Dysphagia

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Dysphagia is a nonspecific symptom that refers to difficulty in swallowing. When present, it should be considered a red flag feature for a potentially serious underlying condition and should be evaluated thoroughly. Oropharyngeal dysphagia refers to difficulty in initiating the swallowing process and is typically associated with coughing or choking. Esophageal dysphagia refers to the impaired passage of a food bolus from the esophagus to the stomach. Dysphagia predominantly with solid foods is usually caused by a mechanical obstruction (e.g., esophageal stricture, oropharyngeal abscess). Dysphagia with liquids and solid food typically indicates a neuromuscular disorder (e.g., esophageal motility disorders, neurodegenerative conditions). Acute dysphagia is commonly caused by food bolus impaction or stroke. Depending on the suspected etiology, the diagnostic workup can include an endoscopic evaluation of the nasopharynx and/or esophagus, a barium swallow, and high-resolution manometry. Neuroimaging and laboratory studies should also be considered as needed. Supportive therapy (e.g., swallowing rehabilitation, measures to minimize aspiration risk) is the mainstay of management, especially in patients with oropharyngeal dysphagia; etiology-specific management (e.g., esophageal dilation, antimicrobials for infectious esophagitis) may be feasible in some conditions. In elderly patients with dysphagia, goals of care should be discussed before considering interventional management.

• Dysphagia: any difficulty swallowing, which can be divided into the following subtypes
  • Oropharyngeal dysphagia: difficulty initiating the swallowing process
  • Esophageal dysphagia: the impaired passage of solid food and liquid through the esophagus towards the stomach
  • Motility-related dysphagia: dysphagia due to a neurological or muscular defect
  • Structural dysphagia: dysphagia due to a mechanical or anatomical obstruction
• Aphagia: the inability to swallow
• Presbyphagia: the characteristic changes and mild decline in swallowing function seen in older adults; typically asymptomatic [2]
• Odynophagia: a painful sensation triggered by swallowing

References: [3][4]

The following table provides an overview of the etiologies of nonacute dysphagia. Food bolus impaction is a common cause of acute dysphagia but is often triggered by an underlying esophageal etiology.

Dysphagia should be distinguished from xerostomia, globus pharyngeus, and presbyphagia. [8]

Do not assume a diagnosis of presbyphagia in elderly patients with difficulty swallowing. Dysphagia is an alarm symptom and should be investigated thoroughly to determine its underlying etiology and start appropriate treatment.

A detailed clinical history and physical examination in patients with dysphagia can help categorize symptoms and select the best initial diagnostic test.

Clinical evaluation [6][7][9]

• Characterize dysphagia.
  • Distinguish between esophageal and oropharyngeal dysphagia.
  • Distinguish between motility-related dysphagia and structural dysphagia
• Observe a swallow.
  • Coughing on swallowing indicates a high aspiration risk.
  • Nasopharyngeal regurgitation is suggestive of oropharyngeal dysphagia.
• Identify red flags for dysphagia.
• Perform a complete physical examination, with particular importance to
  • Neurological evaluation (including cranial nerve examination)
    • Absent gag reflex and facial asymmetry indicate cranial nerve palsies (e.g., due to stroke).
    • Ptosis, diplopia, deviation of the tongue should increase the suspicion for ALS.
  • Head and neck examination: for lymphadenopathy, thyromegaly
• Identify the likely etiology based on history and examination.
• Select the appropriate initial diagnostic test based on the likely site and location of dysphagia.

Oropharyngeal dysphagia should be identified promptly, as it increases the risk of aspiration. Oropharyngeal dysphagia and esophageal dysphagia may occur simultaneously. [7]

Acute dysphagia can be caused by food impaction or a stroke and requires prompt evaluation.

Characterization of dysphagia

Dysphagia predominantly with solid food should raise suspicion for an underlying structural disorder, including malignancy. Dysphagia predominantly with liquids is suggestive of an esophageal motility disorder. [3]

Red flags for dysphagia [3][7][9]

Dysphagia is an alarm feature itself and should be evaluated thoroughly. However, the following features should raise suspicion for malignancy as the underlying etiology.

• > 50 years of age at onset
• Clinically significant involuntary weight loss
• Symptom progression over a short period of time (e.g., < 4 months) [3]
• Evidence of GI bleeding
• Recurrent vomiting
• History of cancer

Elderly patients with recent pneumonia should be screened for dysphagia. [9]

Initial diagnostics [6][9]

See dedicated sections below for details.

• Oropharyngeal dysphagia: modified barium swallow
• Esophageal dysphagia
  • Patients ≥ 50 years of age, and patients < 50 years of age with any red flag for dysphagia: EGD
  • Patients < 50 years of age with no red flags for dysphagia: Consider a 4-week trial of acid suppression therapy before EGD.
• Consider neuroimaging and supplementary laboratory studies as needed, guided by the pretest probability of the underlying etiology.

Etiology

Oropharyngeal dysphagia is commonly caused by neuromuscular and systemic conditions.

Clinical swallow evaluation [17]

• Description: a clinical assessment of the anatomy, function, and reflexes of the mouth, tongue, and mandible along with a trial of food and liquid
• Indications: neurological conditions with associated dysphagia (e.g., ALS, Parkinson disease, acute stroke, Guillain-Barré syndrome)
• Goal: to guide decisions on dietary modification (e.g., pureed food, thickened liquids, nasogastric tube, percutaneous endoscopic gastrostomy) and further testing for oropharyngeal dysphagia
• Interpretation
  • Positive test: patient is unable to drink continuously, coughs up after the swallowing attempt, and/or has a wet, gargling, or hoarse voice
  • A confirmatory test (e.g., modified barium swallow) should be performed if clinical swallow evaluation is positive.

