Dysphagia

Dysphagia is difficulty in swallowing. Although classified under "symptoms and signs" in ICD-10, in some contexts it is classified as a condition in its own right.

It may be a sensation that suggests difficulty in the passage of solids or liquids from the mouth to the stomach, a lack of pharyngeal sensation or various other inadequacies of the swallowing mechanism. Dysphagia is distinguished from other symptoms including odynophagia, which is defined as painful swallowing, and globus, which is the sensation of a lump in the throat. A person can have dysphagia without odynophagia (dysfunction without pain), odynophagia without dysphagia (pain without dysfunction) or both together. A psychogenic dysphagia is known as phagophobia.

Classification

Dysphagia is classified into the following major types:

Oropharyngeal dysphagia
Esophageal and obstructive dysphagia
Neuromuscular symptom complexes
Functional dysphagia is defined in some patients as having no organic cause for dysphagia that can be found.

Signs and symptoms

Some patients have limited awareness of their dysphagia, so the lack of the symptom does not exclude an underlying disease.

Some signs and symptoms of oropharyngeal dysphagia include difficulty controlling 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. The actual site of obstruction is always at or below the level at which the level of obstruction is perceived.

The most common symptom of esophageal dysphagia is the inability to swallow solid food, which the patient will describe as 'becoming stuck' or 'held up' before it either passes into the stomach or is regurgitated. Pain on swallowing or odynophagia is a distinctive symptom that can be highly indicative of carcinoma, although it also has numerous other causes that are not related to cancer. Achalasia is a major exception to the usual pattern of dysphagia in that swallowing of fluid tends to cause more difficulty than swallowing solids. In achalasia, there is idiopathic destruction of parasympathetic ganglia of the Auerbach's (Myenteric) plexus of the entire esophagus, which results in functional narrowing of the lower esophagus, and peristaltic failure throughout its length.

Complications

Complications of dysphagia may include aspiration, pneumonia, dehydration, and weight loss.

Causes

The following table enumerates possible causes of dysphagia:

{|class="wikitable collapsible collapsed"

!Location!! Cause

|Oral dysphagia||

Inflammation and infection
Tonsillitis
Peritonsillar abscess
Stomatitis
Tongue cancer
Neurological
Paralysis of soft palate, usually due to diphtheria in children and bulbar palsy in adults
Bell's palsy
Xerostomia/dry mouth – e.g., Sjogren's syndrome

|Pharyngeal dysphagia||

Lumen:
Impacted foreign body
Wall:
Pharyngitis
Paterson-Kelly syndrome
Pharyngeal spasms
Malignant neoplasm
Outside the wall:
Retropharyngeal abscess
Lymphadenopathy of cervical lymph nodes
Thyroid malignancy
Eagle syndrome
Rabies

|Esophageal dysphagia||

Lumen
Impacted foreign body
Wall:
Esophageal atresia
Benign strictures, due to reflux esophagitis, swallowed corrosives, tuberculosis, and radiotherapy, scleroderma/systemic sclerosis
Spasms, due to achalasia, Paterson-Kelly syndrome, esophageal webs, and esophageal rings
Neoplasms, such as esophageal cancer, esophageal leiomyoma
Nervous disorders, such as bulbar palsy, pseudobulbar palsy, post-vagotomy, myasthenia gravis
Crohn's disease
Candida esophagitis
Eosinophilic esophagitis
Outside the wall:
Retrosternal goitre
Malignancy
Zenker's diverticulum
Aortic aneurysm
Mediastinal growth
Dysphagia lusoria
Periesophagitis
Hiatus hernia
Tight hiatus repairs/laparoscopic fundoplication; gastric banding

Structural anamolies, neurological, GERD, Pulmonary are aetiologies for dysphagia. Difficulty with or inability to swallow may be caused or exacerbated by the use of opioids. Other drugs such as cocaine may also induce it.

Diagnosis

Esophagoscopy and laryngoscopy can give direct view of lumens.
Esophageal motility study is useful in cases of esophageal achalasia and diffuse esophageal spasms.
Exfoliative cytology can be performed on esophageal lavage obtained by esophagoscopy. It can detect malignant cells in the early stage.
Ultrasonography and CT scan are not very useful in finding causes of dysphagia, but can detect masses in the mediastinum and aortic aneurysms.
FEES (Fibreoptic endoscopic evaluation of swallowing), sometimes with sensory evaluation, is usually done by a Medical Speech Pathologist or Deglutologist. This procedure involves the patient eating different consistencies as above.
Swallowing sounds and vibrations could be potentially used for dysphagia screening, but these approaches are in the early research stages.

