Dysphagia
Encyclopedia
Dysphagia is the medical term for the symptom of difficulty in swallowing. Although classified under "symptoms and signs" in ICD-10
, the term is sometimes used as a condition in its own right. Sufferers are sometimes unaware of their dysphagia.
It is derived from the Greek dys meaning bad or disordered, and phago meaning "eat". It is a sensation that suggests difficulty in the passage of solids or liquids from the mouth
to the stomach
. Dysphagia is distinguished from other symptoms including odynophagia
, which is defined as painful swallowing, and globus
, which is the sensation of a lump in the throat. A psychogenic
dysphagia is known as phagophobia
.
It is also worthwhile to refer to the physiology of swallowing
in understanding dysphagia.
and subsequent aspiration pneumonia
secondary to food or liquids going the wrong way into the lungs. Some people present with "silent aspiration" and do not cough or show outward signs of aspiration. Undiagnosed dysphagia can also result in dehydration, malnutrition, and renal failure.
Some signs and symptoms of oropharyngeal dysphagia include difficulty controlling food in the mouth, inability to control food or saliva in the mouth, difficulty initiating a swallow, coughing, choking, frequent pneumonia
, unexplained weight loss, gurgly or wet voice after swallowing, nasal regurgitation, and dysphagia (patient complaint of swallowing difficulty). When asked where the food is getting stuck, patients will often point to the cervical (neck
) region as the site of the obstruction. The actual site of obstruction is always at or below the level at which the level of obstruction is perceived.
The most common symptom of esophageal dysphagia is the inability to swallow solid food, which the patient will describe as 'becoming stuck' or 'held up' before it either passes into the stomach or is regurgitated.
Pain on swallowing or odynophagia
is a distinctive symptom that can be highly indicative of carcinoma
, although it also has numerous other causes that are not related to cancer.
Achalasia
is a major exception to usual pattern of dysphagia in that swallowing of fluid tends to cause more difficulty than swallowing solids. In achalasia, there is idiopathic destruction of parasympathetic ganglia of the auerbach submucosal plexus of the entire esophagus, which results in functional narrowing of the lower esophagus
, and peristaltic failure throughout its length.
Causes of oropharyngeal dysphagia include:
Please refer to Etiology and Differential Diagnosis on the oropharyngeal dysphagia
page for a more extensive list.
Causes of esophageal dysphagia can be divided into mechanical and functional causes.
Esophageal dysphagia is almost always caused by disease in or adjacent to the esophagus but occasionally the lesion is in the pharynx or stomach. In many of the pathological conditions causing dysphagia, the lumen becomes progressively narrowed and indistensible. Initially only fibrous solids cause difficulty but later the problem can extend to all solids and later even to liquids. Patients with difficulty swallowing may benefit from thickened fluids
.
). This is a lateral video X-ray that provides objective information on bolus transport, safest consistency of bolus (honey, nectar, thin, pudding, puree, regular), and possible head positioning and/or maneuvers that may facilitate swallow function depending on each individual's anatomy and physiology. This study is performed by a Speech-Language Pathologist and a Radiologist.
Chest X-ray: to exclude bronchial carcinoma.
OGD: direct inspection and biopsy to look for any mass or ulceration.
Barium swallow and meal: look at mucosal lining and detect achalasia.
among older individuals, and the incidence
of dysphagia is higher in the elderly, in patients who have had stroke
s, and in patients who are admitted to acute care hospitals or chronic care
facilities.
Dysphagia is a symptom of many different causes, which can usually be elicited by a careful history
by the treating physician
. A formal oropharyngeal dysphagia evaluation is performed by a speech-language pathologist.
ICD-10
The International Statistical Classification of Diseases and Related Health Problems, 10th Revision is a medical classification list for the coding of diseases, signs and symptoms, abnormal findings, complaints, social circumstances, and external causes of injury or diseases, as maintained by the...
, the term is sometimes used as a condition in its own right. Sufferers are sometimes unaware of their dysphagia.
It is derived from the Greek dys meaning bad or disordered, and phago meaning "eat". It is a sensation that suggests difficulty in the passage of solids or liquids from the mouth
Mouth
The mouth is the first portion of the alimentary canal that receives food andsaliva. The oral mucosa is the mucous membrane epithelium lining the inside of the mouth....
to the stomach
Stomach
The stomach is a muscular, hollow, dilated part of the alimentary canal which functions as an important organ of the digestive tract in some animals, including vertebrates, echinoderms, insects , and molluscs. It is involved in the second phase of digestion, following mastication .The stomach is...
