Approach
A thorough history reveals the diagnosis in 80% to 85% of patients.[60] It is also useful in differentiating oropharyngeal dysphagia from esophageal dysphagia.
Patients with oral dysphagia most often have problems in initiating the voluntary swallow, with difficulty chewing and controlling food or fluid in their mouth, and transferring a bolus posteriorly.
Pharyngeal dysphagia leads to a range of symptoms including nasal regurgitation, the sensation of residue in the throat after swallowing, difficulty initiating the involuntary pharyngeal stage of swallowing, coughing, choking, or wet voice quality after swallowing.
Patients with esophageal dysphagia often report food sticking in their lower neck or mid-chest region. Patients may use different maneuvers to help the food passing the esophagus, or they may sip water to relieve the obstruction.
The key tests used for the evaluation of dysphagia are esophagogastroduodenoscopy (EGD), videofluoroscopic swallow study, barium radiography, fiberoptic nasopharyngeal laryngoscopy, or esophageal manometry. However, the choice of specific testing depends on the clinical presentation.
History
Age: dysphagia with food impaction in a young, adult, white male should raise suspicion for eosinophilic esophagitis.[43] In a patient over 40 years of age this is commonly due to Schatzki ring.[61] Concern for esophageal cancer must lead to investigation in patients older than 50 years of age.
Symptom onset: dysphagia primarily to solid foods is probably indicative of a structural lesion, whereas dysphagia to both solid and liquid from the onset of symptoms is most likely due to motility or neurologic disorders of the pharynx or esophagus.[62][63]
Duration and progression of symptoms: rapid progression of dysphagia, particularly with weight loss, is suggestive of malignancy, whereas patients with peptic strictures usually have longstanding history of dysphagia. Esophageal rings tend to cause intermittent solid food dysphagia; however, stricture and cancer cause progressive dysphagia.
Site of dysphagia: the site where the patient localizes dysphagia is of limited value; however, retrosternal or epigastric dysphagia usually corresponds with the location of the lesion, whereas suprasternal dysphagia is usually referred from the hypopharynx or lower in the esophagus.[62][64] In one study of 139 patients 21.6% exactly localized the level of obstruction, with over half being within 2 cm. 15% of patients with a distal esophageal etiology for their symptoms believed the source was their throat.[64]
Associated symptoms: difficulty initiating a swallow along with coughing, choking, hoarseness, gagging, nasal regurgitation, aspiration pneumonias, and weight loss are more suggestive of oropharyngeal dysphagia. Neurologic signs and symptoms may also present in patients with oropharyngeal dysphagia. Chest pain is often seen in idiopathic achalasia and diffuse esophageal spasm.[35] Previous history of heartburn is suggestive of peptic stricture.
Medication history: radiation- and/or chemotherapy-induced oral mucositis may cause dysphagia. A thorough medication history should be elicited.
Physical exam
There are no specific exam findings for dysphagia, but there may be findings suggestive of the cause: for example, slurred speech, hemiplegia in stroke, or scleroderma manifestations.
A thorough head and neck exam should be performed in all patients, including exam of the oral cavity. The neck should be palpated to evaluate for lymphadenopathy associated with infections or metastatic tumors, thyroid masses or thyromegaly, and hyolaryngeal elevation during swallowing. Neurologic exam including exam of the cranial nerves is also required. Cranial neuropathies (e.g., glossopharyngeal, vagus nerve) can cause severe dysphagia. See Assessment of cranial nerve mononeuropathy.
Fiberoptic nasopharyngoscopy/laryngoscopy should be performed as part of the initial exam. This is a routine office or bedside awake endoscopy to evaluate structure and some functional aspects of the oropharynx and larynx. Although cricopharyngeus and esophagus are not visualized, pooling of secretions can suggest dysfunction.[Figure caption and citation for the preceding image starts]: Larynx as a result of cricopharyngeal dysfunctionFrom the collection of Dr S. Charous [Citation ends].
Investigations
Patients presenting with associated neurologic symptoms or physical findings without other etiologies for dysphagia may require further evaluation. For patients with dysphagia in which an obvious etiology is not identified based on a history and physical exam (including nasopharyngoscopy/laryngoscopy), a modified barium swallow, flexible endoscopic evaluation of swallowing (FEES), esophagram or transnasal esophagoscopy (or a combination) will be the necessary initial tests required. Laboratory assessment is usually ordered in oropharyngeal dysphagia to assess the neuromuscular causes:[12][65]
Thyroid function test (thyromegaly)
Cerebrospinal fluid analysis (multiple sclerosis)
Botulinum toxin assay
Liver enzymes
Ceruloplasmin levels (Wilson disease)
24-hour urinary copper (Wilson disease)
Creatine phosphokinase (inflammatory myopathies)
Acetylcholine receptor antibodies (myasthenia gravis)
Anti-DNA and antinuclear antibodies (scleroderma).
