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Dysphagia

Basics

Description

  • Dysphagia is the subjective sensation of difficulty swallowing.

  • Oropharyngeal: difficulty transferring bolus from oropharynx to proximal esophagus.

  • Esophageal: difficulty moving bolus through esophagus to stomach.

Epidemiology

  • 5–8% in adults >50 years

  • 25/100,000/year incidence of esophageal food impaction

  • M:F ratio = 1.5:1

  • Prevalence:

    • 14–33% in ≥65 years (community)

    • 40% in hospital patients

    • 29–32% in nursing homes

    • 44–60% in geriatric/institutionalized

Etiology & Pathophysiology

Oropharyngeal

  • Mechanical: tumors, epiglottitis, diverticula

  • Neuromyogenic: stroke, Parkinson, ALS, myasthenia, muscle dystrophies, hypothyroidism, Cushing

Esophageal

  • Mechanical: cancer, Schatzki ring, peptic stricture, foreign body, eosinophilic esophagitis

  • Extrinsic: thyroid disorders, vascular anomalies, tumors

  • Neuromuscular: achalasia, spasm, scleroderma, CNS diseases, myasthenia gravis, botulism, diabetic neuropathy, Chagas

Infectious

  • Candida, herpes, CMV, syphilis, Lyme, rabies

Risk Factors

  • Children: congenital anomalies

  • Adults/Elderly: GERD, stroke, COPD

  • Medications: NSAIDs, tetracycline, bisphosphonates, anticholinergics, psychotropics, SSRIs, muscle relaxants

  • Neurologic: MS, ALS, Parkinson, HIV (CD4 <100)

  • Others: head/neck trauma, smoking, alcohol, obesity

Associated Conditions

  • Peptic stricture, webs, stroke, dementia, pneumonia

Diagnosis

History

  • Oropharyngeal: difficulty initiating swallow

  • Progressive solids to liquids: suggests mechanical obstruction

  • Intermittent dysphagia: lower esophageal ring

  • Red flag symptoms: weight loss, regurgitation, aspiration, odynophagia, globus sensation, GERD

  • Cough, hoarseness, or halitosis → rule out neuromuscular/structural cause

Physical Exam

  • Skin signs: CREST, scleroderma

  • HEENT: pharyngitis, oral thrush, tongue fasciculations (ALS)

  • Neck: lymph nodes, goiter

  • Neuro exam: CN V, VII, IX, X, XI, XII

Differential Diagnosis

  • First step: determine level – oropharyngeal vs esophageal

Diagnostic Tests

Labs

  • CBC, TSH, B12, LFTs, AchR antibodies

Imaging/Procedures

  • EGD: first-line for esophageal dysphagia

  • Barium swallow: if EGD negative

  • Biopsies: midthoracic/distal esophagus for eosinophilic esophagitis

  • Video fluoroscopic swallow: initial test for oropharyngeal symptoms

  • Consider CXR, CT, manometry if needed

Treatment

General Measures

  • Exclude cardiac disease

  • Speech therapy, airway protection, nutrition support

First Line

  • PPI therapy: 8–12 weeks for GERD/esophagitis

  • Screen older patients with chronic illness/pneumonia for dysphagia

Medications

  • Adjust medications based on swallowing function

Referral

  • Speech/swallow therapy

  • Nutrition evaluation

Additional Therapies

  • Self-expanding metal stents (palliation)

  • Esophageal dilation for strictures/achalasia

  • Enteral feeding for total obstruction or high aspiration risk

Ongoing Care

Follow-Up

  • Monitor for progression

  • Review medications

Diet

  • Soft/liquid diet

  • Sit upright, chew thoroughly, small sips/bites

Patient Education

  • Swallowing techniques

  • Avoid lying flat after meals

Prognosis

  • 45% mortality within 12 months in nursing home residents with oropharyngeal dysphagia + aspiration

  • Swallowing therapy reduces pneumonia risk

Complications

  • Aspiration pneumonia

  • Malnutrition, dehydration

  • Airway obstruction, lung abscess

Clinical Pearls

  • Prompt evaluation essential

  • Consider EGD + biopsy in solid food dysphagia

  • Assess neurologic and infectious causes

  • Functional improvement possible with swallow therapy and multidisciplinary approach