Diagnostics [3][7][9]

A multidisciplinary evaluation involving speech-language pathologists, neurologists, and otolaryngologists is recommended for a comprehensive evaluation.

• Modified barium swallow [6][10]
  • Preferred test for suspected oropharyngeal dysphagia [9]
  • Provides functional evaluation of swallowing and can be used to assess the risk of aspiration
• Endoscopic evaluation of the nasopharynx
  • Structural assessment: nasopharyngeal laryngoscopy
  • Functional assessment: fiberoptic endoscopic evaluation of swallowing (FEES)
    • Supplementary modality to modified barium swallow [9]
    • Direct assessment of the oropharyngeal phase of swallowing
    • Superior evaluation of structural dysphagia compared with barium swallow [3]
• Pharyngoesophageal high-resolution manometry : Can help identify patients who are likely to benefit from a myotomy [3]

Consider EGD to rule out an esophageal etiology for dysphagia in patients in whom an oropharyngeal etiology has been ruled out. [9]

Treatment [9][18][19]

Management is primarily supportive and should be tailored to each patient, focus on symptom control, minimize aspiration risk, and ensure adequate nutrition. Goals of care should be discussed before considering interventional therapy (including enteral feeding) for dysphagia in elderly patients.

• Swallowing rehabilitation: compensatory strategies aimed to direct the bolus towards the esophagus and minimize aspiration risk [9][18]
  • Postural techniques (e.g., eating upright, chin tuck , head turn )
  • Exercises and retraining of the tongue, jaw, and neck
• Optimization of nutrition
  • Diet modification as needed (e.g., thickening of liquids, pureeing solid food, small morsels).
  • Consider temporary nasogastric tube feeding (e.g., in patients with acute stroke). [20]
  • See “Specialized nutrition support” for details.
• Management of the underlying cause, e.g.:
  • Optimize pharmacotherapy of underlying neurodegenerative conditions (e.g., Parkinson disease).
  • Surgical intervention for Zenker diverticulum
• Aspiration prevention surgery [21]
  • Consider in patients at a high risk of aspiration despite other supportive measures.
  • Examples include percutaneous endoscopic gastrostomy, tracheotomy, and endolaryngeal stenting

Etiology

Opioid use can cause esophageal hypomotility and thereby dysphagia (opioid-induced esophageal dysfunction). [9]

Diagnostics [6][7][9]

Consult a gastroenterologist early for a comprehensive evaluation. [3]

• Esophagogastroduodenoscopy (EGD): preferred initial test for most patients [7][9]
  • Allows for direct visualization of mucosal lesions and structural abnormalities
  • Biopsies can be taken during the procedure.
  • Simultaneous therapeutic intervention (e.g., dilation) or endoscopic ultrasound is possible
• Esophageal barium swallow [3][7]
  • Consider as an initial test in the following cases:
    • High likelihood of esophageal stricture (e.g., history of esophageal caustic injury, surgery, or radiation) [3][32]
    • If EGD is not immediately available
    • Suspected achalasia if manometry is not immediately available
  • Second-line test (adjunct) if initial EGD is normal [9]
• High-resolution esophageal manometry
  • Gold standard for diagnosing esophageal motility disorders
  • Suspected esophageal motility disorder in individuals with a normal EGD and barium swallow. [3][7][33]
• Thoracic imaging: if extrinsic esophageal compression is suspected (e.g., due to goiter, thoracic aortic aneurysm, mediastinal mass)

Treatment [3][9][19]

Depends on the underlying cause. See “Overview of esophageal dysphagia” and dedicated articles for details; examples include:

• Pharmacotherapy: e.g.,
  • PPI for reflux esophagitis
  • Smooth muscle relaxants for esophageal motility disorders
  • Swallowed aerosolized steroids for eosinophilic esophagitis
• Endoscopic intervention
  • Botox injections: to control hypertonia
  • Dilation: for etiologies that cause significant narrowing (e.g., achalasia, esophageal rings or webs, strictures)
  • Diverticulotomy: for esophageal diverticula
• Surgery
  • Myotomy: Consider for refractory esophageal hypermotility disorders.
  • Curative or palliative tumor resection (e.g., in pharyngeal cancer or esophageal cancer)
  • Surgical resection of refractory rings and/or strictures
• Supportive therapy: Optimize nutrition of patients with dysphagia refractory to therapy.
  • Diet modification as needed (e.g., pureeing solid food, taking small bites, chewing carefully).
  • Consider temporary nasogastric tube feeding (e.g., in patients with acute stroke). [20]
  • See “Specialized nutrition support” for details.

In older patients, discuss goals of care before considering interventional therapy. [9]

In patients < 50 years of age with characteristic features of GERD and no alarm features for malignancy, a trial of empiric treatment with PPIs for 4 weeks may be considered. Persistent dysphagia despite empiric treatment necessitates evaluation by EGD. [3][9]

In all patients with unexplained solid food dysphagia, biopsies should be obtained from normal-appearing mucosa of the mid-third and distal esophagus to evaluate for eosinophilic esophagitis. [9]

• Esophageal bolus impaction: usually manifests as acute dysphagia
• Aspiration pneumonia: common complication of oropharyngeal dysphagia [7]
• Malnutrition (see “Specialized nutrition support” for management)

We list the most important complications. The selection is not exhaustive.