Dysphagia

Basics

Description

  • Difficulty swallowing
  • May occur acutely or be chronic and progressive
  • Can be neuromuscular, mechanical, infectious, inflammatory, or extrinsic to aerodigestive system
  • May occur with solids, liquids, or both
  • Oropharyngeal (transfer) dysphagia:
    • Difficulty transferring from mouth to 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

Etiology

  • Oropharyngeal:
    • Infectious:
      • Botulism
      • CNS infections
      • Mucositis
      • Lyme disease
      • Tuberculosis (pharyngeal or esophageal strictures in chronic cases)
      • Tertiary syphilis
    • Mechanical:
      • Congenital
      • Malignancy
      • Pharyngeal pouch (Zenker diverticulum)
    • Medications:
      • Antibiotics (especially doxycycline)
      • Aspirin and NSAIDs
      • Bisphosphonates
      • Ferrous sulfate
      • Potassium chloride
      • Quinidine
    • Neuromuscular:
      • Amyotrophic lateral sclerosis
      • Cerebrovascular accident
      • Guillain–Barré syndrome
      • Cranial nerve palsy
      • Huntington disease
      • Multiple sclerosis
      • Myasthenia gravis
      • Polymyositis and dermatomyositis
      • Parkinson disease
      • Traumatic brain injury
    • Psychological/behavioral
  • Esophageal:
    • Mechanical:
      • Diverticula
      • Esophageal webs
      • Foreign body
      • Neoplasm
      • Peptic esophageal stricture
      • Postsurgical (laryngeal, spinal)
      • Radiation injury
      • Schatzki ring
    • Motor:
      • Achalasia
      • Chagas disease
      • Cushing syndrome
      • Diffuse esophageal spasm
      • Hyperthyroidism/hypothyroidism
      • Nutcracker esophagus
      • Postvagal nerve injury following surgeries like thyroidectomy or esophagectomy
      • Scleroderma
      • Vitamin B12 deficiency
    • Inflammatory:
      • Eosinophilic esophagitis
      • Pill esophagitis
      • Caustic ingestion
    • Extrinsic:
      • Cardiovascular abnormalities (vascular rings, thoracic aneurysm, left atrial enlargement, aberrant subclavian artery)
      • Cervical osteophytes
      • Mediastinal mass
      • Thyroid mass or goiter

Pediatric Considerations

  • Pediatric dysphagia:
    • Common causes in infants/newborns include prematurity, congenital malformations, neuromuscular disease, infection (eg, 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
    • Life-threatening causes include epiglottitis, retropharyngeal abscess, CNS infection, botulism, esophageal perforation, diphtheria

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