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Editors

PiaJärvenpää
PerttuArkkila

Dysphagia

Essentials

  • Dysphagia is a common problem and a symptom of many diseases; patients are therefore treated by various specialities.
  • Unclear dysphagia requires urgent assessment to identify its precise cause and to begin appropriate treatment.
  • Globus sensation, or the feeling of a lump in the throat, should be distinguished from dysphagia. Globus patients feel as though there is something lodged in their throat but have no problem swallowing.
  • The cause of dysphagia may be structural, functional or of motor origin.
  • Dysphagia may also be a manifestation of a neurological condition.
  • Careful history taking can help to distinguish mild, benign causes of dysphagia from causes where urgent further investigations are indicated.

Definition

  • The swallowing process is divided into oral, pharyngeal and oesophageal phases.
  • Problems in the oral and pharyngeal phases can be examined by an ENT physician or a phoniatrician. Oesophageal symptoms should be examined by a gastroenterologist.
  • In dysphagia, food does not travel onward from the mouth or becomes stuck in the pharynx or oesophagus. The symptom may be associated with regurgitation of liquids or solid food into the nasopharynx or return of swallowed food from the oesophagus to the pharynx. In some cases, the only symptom of dysphagia may be recurrent pneumonia due to aspiration.
  • Malignant disease is suggested by dysphagia with rapid onset and aggravation, possibly associated with pain, hoarseness and weight loss. There is often underlying smoking and excessive alcohol consumption.

Background

  • Patients usually seek medical help only after the symptoms have lasted for some weeks or months, even years.
  • Rapid worsening of symptoms or troublesome dysphagia prompt an earlier consultation.
  • In neurological conditions, dysphagia is rarely the only symptom and often develops only after the condition has become more advanced.
  • In the ageing population, problems associated with swallowing become more common due to factors such as mucosal dryness of various causes, slowing of motor functions, and more ineffective swallowing. Nevertheless, dysphagia in the elderly should not straight away be interpreted as due to normal ageing.
  • Elderly people can suffer from muscle atrophy or what is called sarcopenic dysphagia, where diminishing muscle strength and poor eating lead to weakness of the muscles needed for swallowing, to dysphagia and malnutrition.

Aetiology of dysphagia

  • Causes of dysphagia
    • Oral causes
      • Defective dentition that is in a poor condition or a poorly fitting dental prosthesis
      • Reduced salivation
      • Malignant tumours
      • History of surgery or radiotherapy
      • Oral infections
    • Pharyngeal or oesophageal causes
      • Hypertrophy or defective relaxation of the cricopharyngeal muscle
      • Zenker's diverticulum
      • Gastro-oesophageal reflux disease (GORD) or peptic stricture
      • Eosinophilic oesophagitis
      • Oesophageal hypokinesia or achalasia
      • Distal oesophageal spasm
      • Hypercontractile oesophagus (jackhammer oesophagus)
      • Malignant tumours
      • History of surgery or radiotherapy
      • Pharyngeal and oesophageal infections (candida, Herpes simplex)
      • Foreign bodies
      • Extraoesophageal obstructive processes
    • Neurological causes
      • History of cerebrovascular disorder (cerebral infarction or haemorrhage)
      • Brain injury
      • MS
      • Parkinson's disease
      • Memory diseases
      • Myasthenia gravis
      • Motor neurone disease (ALS)
      • Muscle disorders
    • Inflammatory myopathies
      • Polymyositis, dermatomyositis and inclusion body myositis
      • Scleroderma
      • Systemic sclerosis
      • Mixed connective tissue disease (MCTD)
      • Sjögren's syndrome
    • Advanced age
      • General slowing of motor functions, and impaired coordination
      • Muscle atrophy
      • Mucosal dryness
    • Medication
      • Cardiovascular medication (dry mouth)
      • Anticholinergic psychotropic drugs (dry mouth)
      • Calcium channel blockers (impaired oesophageal peristalsis)
      • Immunosuppressive medication (risk of fungal, bacterial and viral infections)
      • Broad-spectrum antimicrobial medication (risk of fungal infection)
      • Bisphosphonates (oesophageal irritation and erosion)
    • Other causes
      • Insufficient fluid intake
      • Psychological factors
      • Functional disorders