Standardized bedside swallowing assessment
Remains an important early screening tool for dysphagia and aspiration risk, however, it is not reliable for detection of silent aspiration.
Variable sensitivity and specificity depending on the method used.
Trial swallow tests using different viscosities are more sensitive than using water. However, combining swallow tests with pulse oximetry (oxygen desaturation ≥2%) using subjective aspiration assessments has the highest sensitivity (63% to 98%).[66]
Usually nurse-led and can help identify which patients need referral for swallow assessment by a speech and swallowing therapist.
Specific investigational studies:
Transnasal esophagoscopy
Barium swallow (or esophagram)
Radiographic examination of the esophagus is indicated for the detection of structural abnormalities that EGD fails to identify; also useful in detecting pharyngeal motility disorders.
Double-contrast views are best for detecting mucosal lesions (e.g., tumors, esophagitis). Prone single-contrast views are best for detecting lower esophageal rings or strictures, as the distal esophagus is inadequately distended when the patient is upright.[1][69][70]
Videofluoroscopic swallow study (also known as modified barium swallow study)
A videofluoroscopic swallow study is performed by a radiologist and speech therapist on patients with oropharyngeal dysphagia.
It focuses on the oral cavity, pharynx, and cervical esophagus, recording to assess abnormalities of both the oral and pharyngeal phases of swallowing.
Reveals oropharyngeal dysfunction as well as the risk of aspiration during swallowing in such groups of patients.
Patients are given various consistencies of radio-opaque fluids to swallow; hence, the study is helpful in finding the optimal diet, by which the risk of aspiration is minimized.[1][71]
The assessment is also used to trial compensatory or rehabilitative maneuvers and strategies which may have therapeutic benefit for the patient or improve their swallowing safety and efficiency.
A standardized esophageal screening protocol can be performed by a speech therapist in addition to the standard videofluoroscopic swallow study.[72]
Flexible Endoscopic Evaluation of Swallowing (FEES)
Complementary to the videofluoroscopic swallow study in evaluating oropharyngeal swallowing and laryngeal pathology, including laryngeal penetration and aspiration.
An excellent addition to the bedside swallow in determining risk of aspiration, especially in the bedridden patient.
The sensory testing aspect of FEES with sensory testing utilizes an air pulse stimulus of mechanoreceptors within the larynx.[73]
Biphasic esophagram
Permits detection of both structural and functional abnormalities of the esophagus.
Double-contrast views are best for detecting mucosal lesions (e.g., tumors, esophagitis).
Prone single-contrast views with continuous drinking of low-density barium are best for detecting lower esophageal rings or strictures.[1]
Timed barium esophagogram
Simple, noninvasive, widely available barium technique for evaluating esophageal emptying in patients with achalasia.
The films are taken at 1, 2, and 5 minutes after the last swallow of barium; the purpose of 2-minute film is to assess interim emptying.[35][Figure caption and citation for the preceding image starts]: Idiopathic achalasia: barium esophagograms showing a dilated esophageal body and a tapering stricture in the distal esophagus ("bird's beak")From the collection of Dr S. Charous [Citation ends].
May be required following initial studies, as described above.
It reveals structural abnormalities as well as providing the opportunity to perform therapeutic intervention such as balloon dilatation in idiopathic achalasia and resection of webs.
Esophageal biopsies taken during endoscopy, if positive, may confirm conditions such as eosinophilic esophagitis, carcinoma, or gastroesophageal reflux disease as the cause of esophageal dysphagia.
Esophageal dilation at the time of endoscopy can be therapeutic for multiple disorders such as Schatzki rings, stricture, or stenoses.
Esophageal manometry
A diagnostic study that measures intraluminal pressure as well as coordination activity of the upper and lower esophagus sphincter and the esophageal body.
Solid-state, multichannel catheters allow increased accuracy in evaluating esophageal motility.
The diagnostic study of choice in patients with suspected motility abnormalities without evidence of mechanical obstruction.[74]
Also used for evaluation of dysphagia in patients treated for achalasia or who have undergone antireflux surgery.
Surface electromyography
This is a simple, radiation-free method for screening and preliminary differentiation between oral and pharyngeal dysphagia.
The needle electrodes are used within swallowing muscles in the neck to record the timing of muscle contraction patterns and amplitude of electronic activity of the muscles during swallowing.
Dysphagia following oral cavity conditions prolongs drinking time and decreases the activity of the masseter, but it does not affect pharynx and submental muscles.
Not appropriate for the diagnosis of suspected neurogenic dysphagia.
Muscle tension dysphagia is a diagnosis of exclusion made with speech therapists. It cannot yet be diagnosed with conventional testing.[20] The minimum assessment should include a comprehensive clinical swallow evaluation (with thorough history and head and neck exam), laryngoscopic evaluation of the larynx and pharynx, instrumental evaluation of oropharyngeal swallowing, and esophageal evaluation.[21]
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