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Dysphagia
Felix B. Chang, MD, DABMA, FAAMA
image BASICS
Difficulty transmitting the alimentary bolus from the mouth to stomach
DESCRIPTION
  • Oropharyngeal dysphagia: difficulty transferring food bolus from oropharynx to proximal esophagus
  • Esophageal dysphagia: difficulty moving food bolus through the body of the esophagus to the pylorus
EPIDEMIOLOGY
10% of individuals >50 years of age
Prevalence
  • Common primary care complaint
  • Rates of impaired swallowing in nursing home residents range from 29% to 32%.
ETIOLOGY AND PATHOPHYSIOLOGY
  • Oropharyngeal (transfer dysphagia):
    • Mechanical causes: pharyngeal and laryngeal cancer, acute epiglottitis, carotid body tumor, pharyngitis, tonsillitis, strep throat, lymphoid hyperplasia of lingual tonsil, lateral pharyngeal pouch, hypopharyngeal diverticulum
  • Esophageal:
    • Esophageal mechanical lesions: carcinomas, esophageal diverticula, esophageal webs, Schatzki ring, structures (peptic, chemical, trauma, radiation), foreign body
    • Extrinsic mechanical lesions: peritonsillar abscess, thyroid disorders, tumors, mediastinal compression, vascular compression (enlarged left atrium, aberrant subclavius, aortic aneurysm), osteoarthritis cervical spine, adenopathy, esophageal duplication cyst
  • Neuromuscular: achalasia, diffuse esophageal spasm, hypertonic lower esophageal sphincter, scleroderma, nutcracker esophagus, CVA, Alzheimer disease, Huntington chorea, Parkinson disease, multiple sclerosis, skeletal muscle disease (polymyositis, dermatomyositis), neuromuscular junction disease (myasthenia gravis, Lambert-Eaton syndrome, botulism), hyper- and hypothyroidism, Guillain-Barré syndrome, systemic lupus erythematous, acute lymphoblastic leukemia, amyloidosis, diabetic neuropathy, brainstem tumors, Chagas disease
  • Infection: diphtheria, chronic meningitis, tertiary syphilis, Lyme disease, rabies, poliomyelitis, CMV, esophagitis (Candida, herpetic)
  • Globus phenomenon
RISK FACTORS
  • Children: hereditary and/or congenital malformations
  • Adults: age >50 years. Elderly: GERD, stroke, COPD, chronic pain
  • Smoking, excess alcohol intake, obesity
  • Medications: quinine, potassium chloride, vitamin C, tetracycline, Bactrim, clindamycin, NSAIDs, procainamide, anticholinergics, bisphosphates
  • Neurologic events or diseases: CVA, myasthenia gravis, multiple sclerosis, Parkinson disease, amyotrophic lateral sclerosis (ALS), Huntington chorea
  • HIV patients with CD4 cell count <100 cells/mm3
  • Trauma or irradiation of head, neck, and chest; mechanical lesions
  • Extrinsic mechanical lesions: lung, thyroid tumors, lymphoma, metastasis
  • Iron deficiency
  • Anterior cervical spine surgery (up to 71% in the first 2 weeks postop; 12-14% at 1 year postop)
  • Dysphagia lusoria (vascular abnormalities causing dysphagia): complete vascular ring, double aortic arch, right aortic arch with retroesophageal left subclavian artery and left ligamentum arteriosum, and right aortic arch with mirrow-image branching and left ligamentum arteriousum
GENERAL PREVENTION
  • Correct poorly fitting dentures in older patients.
  • Educate patients on prolonged chewing and drinking large volumes of water to accompany meals.
  • Liquid and soft food diet in appropriate patients
  • Avoid alcohol with meals.