Diagnosis

Patient history

  • When assessing dysphagia, the patient's age and any underlying diseases, history of disease events and surgery, and current medication should be considered.
  • The condition of the mouth and dentition should be inspected.
  • Risk factors should be reviewed; smoking and alcohol consumption, including consumption history.
  • Does the patient have systemic symptoms, has their general condition changed, have they lost weight?
  • A history of pneumonia or recurrent coughing in association with meals may suggest aspiration.
  • Has the patient previously had symptoms of oesophageal origin or symptoms of GORD, in particular?
  • Food allergies may suggest eosinophilic oesophagitis.
  • Does the patient have other symptoms, such as hoarseness or neurological symptoms?
  • Specify the nature of dysphagia
    • At what stage does swallowing stop: in the mouth, pharynx or oesophagus?
    • How long have the symptoms lasted?
    • Are the symptoms persistent or intermittent?
    • Have the symptoms become steadily worse or stayed the same?
    • Is it difficult to begin swallowing?
    • Is there pain on swallowing?
    • Is it difficult to swallow solid and/or liquid food? Does it feel that solid food or liquids become stuck when swallowing and, if so, where?
      • If there is mechanical obstruction, swallowing of solid and larger pieces of food typically becomes difficult first but it is easier to swallow liquids.
      • In the case of neurological problems, difficulty swallowing liquids or recurrent coughing when drinking/eating may be the only symptom.
    • Was the appearance of the symptom preceded by a corrosive injury (medicines, accidental ingestion of a corrosive substance)?
    • Does dysphagia threaten sufficient nutrition?

Acute dysphagia

  • Acute inability to swallow solid food and/or liquids suggests that there is a foreign body in the oesophagus, requiring immediate treatment.
  • Patients usually develop symptoms after ingesting meat that becomes lodged in the oesophagus, causing obstruction and leading to salivation.
    • The cause must always be investigated (e.g., tumour, stenosis, eosinophilic oesophagitis).
  • Severe pain, fever and signs of shock may suggest oesophageal perforation, which is a life-threatening condition (mortality 20-50%).
  • Severe upper abdominal or chest pain may suggest an incarcerated diaphragmatic hernia.
  • Acute dysphagia combined with symptoms of infection may be due to pharyngitis, pharyngeal abscess or epiglottitis.
  • When associated with neurological symptoms, dysphagia is suggestive of vertebrobasilar ischaemia, in particular. Other symptoms of disturbances to the posterior circulation include hemiparesis and unilateral sensory disturbances, vertigo, difficulty speaking and diplopia.
  • Distal oesophageal spasm (DOS) and hypercontractile (jackhammer) oesophagus may cause intermittent non-progressive dysphagia when swallowing solid food and liquids. Patients may also report chest pain associated with this.
  • Eating may sometimes be associated with a traumatic experience, such as a feeling of suffocation, after which a young patient can no longer eat normally.

Dysphagia that has lasted for several weeks or months

  • Dysphagia that develops slowly over a few weeks or months and is associated with weight loss is strongly suggestive of a tumour in an elderly person and may suggest achalasia or a narrowing caused by reflux disease in a younger person.
  • Severe pain of a short duration associated with the passage of a piece of food is suggestive of a developing oesophageal stricture (a malignancy or benign stricture).
  • If dysphagia is the only presenting symptom, the possibility of a motor neurone disease should also be considered; other neurological symptoms will lead to the diagnosis of this disease.

Chronic dysphagia that has often lasted for several years

  • Intermittent dysphagia lasting for over a year suggests a functional disorder or achalasia.
  • Intermittent symptoms that do not seem to be related to the consistency of the swallowed food may indicate a psychogenic problem (e.g. anorexia, see Eating Disorders Among Children and Adolescents).
  • Intermittent dysphagia in the pharyngeal phase may also be related to too hasty eating, poor chewing and insufficient fluid intake.
  • May be associated with advanced neurological diseases.
  • Structural causes may include Zenker's diverticulum and tightness of the cricopharyngeal muscle in the area of the upper oesophageal sphincter.

Investigations

Investigations in primary health care

  • The patient's movement, general muscle condition, voice and speech problems should be observed.
  • Physical examination is the basic investigation: facial asymmetry, restricted mouth movements, dentition and prostheses, inspection of the mouth and pharynx (signs of infection, ulcers, tumours), palpation of the floor of the mouth, tongue and tonsil area, palpation of the local lymph nodes and the neck
  • Symmetry of the palatine arches should be assessed during phonation and by touching them with a cotton swab; the pharyngeal palatal reflex will raise the palatine arches. The pharyngeal gag reflex is elicited by pressing on the base of the tongue with a spatula. A cotton swab can be used to examine the symmetry of sensation in the oral cavity and the pharynx. Tongue movements, any deviation or atrophy should be assessed. Flickering movements on the surface of the tongue (fasciculations) may suggest a progressive neurological disease, primarily motor neurone disease.
  • Other cranial nerve and neurological examinations should be done particularly if there are other neurological symptoms.
  • Fibroscopy or indirect laryngoscopy of the lower pharynx and larynx: tumours, movement of the vocal cords and its symmetry, any accumulation of saliva in the lower pharynx
  • Imaging and laboratory examinations as necessary.

