Key points

Background

Dysphagia, defined as impairment of the swallowing mechanism, that may affect 1 in 6 adults and can be associated with significant morbidity and mortality. ^, Dysphagia affects quality of life as patients may adapt their eating with prolonged eating times or excessive liquid intake. ^, Despite symptom severity or need for intervention only half of individuals experiencing symptoms seek medical care. Without proper intervention, patients may avoid eating or develop feelings of isolation and embarrassment.

Each year approximately 1 million new cases of dysphagia are diagnosed in the United States with an estimated annual cost of $4 to $7 million dollars according to a study. ^, Although dysphagia can occur at any age, up to 13% of patients older than 65 years may experience dysphagia.

Swallowing requires the coordination of complex brain signals, 6 cranial nerves and 50 pairs of striated cranial muscles in the space of a few seconds. ^, First, food is chewed and a bolus is formed by skeletal muscle under voluntary control during the oral phase. Next, voluntary and involuntary processes are involved to move the bolus into the pharynx and close the airway during the pharyngeal phase. ^, Finally, food passes through the esophagus via slow peristaltic contractions that may take up to 10 seconds to move the bolus toward the stomach. Because of the complexity of this process, multiple pathologic processes may cause dysphagia.

Clinical presentation

Physicians should remember that dysphagia is a symptom, not a disease unto itself; therefore, investigation to determine and potentially treat the underlying cause is critical. A variety of etiologies may lead to dysphagia, and a good clinical history is the first step in pursuing proper treatment.

Dysphagia may be divided into oropharyngeal and esophageal forms. Oropharyngeal dysphagia is commonly caused by neurologic conditions, such as Parkinson’s disease, dementia, cerebrovascular ischemia, or malignancy and may be a presenting sign of amyotrophic lateral sclerosis or myasthenia gravis. ^, Esophageal dysphagia may be caused by gastroesophageal reflux disease, eosinophilic esophagitis, esophageal strictures, webs or ring, achalasia, medications, infections, or rheumatologic conditions such as scleroderma. ^,

Differentiating oropharyngeal and esophageal dysphagia may be aided by careful analysis of patient symptoms. Difficulty chewing, trouble initiating a swallow, coughing, choking, a wet sounding voice following a swallow, or nasopharyngeal regurgitation suggest oropharyngeal causes. ^, Esophageal causes are suggested when patients describe a feeling of food getting stuck once swallowing has occurred. This should be differentiated from globus pharyngeus which is the sensation of something caught in the throat that improves with swallowing. Patients with esophageal dysphagia may accurately localize an obstruction to the mid or lower chest; however, patients may also report feeling food trapped in the throat when, in reality, the lesion is much lower and the patient is misled by overlapping sensory innervation. ^, Additional clues to esophageal dysfunction can include regurgitation of undigested food which suggests achalasia or a Zenker diverticulum while painful swallowing suggests infection such as candidiasis. Similarly, a history of asthma or food allergies may suggest eosinophilic esophagitis as a cause of symptoms.

One key history element to elicit is if dysphagia occurs with swallowing solids, liquids, or both. Dysphagia resulting from mechanical obstructions that worsen over time, such as strictures or malignancy, tends to present with difficulty swallowing solid foods that progresses to difficulty with solids and liquids. Patients who experience difficulty with both solids and liquids at the onset of symptoms tend to have esophageal motility issues such as achalasia. ^, Further, dysphagia resulting from a neurologic or oropharyngeal cause tends to present with difficulty swallowing liquids first as evidenced by coughing or choking when drinking. ^,

The onset and duration of dysphagia can give clues to the etiology as well. Patients presenting with acute symptoms may have esophagitis, infection, or foreign body impaction.

Rapidly progressing dysphagia over weeks to months may be indicative of malignancy whereas peptic stricture should be considered with lower progression in the setting of reflux. ^, Intermittent dysphagia over the course of years is most likely associated with a benign etiology such as esophageal web or eosinophilic esophagitis.

Medication review is critical to fully evaluate patients presenting with dysphagia. Patients utilizing proton pump inhibitors or histamine-2 blockers may have underlying gastroesophageal reflux disease causing dysphagia. Too, non-steroidal anti-inflammatory medications or bisphosphonates can contribute to pill-induced esophagitis while anti-cholinergic or anti-muscarinic medications may worsen xerostomia and difficulty initiating swallow. ^{, ,} Tricyclic anti-depressants may worsen reflux symptoms and increase dysphagia symptoms, though some evidence suggests that amitriptyline (25 mg) or imipramine (50 mg) may improve dyspepsia symptoms. Sedatives that reduce attention or cause drowsiness as well as steroids which may weaken tongue strength can also lead to an impaired swallow.

