Dysphagia

Dysphagia is a Greek word that means disordered eating.

Typically, dysphagia refers to difficulty in eating as a result of disruption in the
swallowing process.
Dysphagia can be a serious threat to one's health because of the risk of aspiration
pneumonia, malnutrition, dehydration, weight loss, and airway obstruction.
A number of aetiologies have been attributed to dysphagia in populations with
neurologic and nonneurologic conditions.
Disorders leading to dysphagia may affect
Oral, pharyngeal, or oesophageal phases of swallowing.
A thorough history and careful physical eamination are important in the diagnosis
and treatment of dysphagia.
The bedside physical should include eamination of the neck, mouth, oropharyn,
laryn, chest and abdomen. A neurologic eamination also should be performed.
!everal clinical bedside swallowing assessments have been suggested, but
videofluoroscopic swallowing studies have been accepted as the standard for
detecting and evaluating swallowing abnormalities. This method not only estimates
risks of aspiration and respiratory complications, but it also helps determine diet
and compensatory strategies.
"irst, determine how the swallowing process has been impaired and which stage is
involved through careful clinical assessment or bedside evaluation.
Causes of Dysphagia
Oropharyngeal
Anatomical
Post-cricoid cartilage web
Cervical osteophyte
Hypopharyngeal diverticulum
Head or neck tumor
Neurological
Cerebrovascular accident
Poliomyelitis
Amyotrophic lateral sclerosis
Parkinsons disease
Cerebral tumor
!uscular
!yotonic dystrophy
Oculopharyngeal muscular dystrophy
!yasthenia gravis
!etabolic myopathy "eg# thyroto$icosis%
Oesophogeal
Neuromuscular
Achalasia
Diffuse esophageal spasm
&cleroderma
'ower esophageal sphincter hypertension
(ntrinsic obstructive lesion
&tricture
)umor
'ower oesophageal "ie# &chat*kis% ring
+oreign body
,$trinsic obstructive lesion
,nlarged left atrium
,nlarged aorta
Aberrant subclavius
!ediastinal mass "eg# thyroid# lymph nodes%
History
#atients who have dysphagia may present with a variety of signs and symptoms.
They usually report coughing or choking or the abnormal sensation of food sticking
in the back of the throat or upper chest when they are trying to swallow$ however,
some of these presentations can be %uite subtle or even absent &eg, in those with
silent aspiration'.
Signs and symptoms of dysphagia
Oral or pharyngeal dysphagia
(oughing or choking with swallowing
Difficulty initiating swallowing
"ood sticking in the throat
!ialorrhea
)neplained weight loss
(hange in dietary habits
*ecurrent pneumonia
(hange in voice or speech &wet voice'
+asal regurgitation
,sophageal dysphagia
!ensation of food sticking in the chest or throat
Oral or pharyngeal regurgitation
(hange in dietary habits
*ecurrent pneumonia
A careful history enables the physician to identify the numerous causes of dysphagia.
The following list includes the causes of dysphagia most fre%uently seen in rehabilitation
medicine.
Frequent neurological causes of dysphagia
!troke, traumatic brain in-ury &T./'
0otor neuron disease &eg, amyotrophic lateral sclerosis 1A2!3'
#arkinson disease and other degenerative disorders &apraic patient'
#oliomyelitis
0ultiple sclerosis
0yasthenia gravis
0yopathy &dermatomyositis, myotonic dystrophy'
Oesophageal dysphagia
!cleroderma
Achalasia and other spastic motor disorders, such as diffuse esophageal spasm,
hypertensive lower oesophageal sphincter, nutcracker esophagus
Obstructive lesions4 Tumors, strictures, lower esophageal rings &!chat5ki ring',
oesophageal webs, foreign bodies, vascular compression, neck and mediastinal
masses.
Others
2aryngectomy
#haryngectomy, esophagectomy reconstructed by gastric pull6up
7ead and neck surgery &oral cavity cancer'
(ervical brace, cervical spondylosis
8entilator6dependent patient
,lderly patients
(erebral palsy and other movement disorders &mental retardation, developmental
delay'
DIFFERENTIAS
Oropharyngeal dysphagia
!ere"ro#ascular accident
$ar%inson disease
&rain stem tumors
Degenerati#e diseases' such as AS' multiple sclerosis ()S*' Huntington disease
$oliomyelitis' syphilis
$eripheral neuropathy
)yasthenia gra#is
$olymyositis' dermatomyositis' muscular dystrophy (myotonic dystrophy'
oculopharyngeal dystrophy*
!ricopharyngeal achalasia
"
O"structi#e lesions' such as tumors' inflammatory masses' +en%er di#erticulum'
esophageal ,e"s' e-trinsic structural lesions' anterior mediastinal masses' and
cer#ical spondylosis.