. Dysphagia is distinguished from other symptoms including odynophagia
Odynophagia
Odynophagia is painful swallowing, in the mouth or esophagus. It can occur with or without dysphagia, or difficult swallowing....
, which is defined as painful swallowing, and globus
Globus Pharyngis
Globus pharyngis is the persistent sensation of having phlegm, a pill or some other sort of obstruction in the throat when there is none...
, which is the sensation of a lump in the throat. A psychogenic
Psychogenic disease
A psychogenic disease is a set of symptoms or complaints whose origin likely lies within the complex interactions of the frontal lobes of the brain and the system in which the complaint manifests...
dysphagia is known as phagophobia
Phagophobia
Phagophobia is a psychogenic dysphagia, a fear of swallowing. It is expressed in various swallowing complaints without any apparent physical reason detectable by physical inspection and laboratory analyses...
.
It is also worthwhile to refer to the physiology of swallowing
Swallowing
Swallowing, known scientifically as deglutition, is the process in the human or animal body that makes something pass from the mouth, to the pharynx, and into the esophagus, while shutting the epiglottis. If this fails and the object goes through the trachea, then choking or pulmonary aspiration...
in understanding dysphagia.
Signs and symptoms
Some patients have limited awareness of their dysphagia, so lack of the symptom does not exclude an underlying disease. When dysphagia goes undiagnosed or untreated, patients are at a high risk of pulmonary aspirationPulmonary aspiration
Pulmonary aspiration is the entry of material from the oropharynx or gastrointestinal tract into the larynx and lower respiratory tract...
and subsequent aspiration pneumonia
Aspiration pneumonia
Aspiration pneumonia is bronchopneumonia that develops due to the entrance of foreign materials into the bronchial tree, usually oral or gastric contents...
secondary to food or liquids going the wrong way into the lungs. Some people present with "silent aspiration" and do not cough or show outward signs of aspiration. Undiagnosed dysphagia can also result in dehydration, malnutrition, and renal failure.
Some signs and symptoms of oropharyngeal dysphagia include difficulty controlling food in the mouth, inability to control food or saliva in the mouth, difficulty initiating a swallow, coughing, choking, frequent pneumonia
Pneumonia
Pneumonia is an inflammatory condition of the lung—especially affecting the microscopic air sacs —associated with fever, chest symptoms, and a lack of air space on a chest X-ray. Pneumonia is typically caused by an infection but there are a number of other causes...
, unexplained weight loss, gurgly or wet voice after swallowing, nasal regurgitation, and dysphagia (patient complaint of swallowing difficulty). When asked where the food is getting stuck, patients will often point to the cervical (neck
Neck
The neck is the part of the body, on many terrestrial or secondarily aquatic vertebrates, that distinguishes the head from the torso or trunk. The adjective signifying "of the neck" is cervical .-Boner anatomy: The cervical spine:The cervical portion of the human spine comprises seven boney...
) region as the site of the obstruction. The actual site of obstruction is always at or below the level at which the level of obstruction is perceived.
The most common symptom of esophageal dysphagia is the inability to swallow solid food, which the patient will describe as 'becoming stuck' or 'held up' before it either passes into the stomach or is regurgitated.
Pain on swallowing or odynophagia
Odynophagia
Odynophagia is painful swallowing, in the mouth or esophagus. It can occur with or without dysphagia, or difficult swallowing....
is a distinctive symptom that can be highly indicative of carcinoma
Carcinoma
Carcinoma is the medical term for the most common type of cancer occurring in humans. Put simply, a carcinoma is a cancer that begins in a tissue that lines the inner or outer surfaces of the body, and that generally arises from cells originating in the endodermal or ectodermal germ layer during...
, although it also has numerous other causes that are not related to cancer.
Achalasia
Achalasia
Achalasia , also known as esophageal achalasia, achalasia cardiae, cardiospasm, and esophageal aperistalsis, is an esophageal motility disorder involving the smooth muscle layer of the esophagus and the lower esophageal sphincter...
is a major exception to usual pattern of dysphagia in that swallowing of fluid tends to cause more difficulty than swallowing solids. In achalasia, there is idiopathic destruction of parasympathetic ganglia of the auerbach submucosal plexus of the entire esophagus, which results in functional narrowing of the lower esophagus
Esophagus
The esophagus is an organ in vertebrates which consists of a muscular tube through which food passes from the pharynx to the stomach. During swallowing, food passes from the mouth through the pharynx into the esophagus and travels via peristalsis to the stomach...
, and peristaltic failure throughout its length.
