from Three Levels in the Esophagus. Measurements are Made in Terms of Centimeters from the Nostrils to the Proximal Opening of the Recording Catheter (PROX). The Medial Catheter (MED) Records Pressures 5 cm Distal to the Proximal Opening and the Distal Catheter (DIST) 5 cm below This. The Intraesophageal pH Electrode is Used to Document Gastroesophageal Reflux.

From Townsend CM et al: Sabiston textbook of surgery, ed 17, Philadelphia, 2004, Saunders.

Complications

Dehydration
Malnutrition
Aspiration pneumonia
Airway obstruction
Death resulting from pulmonary complications

Prognosis

Depends on the etiology.
Nursing home patients with oropharyngeal dysphagia and a history of aspiration have an approximately 45% mortality rate over 1 yr.
All patients, especially the elderly, should take their medications with a full glass of water while in upright position well before bedtime.
Dysphagia should be considered an alarm symptom, indicating the need for immediate evaluation.

Patient Education

Elderly patients with dysphagia should not attribute their symptoms to aging.

Related Content

Achalasia (Related Key Topic)

Dyspepsia, Nonulcerative (Related Key Topic)

Esophageal Tumors (Related Key Topic)

Gastroesophageal Reflux Disease (Related Key Topic)

section name header

Basic Information ⬇

Diagnosis ⬆ ⬇

Treatment ⬆ ⬇

Related Content ⬆