Disorders in the cer#ical esophageal aspect of deglutition (esophageal/
pharyngeal "ac%flo,' tracheoesophageal 0T/E1 fistula' +en%er di#erticulum'
reflu-*
History
!pecific %uestions about onset, duration, and severity of dysphagia and a
variety of associated symptoms may help narrow the differential diagnoses to
a specific diagnosis or to an anatomic or pathophysiologic6related diagnosis.
*eview the patient's general health information, including long6term illnesses
and current prescription medications.
0ucosal in-ury may be caused by potassium chloride tablets, nonsteroidal
anti6inflammatory drugs &+!A/Ds', and antibiotics &eg, doycycline,
tetracycline, clindamycin, trimethoprim6sulfamethoa5ole'.
9erostomia may be caused by anticholinergics, alpha6adrenergic blockers,
angiotensin6converting en5yme &A(,' inhibitors, and antihistamines. .
The history also should be directed at eliciting information about symptoms
related to gastroesophageal reflu disease including heartburn, belching, sour
regurgitation, and water brash.
$hysical e-amination
During the physical eamination, look for oral6motor and laryngeal mechanisms.
(ranial nerve testing of 8, 8//, through 9// is essential for determining physical
evidence of oropharyngeal dysphagia.
Direct observation of lip closure, -aw closure, chewing and mastication, tongue
mobility and strength, palatal and laryngeal elevation, salivation, and oral
sensitivity is necessary.
(heck the patient's level of alertness and cognitive status because they can
impact the safety of swallowing and ability to learn compensatory measures.
Dysphonia and dysarthria are signs of motor dysfunction of the structures
involved in oral and pharyngeal swallowing.
/nspect the oral cavity and pharyn for mucosal integrity and dentition.
,amine the soft palate for position and symmetry during phonation and at rest.
,valuate pharyngeal elevation by placing : fingers on the laryn and assessing
movement during a volitional swallow. This techni%ue helps to identify the
presence or absence of key laryngeal protective mechanisms.
The gag refle is elicited by stroking the pharyngeal mucosa with a tongue
depressor. Testing for the gag refle is helpful, but absence of a gag refle does
not necessarily indicate that a patient is unable to swallow safely. /ndeed, many
persons with no gag refle have normal swallowing, and some patients with
dysphagia have a normal gag refle. #ulling of the palate to one side during gag
refle testing indicates weakness of the muscles of the contralateral palate and
suggests the presence of unilateral bulbar pathology.
(ervical auscultation becomes part of the clinical evaluation of dysphagic
patients. Assess sound strength and clarity, timing of apneic episode, and speed
of swallowing.
Assessing respiratory function also is essential. /f there is inade%uate respiratory
force of a cough or clearing the throat, risk of aspiration is increased.
The final step in physical eamination is direct observation of the act of
swallowing. At a minimum, watch the patient while he or she drinks a few ounces
of tap water. /f possible, assess the patient's eating of various food tetures.
!ialorrhea, delayed swallow initiation, coughing, a wet or hoarse voice %uality
may indicate a problem. After the swallow, observe the patient for ; minute or
more to see if delayed cough response is present.
A ;<< ml water swallow test, which identified =<> of stroke patients
subse%uently found to be aspirating based on videofluoroscopic studies.


In#estigations
/nitial investigations should be limited to specific studies based on the differential
diagnosis.
(hest radiography is a simple assessment of pneumonia.
A complete blood count screens for infectious or inflammatory conditions.
+utritional assessment 6 !erum protein and albumin levels
Thyroid function studies may detect dysphagia associated with causes related to
hypothyroidism or hyperthyroidism.
Special studies
8ideofluorographic swallowing study
The terms videofluorographic swallowing study &8"!!' and modified barium
swallow &0.!' often are used interchangeably.
0ost clinical researchers, however, agree that videofluoroscopy is the standard
for detecting patients who have potential to develop pneumonia and for
diagnosing aspiration and swallowing problems from potential discrepancies
between findings of bedside tests and videofluoroscopy.
8ideofluoroscopy is designed to study the anatomy and physiology of the oral,
pharyngeal, and esophageal stages of deglutition and to define treatment
strategies to improve the dysphagic patient's swallowing safety or efficiency.
/f aspiration occurs or food is retained after swallowing, the net step is to
evaluate the %uantity of retained food, the mechanism of retention or aspiration,
and the patient's response.