  • Prophylactic swallowing exercises in patients with head and neck cancer undergoing chemoradiation
COMMONLY ASSOCIATED CONDITIONS
Peptic structure, esophageal webs and rings, carcinoma; history of stroke, dementia, pneumonia
image DIAGNOSIS
PHYSICAL EXAM
  • General: vital signs
  • Skin:
    • Telangiectasia, sclerodactyly, calcinosis (r/o autoimmune disease); Reynaud phenomenon, sclerodactyly may be found in CREST syndrome or systemic scleroderma; stigmata of alcohol abuse (palmar erythema; telangiectasia)
  • Head, eye, ear, nose, throat (HEENT):
    • Oropharyngeal:
      • Pharyngeal erythema/edema, tonsillitis, pharyngeal ulcers or thrush, odynophagia (bacterial, viral, fungal infections)
      • Tongue fasciculations (ALS)
    • Neck:
      • Neck masses, lymphadenopathy, neck tenderness, goiter
      • Neck tenderness: acute thyroiditis
  • Neurologic:
    • Cranial nerve exam:
      • Sensory: cranial nerves V, IX, and X
      • Motor: cranial nerves V, VII, X, XI, and XII
    • CNS, mental status exam, strength testing, Horner syndrome, ataxia, cogwheel rigidity (CVA, dementia, Parkinson disease, Alzheimer disease)
      • Eye position, extraocular motility
    • Informal bedside swallowing evaluation:
      • Observe level of consciousness, postural control-upright position, oral hygiene, mobilization of oral secretions.
DIFFERENTIAL DIAGNOSIS
See “Etiology and Pathophysiology.”
DIAGNOSTIC TESTS & INTERPRETATION
Adults: (1)[C]
  • Barium swallow
  • Fiberoptic endoscopic examination of swallowing (FEES)
  • Gastroesophageal endoscopy
  • Barium cine/video esophagogram
  • Ambulatory 24-hour pH testing
  • Esophageal manometry
  • Videofluoroscopic swallowing study (VFSS): oropharyngeal dysphagia
Initial Tests (lab, imaging)
  • Guided by diagnostic considerations (2)[C]
    • CBC (infection and inflammation)
    • Serum protein and albumin levels for nutritional assessment
    • Thyroid function studies to detect dysphagia associated with hypothyroidism or hyperthyroidism, cobalamin levels
    • Antiacetylcholine antibodies (myasthenia)
  • Barium swallow: detects strictures or stenosis
Follow-Up Tests & Special Considerations
  • CT scan of chest
  • MRI of brain and cervical spine
  • P.327

  • Videofluoroscopic swallowing function study (VSFS) (lips, tongue, palate, pharynx, larynx, proximal esophagus)
  • Fiberoptic endoscopy and videofluoroscopy are similar in terms of diagnostic sensitivity (3)[C].
Diagnostic Procedures/Other
Endoscopy with biopsy; esophageal manometry; esophageal pH monitoring
Test Interpretation
  • Squamous cell or adenocarcinoma
  • Barrett metaplasia
  • Fibrous tissue of a ring, web, or stricture
  • Loss of smooth muscle (scleroderma)
image TREATMENT
GENERAL MEASURES
Exclude cardiac disease. Ensure airway patency and adequate pulmonary function. Assess nutritional status. Speech therapy evaluation is helpful.
MEDICATION
First Line
  • For esophageal spasms: calcium channel blockers: nifedipine 10 to 30 mg TID; imipramine 50 mg at bedtime; sildenafil 50 mg/day PRN
  • For esophagitis:
    • Antacids: Tums, Mylanta, Maalox
    • H2 blockers:
      • Cimetidine: up to 1,600 mg orally per day in 2 or 4 divided doses for 12 weeks
      • Ranitidine: initial 150 mg orally 4 times daily and maintenance 150 mg orally twice daily
      • Nizatidine: 150 mg orally twice daily for 12 weeks
      • Famotidine: 20 to 40 mg orally twice daily for 12 weeks
    • Proton pump inhibitors:
      • Omeprazole: 20 mg once daily for 4 to 8 weeks
      • Lansoprazole: 30 mg once daily for up to 8 weeks
      • Rabeprazole: 20 mg orally once daily for 4 to 8 weeks
      • Esomeprazole: 20 to 40 mg orally once daily for 4 to 8 weeks
      • Pantoprazole: 40 mg orally once daily for up to 8 weeks
    • Prokinetic agents: rarely used
    • Precautions: may need to use liquid forms of medications because patients might have difficulty swallowing pills
ISSUES FOR REFERRAL
  • Gastroenterology: endoscopy, refractory symptoms
  • Surgery: dilation, esophageal myotomy, biopsy
ADDITIONAL THERAPIES
Speech therapy to assess swallowing; nutritional evaluation for dietary and positioning recommendations; physical therapy for muscle-strengthening exercise; no eating at bedtime; remaining upright after eating
  • Self-expanded metal stent is safe, effective, and quicker in palliating dysphagia compared to other modalities.