Consultation of an ENT specialist

  • If an oropharyngeal cause of dysphagia is suspected, an ENT specialist or phoniatrician should be consulted.
    • At the doctor's office, oral, pharyngeal and laryngeal structures are examined to detect any tumours, and sensory and motor problems affecting swallowing are assessed by observing the patient drinking. A significant share of patients need no further investigations.
    • Fibre optic endoscopic evaluation of swallowing (FEES) is carried out as necessary. In the test, a flexible scope is inserted through the nose to observe the passage of liquids, pureed and solid food in the area of the pharynx. FEES is often done together with a speech therapist, and it is associated with patient guidance.
    • In videofluorography, the passage of contrast medium boluses (liquid, pureed, solid) is observed from the oral cavity all the way to the stomach. The examination is used if causes such as Zenker's diverticulum are suspected.
    • Thorough examination of the lower pharynx when a tumour is suspected, for example, requires endoscopy using a rigid scope under general anaesthesia.
  • A gastroenterologist should be consulted if dysphagia of oesophageal origin is suspected.
    • If an evidently oesophageal cause of dysphagia is suspected, the patient should be referred for gastroscopy.
      • Gastroscopy is mostly done as an urgent examination considering the possibility of oesophageal cancer.
      • Biopsies are taken from the oesophagus even if the appearance is macroscopically normal (to diagnose eosinophilic oesophagitis).
      • Barium imaging of the oesophagus is done as indicated case by case (to evaluate the stricture in more detail).
    • Long-term monitoring of oesophageal pH and impedance and precision manometry
      • Manometric measurement to analyse the function of the oesophageal body as well as the upper and lower oesophageal sphincters. The investigation is indicated where a functional disorder is suspected or when surgery is planned for GORD.
      • Can be used to demonstrate acid reflux into the oesophagus.

If a neurological cause of dysphagia is suspected

  • If neurological dysphagia is suspected, the patient needs to be assessed by a neurologist. Investigations should be requested depending on other neurological symptoms and physical examination.
  • If a central aetiology is suspected, cranial MRI is indicated. This may reveal the causes of both bulbar and pseudobulbar paresis.
  • Motor neurone disease and myasthenia gravis are principally diagnosed with an ENMG test.
  • In cases of suspected muscle disorder, the ENMG test may need to be complemented with other specialist investigations, such as muscle MRI and muscle biopsy.

Treatment , Treatment of Dysphagia in Long-Term, Chronic Muscle Disease

Treatment of oral or pharyngeal phase dysphagia

  • If there is benign dysphagia of the oral and/or pharyngeal phase, it will be sufficient to instruct the patient to eat calmly, chew the food sufficiently and to drink sufficient liquids. Defective dentition or prostheses should be fixed.
  • Sufficient nutrition can often be achieved by changing the consistency of the food, such as by favouring soft foods that are easy to swallow and possibly by thickening liquids.
  • A speech therapist can provide guidance and rehabilitation.
  • Don't hesitate to consult a therapeutic dietitian if there is a risk of malnutrition associated with the dysphagia.
  • Rehabilitation and other treatment may not always be enough, swallowing may not be safe due to the risk of aspiration or oral nutrition may be insufficient. If so, a percutaneous endoscopic gastrostomy (PEG) tube is installed through the abdominal wall into the stomach to ensure nutrition by administering a nutrient solution.

Oesophageal diseases

  • If the stricture is caused by GORD, acid reflux should primarily be prevented by using a proton pump inhibitor or, if necessary, by anti-reflux surgery.
  • Eosinophilic oesophagitis is treated with a proton pump inhibitor, budesonide or an avoidance diet.
  • A stricture can be dilated by endoscopy.
  • If a diverticulum or tight cricopharyngeal muscle causes severe symptoms (dysphagia or regurgitation), it can be treated by endoscopy or sometimes by open surgery.

Carcinoma Preoperative Chemotherapy in Esophageal Carcinoma, Interventions for Dysphagia in Inoperable Oesophageal Cancer

  • In oesophageal cancer, the first line treatment consists of resection either alone or combined with cytostatic drugs and possibly radiotherapy.
  • In head and neck cancer, the treatment depends on the location and stage of the tumour. The primary treatment for hypopharyngeal cancer is usually chemoradiotherapy.
  • If the treatment is palliative, the aim is to keep the oesophagus patent for eating. Insertion of a stent inside the tumour is the most commonly used approach.

Disordered oesophageal motor function Endoscopic Pneumatic Dilation Versus Botulinum Toxin Injection in the Management of Primary Achalasia

  • Diffuse oesophageal spasm and nutcracker oesophagus is treated with calcium channel blockers, such as nifedipine.
  • Procedures that improve the patient's ability to eat in achalasia include endoscopic balloon dilatation of the lower oesophageal sphincter and surgical incision of its muscles (Heller myotomy or peroral endoscopic myotomy, or POEM). Surgery is favoured for younger patients, balloon dilatation for others.

Functional dysphagia

  • A multiprofessional treatment approach is often beneficial. A specialist physician, speech therapist, therapeutic dietitian and psychologist can be involved.

    References

    • Järvenpää P, Arkkila P, Aaltonen LM. Globus pharyngeus: a review of etiology, diagnostics, and treatment. Eur Arch Otorhinolaryngol 2018;275(8):1945-1953 [PubMed]
    • Dumper J, Mechor B, Chau J et al. Lansoprazole in globus pharyngeus: double-blind, randomized, placebo-controlled trial. J Otolaryngol Head Neck Surg 2008;37(5):657-63. [PubMed]