Differential diagnosis

All causes of dysphagia are considered as differential diagnoses. Some common ones are:

Esophageal atresia
Paterson-Kelly syndrome
Zenker's diverticulum
Esophageal varices
Benign strictures
Achalasia
Esophageal diverticula
Scleroderma
Diffuse esophageal spasm
Polymyositis
Webs and rings
Esophageal cancer
Eosinophilic esophagitis
Hiatus hernia, especially paraesophageal type
Dysphagia lusoria
Stroke
Fahr's disease
Wernicke encephalopathy
Charcot–Marie–Tooth disease
Parkinson's disease
Multiple sclerosis
Amyotrophic lateral sclerosis
Rabies
Cervical Spondylosis

Esophageal dysphagia is almost always caused by disease in or adjacent to the esophagus, but occasionally the lesion is in the pharynx or stomach. In many of the pathological conditions causing dysphagia, the lumen becomes progressively narrowed and indistensible. Initially, only fibrous solids cause difficulty, but later the problem can extend to all solids and even to liquids. Patients with difficulty swallowing may benefit from thickened fluids if the person is more comfortable with those liquids, although, so far, there is no scientific study that proves that those thickened liquids are beneficial. Transnasal esophagoscopy (TNE) has emerged as a valuable diagnostic tool in the evaluation of esophageal dysphagia, particularly in outpatient and minimally invasive settings. A key clinical indicator of esophageal origin is the sensation of retrosternal bolus hold-up, where patients report that food appears to be stuck behind the sternum after swallowing. The presence of alarm symptoms, such as progressive dysphagia and unintentional weight loss, raises concern for serious underlying conditions, including esophageal malignancy, and necessitates prompt investigation. TNE allows direct visualization of the esophageal mucosa without the need for sedation and facilitates early detection of structural abnormalities such as strictures, lesions, or tumors. Therefore, it serves as an effective and accessible tool in the clinical assessment and early diagnosis of esophageal dysphagia (Clinical Diagnosis Using Transnasal Esophagoscopy, 2024).

Dysphagia may manifest as the result of autonomic nervous system pathologies including stroke and ALS, or due to rapid iatrogenic correction of an electrolyte imbalance.

In older adults, presbyphagia - the normal healthy changes in swallowing associated with age - should be considered as an alternative explanation for symptoms.

Treatments

There are many ways to treat dysphagia, such as swallowing therapy, dietary changes, feeding tubes, certain medications, and surgery. Treatment for dysphagia is managed by a group of specialists known as a multidisciplinary team. Members of the multidisciplinary team include: a speech language pathologist specializing in swallowing disorders (swallowing therapist), primary physician, gastroenterologist, nursing staff, respiratory therapist, dietitian, occupational therapist, physical therapist, pharmacist, and radiologist.

Swallowing difficulties in dementia

A 2018 Cochrane review found no conclusive evidence about the immediate and long-term effects of modifying the thickness of fluids for swallowing difficulties in people with dementia. While thickening fluids may have an immediate positive effect on swallowing and improving oral intake, the long-term impact on the health of the person with dementia should also be considered.

Oral and pharyngeal range-of-motion exercises
Resistance exercises
Bolus control exercises
Swallowing maneuvers
Supraglottic swallow
Super-supraglottic swallow
Effortful swallow
Mendelsohn maneuver

Patients may need a combination of treatment procedures to maintain a safe and nutritionally adequate swallow. For example, postural strategies may be combined with swallowing maneuvers to allow the patient to swallow safely and efficiently.

The most common interventions used for those with oropharyngeal dysphagia by speech language pathologists are rehabilitation of the swallow through oral motor exercises, texture modification of foods, thickening fluids and positioning changes during swallowing. The effectiveness of modifying food and fluid in preventing aspiration pneumonia has been questioned and these can be associated with poorer nutrition, hydration and quality of life. Also, there has been considerable variability in national approaches to describing different degrees of thickened fluids and food textures.  However, in 2015, the International Dysphagia Diet Standardisation Initiative (IDDSI) group produced an agreed IDDSI framework consisting of a continuum of 8 levels (0–7), where drinks are measured from Levels 0 – 4, while foods are measured from Levels 3 – 7. It is likely that this initiative, which has widespread support among dysphagia practitioners, will improve communication with caregivers and will lead to greater standardization of modified diets. There is also a larger movement within the field of speech-language pathology that advocates for dysphagia to be elevated within the school setting, as it is currently not considered necessary during a speech-language and oral evaluation of a child. However, proper nutrition, hydration, and the ability to swallow are critical for child's academic, social, and personal success.

Epidemiology

Swallowing disorders can occur in all age groups, resulting from congenital abnormalities, structural damage, and/or medical conditions. and in patients who have had strokes.

Dysphagia affects about 3% of the population.

Etymology

The word "dysphagia" is derived from the Greek dys meaning bad or disordered, and the root phag- meaning "eat".