Opioids are an important medication to consider when evaluating dysphagia as increasing potency and 24-hour morphine equivalent doses are frequently associated with esophageal dysfunction and dysphagia. This opioid-induced esophageal dysmotility may improve with cessation of opioid medications or dose reductions, though evidence is lacking to guide optimal therapy.

In addition to history, a thorough physical examination may yield clues to determine the cause of dysphagia. Neurologic examination may reveal subtle findings suggesting a neurologic syndrome of which dysphagia is a feature. Examination of cranial nerve function, soft palate elevation, tongue mobility, jaw movement, and voice changes with swallow can provide important clues to the cause of dysphagia. ^, A simple observation of ill-fitting dentures or dry mouth may elucidate an easily remedied cause of difficulty swallowing. However, in the ambulatory environment, physicians may be limited in the ability to observe a patient swallowing liquids and solids of various textures or to directly visualize the larynx and esophagus. Thus, while an important source of information to direct the workup, physical examination alone will likely not diagnose all underlying causes of dysphagia.

Clinical workup

When oropharyngeal dysphagia is suspected based upon history and physical examination, a speech and language pathologist may be an important health care team member to involve in the care of the patient. Patients often undergo bedside swallow evaluations which include a thorough history and physical examination as well as administration of various sizes, textures, and types of food. Such bedside swallow examinations can provide important information to help elucidate a diagnosis, though insufficient evidence exists to utilize bedside evaluations alone to determine optimal treatment. ^, Direct visualization of the vocal cords can also assist to diagnose oropharyngeal dysphagia, particularly if related to structural masses or lesions.

Esophagogastroduodenoscopy (EGD) may be the most effective tool for evaluating suspected esophageal swallowing disorders, especially in patients older than 40 years of age. It provides the best direct visualization of tissues, and it allows for direct mucosal biopsies. Biopsies should be taken to evaluate for malignant pathology and eosinophilic esophagitis. Endoscopy also allows for immediate, therapeutic intervention with dilation if indicated.

Videofluoroscopic swallowing studies may be beneficial if both oropharyngeal and esophageal causes are suspected. Such studies allow for evaluation of both structure and function of relevant anatomic structures and are the studies of choice when evaluation of the swallowing mechanism and peristalsis is sought. Modified barium swallow studies are preferred over endoscopy to detect subtle narrowing or webs. In addition to the videofluoroscopic studies, fiberoptic endoscopic evaluation of swallowing study may be recommend if there is concern for silent aspiration, as it is most useful to evaluate management of secretions.

Discussion

Dysphagia can result in significant morbidity and mortality related to aspiration pneumonia and malnutrition, particularly in elderly patients and those presenting with neurologic disease ^, Management is directed at identifying the underlying cause and providing treatment of that cause when possible. Behavioral, pharmacologic, and surgical interventions may be helpful depending on the underlying cause of the dysphagia symptoms. Behavioral interventions may include recommendations about posture when eating, food size, food texture, sequence of solid and liquids when eating, or exercises designed to improve voluntarily controlled muscles of swallowing. These all have been shown to have varying degrees of improvement of dysphagia and patient adherence depending on the underlying condition, patient population, and intervention recommended. Use of food thickeners, for example, has been shown to have decreasing patient adherence over time with inconsistent definitions of food consistency across geographic locations and institutions limiting generalizability of research findings. ^,

Summary

Dysphagia is a symptom of an underlying pathology rather than a disease unto itself. A thorough history and physical examination can provide rich detail that enhances a physician’s ability to accurately diagnose the cause of swallowing impairment. Additional workup with EGD provides confirmation of diagnoses and may allow for treatment. Ultimately, patients benefit from treatment directed at the underlying illness targeting either cure or palliation as appropriate.

Clinics care points

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  Dysphagia is a symptom of an underlying pathology, not a disease unto itself; thus, focusing on identifying and treating the underlying cause of dysphagia is the key.

  
  
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  Opioid-induced dysphagia is an emerging concern and should be considered a risk for long-term opiate therapy.

  
  
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  Dysphagia evaluations and dietary interventions lack standardization across institutions and geographic regions making ongoing research difficult.

  
  
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  COVID-19-associated dysphagia may predict a worse outcome of acute infection.

  
  
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  Dysphagia symptoms in children may be a first indicator of congenital neurologic disease.

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