/n general, various food consistencies, volumes, postural techni%ues, and
swallowing maneuvers to enhance swallowing efficiency or safety are tested in
the process of the study, and clinical decisions &eg, changing food groups, finding
appropriate swallowing postures or maneuvers' are made. This type of study is
epensive because of the special epertise, e%uipment, and facilities re%uired.
"iberoptic endoscopic eamination of swallowing A transnasal laryngoscope is
used to assess pharyngeal swallowing. The procedure is a sensitive techni%ue
for detecting premature bolus loss, laryngeal penetration, tracheal aspiration, and
pharyngeal residue. .ecause pharyngeal contraction obstructs the lumen, the
fiberoptic endoscopic eamination of swallowing &",,!' does not show motion of
essential food pathway structures or the food bolus during the swallow.
!wallowing is evaluated directly, using measured %uantities of food colored with
blue li%uid dye. An ",,! may be helpful when a 8"!! is not feasible &eg, in
critically ill patients unable to tolerate any risk of aspiration, patients in intensive
care units who cannot be transferred to the fluoroscopy room, patients who
re%uire prompt evaluation'.
!cintigraphy. !cintigraphy has very limited value in evaluation of pharyngeal
swallowing disorders. This test is useful in %uantitative and %ualitative evaluation
of subglottic aspiration, esophageal motility disorders, and gastroesophageal
reflu.
Oropharyngeal transit time can be measured through time6activity curves
constructed from a specific region of interest &*O/' of the mouth, pharyn, and
esophagus. #eaks and nadirs of the first derivative curve correspond to peak
emptying or filling rates of the respective regions.
*efle cough test. The test uses a :<> solution of 26tartaric acid dissolved in :
m2 of sterile normal saline. The solution is inhaled by the patient through a nasal
nebuli5er, which stimulates cough receptors in the vestibule of the laryn and
initiates the laryngeal cough refle.
The laryngeal cough refle protects the laryngeal aditus from significant
aspiration and reduces risk of respiratory complications &eg, pneumonia'.
/mpaired laryngeal cough refle may permit laryngeal penetration and increase
risk of aspiration pneumonia.
An acute cerebrovascular accident often appears to affect the protective cough
refle. Addington et al used the refle cough test to identify ;<<> of stroke
patients subse%uently found to be free of pneumonia &specificity of ;<<>'.
!wallowing electromyography. 0echanical upward6downward movement of the
laryn is detected using a pie5oelectric sensor while submental integrated
electromyography &,0G' activity is recorded during dry and wet swallowing.
,0G activity of the cricopharyngeal muscle of the upper esophageal sphincter
also can be recorded.
/n the group of patients with muscular disorders, laryngeal elevators are involved
while the cricopharyngeal sphincter is intact. /n the group of patients with clinical
signs of corticobulbar fiber involvement &eg, patients with A2! and pseudobulbar
palsy', dyscoordination between paretic laryngeal elevators and the hyperrefleic
cricopharyngeal sphincter is present.
,0G can be used for both muscle selection and performing in-ections of
botulinum toin in patients with dysphagia caused by cricopharyngeus muscle
spasm or hypertonicity.
2aryngeal electromyography. 2aryngeal ,0G can help the clinician diagnose
oropharyngeal dysphagia of peripheral nerve origin &ie, recurrent laryngeal or
superior laryngeal nerve in-ury'.
0anometry. 0anometry assesses motor function of the esophagus. A catheter
with multiple electronic pressure probes is passed into the stomach, measuring
esophageal contractions and defining upper and lower esophageal responses to
swallowing. 0anometry detects definitive abnormalities in only :?> of patients
with nonobstructive lesions, so its clinical use in oropharyngeal dysphagia is very
limited.
Oesophageal p7 meter. Oesophageal p7 monitoring remains the criterion
standard for diagnosing patients with suspected reflu disease. A nasogastric
probe is inserted into the patient's esophagus and records p7 levels. These
levels are compared with the patient's record of symptoms over a :@6hour period
to determine whether acid reflu contributes to hisAher symptoms.
,ndoscopy. .Gastroesophageal endoscopy provides the best assessment of the
esophageal mucosa. ,ndoscopy has the added benefit of detecting infection,
erosions, neoplasms and providing biopsy capability.
)ltrasonography. )ltrasonography only evaluates the region of the tongue
posterior to the hyoid level and may aid in evaluation of submucosal and
etramural lesions of the esophagus.
(omputed tomography and magnetic resonance imaging. (omputed tomography
&(T' scan and magnetic resonance imaging &0*/' provide ecellent definition of
structural abnormalities, particularly when used to evaluate patients with
suspected central nervous system &(+!' causes of dysphagia.