Differential diagnosis
Dysphagia is classified into two major types:- oropharyngeal dysphagiaOropharyngeal dysphagiaSwallowing disorders can occur in all age groups, resulting from congenital abnormalities, structural damage, and/or medical conditions. Swallowing problems are a common complaint among older individuals, and the incidence of dysphagia is higher in the elderly, in patients who have had strokes, and...
and - esophageal dysphagiaEsophageal dysphagiaEsophageal dysphagia arises from the body of the esophagus, lower esophageal sphincter, or cardia of the stomach, usually due to mechanical causes or motility problems.-Symptoms, signs, and evaluation:...
. - functional dysphagia is defined in some patients as having no organic cause for dysphagia that can be found.
Causes of oropharyngeal dysphagia include:
- Cerebrovascular Stroke
- Multiple SclerosisMultiple sclerosisMultiple sclerosis is an inflammatory disease in which the fatty myelin sheaths around the axons of the brain and spinal cord are damaged, leading to demyelination and scarring as well as a broad spectrum of signs and symptoms...
- Myasthenia gravisMyasthenia gravisMyasthenia gravis is an autoimmune neuromuscular disease leading to fluctuating muscle weakness and fatiguability...
- Parkinson's diseaseParkinson's diseaseParkinson's disease is a degenerative disorder of the central nervous system...
& Parkinsonism syndromes - Amyotrophic Lateral SclerosisAmyotrophic lateral sclerosisAmyotrophic lateral sclerosis , also referred to as Lou Gehrig's disease, is a form of motor neuron disease caused by the degeneration of upper and lower neurons, located in the ventral horn of the spinal cord and the cortical neurons that provide their efferent input...
- Bell's palsyBell's palsyBell's palsy is a form of facial paralysis resulting from a dysfunction of the cranial nerve VII that results in the inability to control facial muscles on the affected side. Several conditions can cause facial paralysis, e.g., brain tumor, stroke, and Lyme disease. However, if no specific cause...
- Bulbar Palsy & Pseudobulbar palsy
- XerostomiaXerostomiaXerostomia is the medical term for the subjective complaint of dry mouth due to a lack of saliva. Xerostomia is sometimes colloquially called pasties, cottonmouth, drooth, or doughmouth. Several diseases, treatments, and medications can cause xerostomia. It can also be exacerbated by smoking or...
- Radiation
- Neck malignancies
- Neurotoxins (e.g. snake venom)
- Eosinophilic esophagitisEosinophilic esophagitisEosinophilic esophagitis is an allergic inflammatory condition of the esophagus. Symptoms are swallowing difficulty, food impaction, and heartburn. The disease was first described in children but occurs in adults as well...
- PharyngitisPharyngitisPharyngitis is an inflammation of the throat or pharynx. In most cases it is quite painful, and is the most common cause of a sore throat.Like many types of inflammation, pharyngitis can be acute – characterized by a rapid onset and typically a relatively short course – or chronic....
, etc.
Please refer to Etiology and Differential Diagnosis on the oropharyngeal dysphagia
Oropharyngeal dysphagia
Swallowing disorders can occur in all age groups, resulting from congenital abnormalities, structural damage, and/or medical conditions. Swallowing problems are a common complaint among older individuals, and the incidence of dysphagia is higher in the elderly, in patients who have had strokes, and...
page for a more extensive list.
Causes of esophageal dysphagia can be divided into mechanical and functional causes.
- Functional causes include
- achalasiaAchalasiaAchalasia , also known as esophageal achalasia, achalasia cardiae, cardiospasm, and esophageal aperistalsis, is an esophageal motility disorder involving the smooth muscle layer of the esophagus and the lower esophageal sphincter...
, - myasthenia gravisMyasthenia gravisMyasthenia gravis is an autoimmune neuromuscular disease leading to fluctuating muscle weakness and fatiguability...
, and - bulbar or pseudobulbar palsyPseudobulbar palsyPseudobulbar palsy results from an upper motor neuron lesion to the corticobulbar pathways in the pyramidal tract. Patients have difficulty chewing, swallowing and demonstrate slurred speech...
.
- achalasia
- Mechanical causes include
- peptic esophagitisEsophagitisEsophagitis is inflammation of the esophagus. It may be acute or chronic. The acute esophagitis can be catarrhal or phlegmonous, whereas the chronic esophagitis may be hypertrophic or atrophic.-Infectious:...
