Dysphagia
Dysphagia is difficulty in swallowing. Although classified under "symptoms and signs" in ICD-10, in some contexts it is classified as a condition in its own right.
It may be a sensation that suggests difficulty in the passage of solids or liquids from the mouth to the stomach, a lack of pharyngeal sensation or various other inadequacies of the swallowing mechanism. 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 person can have dysphagia without odynophagia, odynophagia without dysphagia or both together. A psychogenic dysphagia is known as phagophobia.
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 aspiration 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 kidney 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. When asked where the food is getting stuck, patients will often point to the cervical 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's plexus of the entire esophagus, which results in functional narrowing of the lower esophagus, and peristaltic failure throughout its length.
Complications
Complications of dysphagia may include aspiration, pneumonia, dehydration, and weight loss.Classification and cause
Dysphagia is classified into the following major types:- Oropharyngeal dysphagia
- Esophageal and obstructive dysphagia
- Neuromuscular symptom complexes
- Functional dysphagia is defined in some patients as having no organic cause for dysphagia that can be found.
| Location | Cause |
| Oral dysphagia |
|
| Pharyngeal dysphagia | |
| Esophageal dysphagia |
Diagnostic approach
Asking the patient about heartburn or acid regurgitation is essential to the diagnostic process because gastroesophageal reflux disease is the most common disease associated with dysphagia.- Esophagoscopy and laryngoscopy can give direct view of lumens.
- Esophageal motility study is useful in cases of esophageal achalasia and diffuse esophageal spasms.
- Exfoliative cytology can be performed on esophageal lavage obtained by esophagoscopy. It can detect malignant cells in early stage.
- Ultrasonography and CT scan are not very useful in finding cause of dysphagia; but can detect masses in mediastinum and aortic aneurysms.
- FEES, sometimes with sensory evaluation, is done usually by a Medical Speech Pathologist or Deglutologist. This procedure involves the patient eating different consistencies as above.
- Swallowing sounds and vibrations could be potentially used for dysphagia screening, but these approaches are in the early research stages.
Differential diagnosis
- Esophageal atresia
- Paterson-Kelly syndrome
- Zenker's diverticulum
- Esophageal varices
- Benign strictures
- Achalasia
- Esophageal diverticula
- Scleroderma
- Diffuse esophageal spasm
- Polymyositis
- Webs and rings
- Esophageal cancer
- Eosinophilic esophagitis
- Hiatus hernia, especially paraesophageal type
- Dysphagia lusoria
- Stroke
- Fahr's disease
- Wernicke encephalopathy
- Charcot–Marie–Tooth disease
- Parkinson's disease
- Multiple sclerosis
- Amyotrophic lateral sclerosis
Dysphagia may manifest as the result of autonomic nervous system pathologies including stroke and ALS, or due to rapid iatrogenic correction of an electrolyte imbalance.
Treatments
There are many ways to treat dysphagia, such as swallowing therapy, dietary changes, feeding tubes, certain medications, and surgery. Treatment for dysphagia is managed by a group of specialists known as a multidisciplinary team. Members of the multidisciplinary team include: a speech language pathologist specializing in swallowing disorders, primary physician, gastroenterologist, nursing staff, respiratory therapist, dietitian, occupational therapist, physical therapist, pharmacist, and radiologist. The role of the members of the multidisciplinary team will differ depending on the type of swallowing disorder present. For example, the swallowing therapist will be directly involved in the treatment of a patient with oropharyngeal dysphagia, while a gastroenterologist will be directly involved in the treatment of an esophageal disorder.Treatment strategies
The implementation of a treatment strategy should be based on a thorough evaluation by the multidisciplinary team. Treatment strategies will differ on a patient to patient basis and should be structured to meet the specific needs of each individual patient. Treatment strategies are chosen based on a number of different factors including diagnosis, prognosis, reaction to compensatory strategies, severity of dysphagia, cognitive status, respiratory function, caregiver support, and patient motivation and interest.Oral vs. nonoral feeding
Adequate nutrition and hydration must be preserved at all times during dysphagia treatment. The overall goal of dysphagia therapy is to maintain, or return the patient to, oral feeding. However, this must be done while ensuring adequate nutrition and hydration and a safe swallow. If oral feeding results in increased mealtimes and increased effort during the swallow, resulting in not enough food being ingested to maintain weight, a supplementary nonoral feeding method of nutrition may be needed. In addition, if the patient aspirates food or liquid into the lungs despite the use of compensatory strategies, and is therefore unsafe for oral feeding, nonoral feeding may be needed. Nonoral feeding includes receiving nutrition through a method that bypasses the oropharyngeal swallowing mechanism including a nasogastric tube, gastrostomy, or jejunostomy.Treatment procedures
Compensatory Treatment Procedures are designed to change the flow of the food/liquids and eliminate symptoms, but do not directly change the physiology of the swallow.- Postural Techniques
- Food Consistency Changes
- Modifying Volume and Speed of Food Presentation
- Technique to Improve Oral Sensory Awareness
- Intraoral Prosthetics
- Oral and Pharyngeal Range-of-Motion Exercises
- Resistance Exercises
- Bolus Control Exercises
- Swallowing Maneuvers
- * Supraglottic swallow
- * Super-supraglottic swallow
- * Effortful swallow
- * Mendelsohn maneuver
The most common interventions used for those with oropharyngeal dysphagia by speech language pathologists are texture modification of foods, thickening fluids and positioning changes during swallowing. The effectiveness of modifying food and fluid in preventing aspiration pneumonia has been questioned and these can be associated with poorer nutrition, hydration and quality of life. Also, there has been considerable variability in national approaches to describing different degrees of thickened fluids and food textures. However, in 2015, the International Dysphagia Diet Standardisation Initiative group produced an agreed IDDSI framework consisting of a continuum of 8 levels, where drinks are measured from Levels 0 – 4, while foods are measured from Levels 3 – 7. It is likely that this initiative, which has widespread support among dysphagia practitioners, will improve communication with carers and will lead to greater standardisation of modified diets
Epidemiology
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, and in patients who have had strokes.Dysphagia is estimated to affect about 3% of the general population.