Approach to dysphagia

Definition of Dysphagia The word dysphagia is derived from the Greek phagia (to eat) and dys (with difficulty). It specifically refers to the sensation of food being hindered in its normal passage from the mouth to the stomach.

CLASSIFICATION Two distinct syndromes Oropharyngeal dysphagia Esophageal dysphagia Produced by abnormalities affecting the finely tuned neuromuscular mechanism of the striated muscle of the mouth, pharynx, and UES Caused by the variety of disorders affecting the smooth muscle esophagus

Oropharyngeal dysphagia Inability to initiate the act of swallowing. It is a transfer problem caused by impaired ability to transfer food from mouth to upper esophagus impaired oral preparatory phase Clinical presentation: food sticking in the throat difficulty initiating a swallow nasal regurgitation coughing during swallowing They may also complain of dysarthria nasal speech because of associated muscle weaknesses Other Neurological clinical findings

Abnormalities Causing Oropharyngeal Dysphagia Neuromuscular Diseases Neuromuscular Diseases Central nervous system (CNS) Central nervous system (CNS) Cerebral vascular accident (e.g., brain stem or pseudobulbar palsy) Cerebral vascular accident (e.g., brain stem or pseudobulbar palsy) Parkinson disease Parkinson disease Wilson disease Wilson disease Multiple sclerosis Multiple sclerosis Amyotrophic lateral sclerosis Amyotrophic lateral sclerosis Brain stem tumors Brain stem tumors Tabes dorsalis Tabes dorsalis Miscellaneous congenital and degenerative disorders of CNS Miscellaneous congenital and degenerative disorders of CNS

Abnormalities Causing Oropharyngeal Dysphagia Neuromuscular Diseases Neuromuscular Diseases Peripheral nervous system Peripheral nervous system Bulbar poliomyelitis Bulbar poliomyelitis Peripheral neuropathies (e.g., diphtheria, botulism, rabies, diabetes mellitus) Peripheral neuropathies (e.g., diphtheria, botulism, rabies, diabetes mellitus) Motor end plate Motor end plate Myasthenia gravis Myasthenia gravis Muscle Muscle Muscular dystrophies Muscular dystrophies Primary myositis Primary myositis Metabolic myopathy (e.g., thyrotoxicosis, myxedema, steroid myopathy) Metabolic myopathy (e.g., thyrotoxicosis, myxedema, steroid myopathy) Amyloidosis Amyloidosis SLE SLE

Abnormalities Causing Oropharyngeal Dysphagia Local Structural Lesions Local Structural Lesions Inflammatory Inflammatory Pharyngitis Pharyngitis Abscess Abscess Tuberculosis Tuberculosis Syphilis Syphilis Neoplastic Neoplastic Congenital webs Congenital webs Plummer-Vinson syndrome Plummer-Vinson syndrome Extrinsic compression Extrinsic compression Thyromegaly Thyromegaly cervical spine hyperostosis cervical spine hyperostosis Lymphadenopathy Lymphadenopathy Surgical resection of the oropharynx Surgical resection of the oropharynx

Abnormalities Causing Oropharyngeal Dysphagia Disorders of the Upper Esophageal Sphincter (UES) Disorders of the Upper Esophageal Sphincter (UES) Hypertensive UES (i.e., spasm, possibly in globus, or gastroesophageal reflux Hypertensive UES (i.e., spasm, possibly in globus, or gastroesophageal reflux Hypotensive UES (e.g., esophagopharyngeal regurgitation or aspiration) Hypotensive UES (e.g., esophagopharyngeal regurgitation or aspiration) Abnormal UES relaxation or opening Abnormal UES relaxation or opening Incomplete relaxation (e.g., cricopharyngeal achalasia CNS lymphoma, oculopharyngeal muscular dystrophy) Incomplete relaxation (e.g., cricopharyngeal achalasia CNS lymphoma, oculopharyngeal muscular dystrophy) Inadequate opening (e.g., cricopharyngeal bar, Zenker diverticulum) Inadequate opening (e.g., cricopharyngeal bar, Zenker diverticulum) Delayed relaxation (e.g., familial dysautonomia) Delayed relaxation (e.g., familial dysautonomia)

Etiology Of Esophageal Dysphagia Neuromuscular (Motility) Disorders Most common Most common Achalasia Achalasia Scleroderma Scleroderma Diffuse esophageal spasm Diffuse esophageal spasm Other associated motility abnormalities Other associated motility abnormalities Nutcracker esophagus Nutcracker esophagus Hypertensive lower esophageal sphincter Hypertensive lower esophageal sphincter Vigorous achalasia Vigorous achalasia Nonspecific esophageal dysmotility Nonspecific esophageal dysmotility Other secondary motility disorders Other secondary motility disorders Other collagen disorders Other collagen disorders Chagas disease Chagas disease

Etiology Of Esophageal Dysphagia Mechanical Lesions, Intrinsic Most common Most common Peptic stricture Peptic stricture Lower esophageal (Schatzki) ring Lower esophageal (Schatzki) ring Carcinoma Carcinoma Other Other Esophageal webs Esophageal webs Esophageal diverticula Esophageal diverticula Benign tumors Benign tumors Foreign bodies Foreign bodies

Etiology Of Esophageal Dysphagia Mechanical Lesions, Extrinsic Vascular compression Vascular compression Mediastinal abnormalities Mediastinal abnormalities Cervical osteoarthritis Cervical osteoarthritis

Esophageal Dysphagia Three important questions are particularly crucial. What kind of food (i.e., liquid or solid) produces the symptom? Is the dysphagia intermittent or progressive? Is there associated heartburn? Physical examination is usually not revealing in patients with esophageal dysphagia, with the exception of scleroderma.

Diagnosis History Examination CBC CxR Barium studies Endoscopy Computed tomography scanning Endoscopic ultrasound Endoscopy Esophageal Manometry Esophageal pH studies