, - carcinoma of the esophagus or gastric cardiaRoemheld syndromeRoemheld syndrome , also known as Roemheld-Techlenburg-Ceconi-Syndrome or gastric-cardia, is a complex of gastrocardiac symptoms first described by Ludwig Roemheld . It is a syndrome where maladies in the gastrointestinal tract or abdomen trigger/cause cardiac symptoms...
- external compression of the esophagus, such as obstruction by lymph node and left atrial dilatation in mitral stenosis.
- Candida esophagitis,
- pharyngeal pouchZenker's diverticulumIn anatomy, Zenker's diverticulum, also pharyngoesophageal diverticulum, also pharyngeal pouch, is a diverticulum of the mucosa of the pharynx, just above the cricopharyngeal muscle...
, - esophageal webEsophageal web-Presentation:Its main symptoms are pain and difficulty in swallowing .Esophageal webs are thin membranes of normal esophageal tissue consisting of mucosa and submucosa. They can be congenital or acquired. Congenital webs commonly appear in the middle and inferior third of the esophagus, and they...
, - esophageal leiomyoma,
- systemic sclerosis
- peptic esophagitis
Esophageal dysphagia is almost always caused by disease in or adjacent to the esophagus but occasionally the lesion is in the pharynx or stomach. In many of the pathological conditions causing dysphagia, the lumen becomes progressively narrowed and indistensible. Initially only fibrous solids cause difficulty but later the problem can extend to all solids and later even to liquids. Patients with difficulty swallowing may benefit from thickened fluids
Thickened fluids
Thickened fluids are often used for people with dysphagia, a disorder of swallowing function. The thicker consistency makes it less likely that an individual with dysphagia will aspirate while they are drinking...
.
Diagnostic approach
The gold-standard for diagnosing oropharyngeal dysphagia in countries of the Commonwealth are via a Modified Barium Swallow Study or Videofluoroscopic Swallow Study (FluoroscopyFluoroscopy
Fluoroscopy is an imaging technique commonly used by physicians to obtain real-time moving images of the internal structures of a patient through the use of a fluoroscope. In its simplest form, a fluoroscope consists of an X-ray source and fluorescent screen between which a patient is placed...
). This is a lateral video X-ray that provides objective information on bolus transport, safest consistency of bolus (honey, nectar, thin, pudding, puree, regular), and possible head positioning and/or maneuvers that may facilitate swallow function depending on each individual's anatomy and physiology. This study is performed by a Speech-Language Pathologist and a Radiologist.
Chest X-ray: to exclude bronchial carcinoma.
OGD: direct inspection and biopsy to look for any mass or ulceration.
Barium swallow and meal: look at mucosal lining and detect achalasia.
Epidemiology
Swallowing disorders can occur in all age groups, resulting from congenital abnormalities, structural damage, and/or medical conditions. Swallowing problems are a common complaintComplaint
In legal terminology, a complaint is a formal legal document that sets out the facts and legal reasons that the filing party or parties In legal terminology, a complaint is a formal legal document that sets out the facts and legal reasons (see: cause of action) that the filing party or parties In...
among older individuals, and the incidence
Incidence (epidemiology)
Incidence is a measure of the risk of developing some new condition within a specified period of time. Although sometimes loosely expressed simply as the number of new cases during some time period, it is better expressed as a proportion or a rate with a denominator.Incidence proportion is the...
of dysphagia is higher in the elderly, in patients who have had stroke
Stroke
A stroke, previously known medically as a cerebrovascular accident , is the rapidly developing loss of brain function due to disturbance in the blood supply to the brain. This can be due to ischemia caused by blockage , or a hemorrhage...
s, and in patients who are admitted to acute care hospitals or chronic care
Chronic care
Chronic care refers to medical care which addresses preexisting or long term illness, as opposed to acute care which is concerned with short term or severe illness of brief duration. Chronic medical conditions include, but are not limited to, asthma, emphysema, chronic bronchitis, congestive heart...
facilities.
Dysphagia is a symptom of many different causes, which can usually be elicited by a careful history
History
History is the discovery, collection, organization, and presentation of information about past events. History can also mean the period of time after writing was invented. Scholars who write about history are called historians...
by the treating physician
Physician
A physician is a health care provider who practices the profession of medicine, which is concerned with promoting, maintaining or restoring human health through the study, diagnosis, and treatment of disease, injury and other physical and mental impairments...
. A formal oropharyngeal dysphagia evaluation is performed by a speech-language pathologist.
External links
- Overview of Feeding Problems in Children
- Dysphagia Guideline at the World Gastroenterology Organisation (WGO)
- Speech Language Pathology Scope of Practice
- American Speech-Language-Hearing Association
- Swallowing and Feeding