SURGERY/OTHER PROCEDURES
  • Esophageal dilatation (pneumatic or bougie)
  • Esophageal stent; laser for cancer palliation (4)[A]
  • Treatment for underlying problem (e.g., thyroid goiter, vascular ring, esophageal atresia)
  • Nd:YAG laser incision of lower esophageal rings refractory to dilation
  • Photodynamic therapy (cancer) (4)[C]
  • Cricopharyngeal myotomy (oropharyngeal dysphagia)
  • Surgery for Zenker diverticulum, refractory strictures, or myotomy (for achalasia)
  • Percutaneous endoscopic gastrostomy (PEG) decreases risk of dysphagia when compared with nasogastric tube.
COMPLEMENTARY & ALTERNATIVE MEDICINE
  • Acupuncture has been used for neurogenic dysphagia.
  • Electroacupuncture combined with dilating granule has been used in the treatment of GERD.
  • Insufficient evidence for routine use of botulinum toxin
INPATIENT CONSIDERATIONS
Admission Criteria/Initial Stabilization
  • Complete or partial esophageal obstruction with malnutrition or hypovolemia/dehydration
  • Comorbid conditions complicating dysphagia
  • Need for enteral feeding
  • Outpatient for conditions where patient is able to maintain nutrition and has little risk of complications.
  • Hospitalization may be required for adults when dysphagia is associated with total or near-total obstruction of esophageal lumen.
  • Hospitalization may be needed for endoscopy and/or esophageal dilation and is generally indicated for diagnostic or therapeutic surgical procedures.
IV Fluids
For dehydrated, hypovolemic patients, and patients with impaired consciousness
Discharge Criteria
Tolerating adequate diet without nausea/pain
image ONGOING CARE
DIET
See “General Prevention.”
PATIENT EDUCATION
Dietary modification; no eating at bedtime; remaining upright after eating; smoking cessation
PROGNOSIS
Vary with specific diagnosis.
REFERENCES
1. American College of Radiology. ACR appropriateness criteria for dysphagia. National Guideline Clearinghouse. https://www.guidelinecentral.com/summaries/acr-appropriateness-criteria-dysphagia/. Accessed 2014.
2. Al-Hussaini A, Latif EH, Singh V. 12-minute consultation: an evidence-based approach to the management of dysphagia. Clin Otolaryngol. 2013; 38(3):237-243.
3. ASGE Standards of Practice Committee, Pasha SF, Acosta RD, et al. The role of endoscopy in the evaluation and management of dysphagia. Gastrointest Endosc. 2014;79(2):191-201.
4. Dai Y, Li C, Xie Y, et al. Interventions for dysphagia in oesophageal cancer. Cochrane Database Syst Rev. 2014;(10):CD005048.
Additional Reading
&NA;
  • Anderson U, Beck A, Kjaersgaard A, et al. Systematic review and evidence based recommendations on texture modified foods and thickened fluids for adults (≥18 years) with oropharyngeal dysphagia. e-SPEN Journal. 2013;8(4):e127-e134.
  • Cho SK, Lu Y, Lee DH. Dysphagia following anterior cervical spinal surgery: a systematic review. Bone Joint J. 2013;95-B(7):868-873.
  • Geeganage C, Beavan J, Ellender S, et al. Interventions for dysphagia and nutritional support in acute and subacute stroke. Cochrane Database Syst Rev. 2012;(10):CD000323.
  • Regan J, Murphy A, Chiang M, et al. Botulinum toxin for upper oesophageal sphincter dysfunction in neurological swallowing disorders. Cochrane Database Syst Rev. 2014;(5):CD009968.
Codes
&NA;
ICD10
  • R13.10 Dysphagia, unspecified
  • R13.12 Dysphagia, oropharyngeal phase
  • R13.14 Dysphagia, pharyngoesophageal phase
Clinical Pearls
&NA;
  • Preventing aspiration is a priority.
  • Swallow therapy is recommended in patients with oropharyngeal dysphagia following a stroke, head or neck trauma, surgery, or degenerative neurologic diseases.
  • Patients with oropharyngeal dysphagia usually report feeling an obstruction in the neck and point to this area when asked to identify the site of their symptoms.
  • Weight loss is usually associated with malignancy or achalasia.
  • Most patients with Sjögren syndrome have associated dysphagia.