Dysphagia

Description

• Difficulty swallowing
• Can be neuromuscular, mechanical, infectious, inflammatory, or extrinsic to aerodigestive system
• Difficulty may be with solids, liquids, or both

Etiology

• Oropharyngeal (transfer) dysphagia:
  • Difficulty transferring from the mouth to the proximal esophagus (difficulty initiating a swallow)
  • Easier to swallow solids vs. liquids
  • Immediate, within seconds of swallowing
  • Associated with nasal or oral regurgitation, coughing, or choking
  • Usually a neuromuscular disorder resulting in bulbar muscle weakness or impaired coordination
• Esophageal (transport) dysphagia:
  • Failure of normal transit through the esophagus
  • Retrosternal sticking sensation seconds after swallowing
  • Nocturnal regurgitation/aspiration
  • Drooling or regurgitation of undigested food and liquid (characteristic of esophageal obstruction)
  • Motility disorder vs. mechanical obstruction
• Functional dysphagia:
  • Diagnosis of exclusion
  • Full workup without evidence of mechanical or neuromuscular pathology
  • Symptoms >12 wk
• Odynophagia:
  • Pain with swallowing
  • Separate, but often related, entity
  • Causes include infectious, medication-induced, and inflammatory conditions
• Pain pattern:
  • Overall poor ability to localize pain with dysphagia, although oropharyngeal source is better
  • Somatic nerve fibers in the upper esophagus; better pain localization
  • Visceral pain from the lower esophagus is poorly localized and may be difficult to distinguish from that of acute coronary syndrome

• Pediatric dysphagia:
  • Common causes in infants/newborns include prematurity, congenital malformations, neuromuscular disease, infection (e.g., candidiasis), inflammation
  • Always consider foreign body aspiration in a child presenting with dysphagia
  • Other common causes in children include caustic ingestions, infections, and neurologic disorders including sequelae from head injury
  • Acquired tracheoesophageal fistula in children may result from ingestions (button battery, caustic ingestions) or prior surgery
  • Other life-threatening causes of dysphagia include epiglottitis, retropharyngeal abscess, CNS infection, botulism, esophageal perforation, diphtheria