Dysphagia
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Basics

Difficulty during the progression of the alimentary bolus from the mouth to the stomach

Description

  • Oropharyngeal: Difficulty transferring food bolus from oropharynx to proximal esophagus
  • Esophageal dysphagia: Difficulty moving food bolus through esophagus
  • Associated symptoms: Pain, weight loss, globus

Epidemiology

Incidence
In the US: 7% incidence during lifetime

Prevalence
  • 23% prevalence of dysphagia reported in family medicine patients (1)
  • Impaired swallowing common in nursing home residents 29–32%
  • Dysphagia common after stroke: 51–55% clinical testing; 64–78% instrumental testing
  • 13–35% of elderly individuals who live independently

Risk Factors

  • Children: Hereditary and/or congenital malformations
  • Adults: Age >50 years. Elderly: GERD, stroke, COPD, chronic pain (2)
  • Smoking, excess alcohol intake, obesity
  • Infection: Diphtheria, chronic meningitis, tertiary syphilis, Lyme disease, rabies, poliomyelitis, cytomegalovirus (CMV), HIV
  • Medications: For example, 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

General Prevention

  • Correct poorly fitting dentures in older patients.
  • Education on prolonged chewing, drinking large amounts of water with meals, and diet consisting of liquids and soft foods
  • Avoid drinking alcohol with meals.
  • Swallowing evaluation:
    • Observe level of consciousness, postural control-upright position, oral hygiene, mobilization of oral secretions (3)[A].
  • Prophylactic swallowing exercises in patients with head and neck cancer undergoing chemoradiation (3)[A]

Etiology

  • Oropharyngeal (Transfer dysphagia):
    • Mechanical causes: Pharyngeal carcinoma, 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's 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 of the cervical spine, adenopathy, esophageal duplication cyst
  • Neuromuscular: Achalasia, diffuse esophageal spasm, hypertensive lower esophageal sphincter, scleroderma, nutcracker esophagus, CVA, Alzheimer's disease, Huntington chorea, Parkinson disease, multiple sclerosis, skeletal muscle disease (polymyositis, dermatomyositis), neuromuscular junction disease (myasthenia gravis, Eaton-Lambert syndrome, botulism), hyper/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)

Commonly Associated Conditions

Peptic structure, esophageal webs and rings, carcinoma; history of stroke, dementia, pneumonia

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