Dysphagia refers to the medical condition of difficulty in swallowing, while odynophagia describes pain associated with swallowing. Odynophagia is often found in ulcerative and inflammatory conditions of the oral cavity, oropharynx, and oesophagus.
Aetiology
The causes of dysphagia are classified as either pre-oesophageal (disturbances in the oral or pharyngeal stages of swallowing) or oesophageal (issues within the oesophageal phase). This classification aids clinicians by allowing pre-oesophageal causes to be identified through physical examination, whereas oesophageal causes usually require further diagnostic investigation.
Pre-Oesophageal Causes
- Oral Phase: During this stage, food is masticated, mixed with saliva, formed into a bolus by tongue movements, and pushed into the pharynx. Disruptions in these events may cause dysphagia:
- Mastication Issues: Conditions like trismus, jaw fractures, jaw tumours, or temporomandibular joint disorders.
- Saliva Production Issues: Conditions like xerostomia (dry mouth) post-radiotherapy or Mikulicz’s disease.
- Tongue Mobility: Impaired due to paralysis, ulcers, tongue tumours, abscesses, or total glossectomy.
- Palate Defects: Cleft palate or oronasal fistulas may impede swallowing.
- Lesions in the Buccal Cavity and Floor of Mouth: Including stomatitis, ulcerations, and Ludwig’s angina.
- Pharyngeal Phase: For normal swallowing, food must enter the pharynx and move smoothly towards the oesophagus. The nasopharynx, larynx, and oral cavity should be closed to prevent misdirection.
- Obstructive Lesions: These include tumours in the tonsils, soft palate, pharynx, base of the tongue, supraglottic larynx, and hypertrophic tonsils.
- Inflammatory Conditions: Acute tonsillitis, peritonsillar abscesses, retro/parapharyngeal abscesses, epiglottitis, and laryngeal oedema.
- Spasmodic Conditions: Disorders such as tetanus or rabies.
- Paralytic Conditions: Paralysis of the soft palate from conditions like diphtheria, bulbar palsy, or cerebrovascular accidents, causing nasal regurgitation. Paralysis in the larynx or vagus nerve lesions may lead to aspiration of food into the larynx.
Oesophageal Causes
Oesophageal causes of dysphagia can originate from obstructions within the lumen, conditions affecting the wall of the oesophagus, or extrinsic structures compressing the oesophagus.
- Lumen: Obstructions such as oesophageal atresia, foreign bodies, strictures, or tumours (benign or malignant).
- Wall: Conditions include:
- Inflammatory Disorders: Acute or chronic oesophagitis.
- Motility Disorders:
- Hypomotility: Conditions like achalasia, scleroderma, and amyotrophic lateral sclerosis.
- Hypermotility: Disorders such as cricopharyngeal and diffuse oesophageal spasms.
- External Compression: Structures pressing on the oesophagus may obstruct the lumen, including:
- Hypopharyngeal Diverticulum
- Hiatus Hernia
- Cervical Osteophytes
- Thyroid Lesions: Enlargement, tumours, or Hashimoto’s thyroiditis.
- Mediastinal Lesions: Tumors, lymphadenopathy, aortic aneurysms, or cardiac enlargement.
- Vascular Anomalies: Such as vascular rings causing dysphagia lusoria.
Investigations for Dysphagia
1. History
A thorough patient history is essential in diagnosing dysphagia. Patients commonly report difficulty in swallowing solids or liquids and may feel food “sticking.”
- High dysphagia (oropharyngeal) often involves difficulty initiating a swallow, sometimes leading to aspiration or nasopharyngeal regurgitation.
- Low dysphagia (oesophageal) is characterized by a sensation of food sticking in the lower neck, chest, or epigastrium, although this symptom’s location is not highly specific.
A detailed history examines the onset, duration, and severity of symptoms, noting if they:
- Develop suddenly (often from foreign bodies, impaction of food on a pre-existing stricture, malignancy or neurological causes),
- Progress gradually (suggesting malignancy), or
- Are intermittent (suggesting spasms or spasmodic episodes over an organic lesion).
Symptom patterns include:
- Difficulties with liquids (paralytic conditions),
- Difficulty with solids progressing to liquids (malignancy or stricture),
- Sensitivity to acidic foods or fruit juices (indicating possible ulcerative lesions).
2. Clinical Examination.
A clinical examination involves assessing the oral cavity, oropharynx, larynx, hypopharynx, neck, chest, and nervous system (including cranial nerves). This can help identify structural issues or systemic complications related to dysphagia, such as weight loss, malnutrition, and aspiration-induced lung problems.
Key assessments include:
- Oral cavity and oropharynx: Check for lesions, xerostomia, tongue movement, and tongue wasting. Dental health and the fit of dentures are also evaluated, as they impact oral competence.
- Nasendoscopy: This procedure examines the pharynx and larynx, assesses vocal cord mobility, and detects UADT lesions or saliva pooling in the piriform fossa or postcricoid area.
- Neck examination: This includes checking for lymphadenopathy, thyroid issues, and signs of laryngeal cartilage integrity.
- Neurological examination: General physical and neurological assessments can reveal malnutrition, weight loss, chest disease, tremor, fasciculation, and other related signs.
3. Blood Examination
Laboratory tests aid in evaluating dysphagia, with hemograms assessing anaemia, a common sign of Plummer–Vinson syndrome or nutritional deficiency. Liver and renal function tests, serum calcium levels, and thyroid function tests can assess underlying conditions, particularly in cases of suspected metastasis or thyroid-related dysphagia. Elevated creatine kinase may indicate myopathies.
4. Bedside Assessments
Bedside swallowing tests, though limited in standardization and reliability, can screen for aspiration risk in neurological dysphagia.
- Water Swallow Test (WST), where a patient drinks 30 mL of water and is monitored for abnormal voluntary cough, post-swallow cough or throat clear.
- Evans blue dye test, used for tracheostomized patients, assesses aspiration risk by checking for blue dye from the tracheostomy site after a swallow.
5. Radiography
- X-ray Chest: Excludes cardiovascular, pulmonary, and mediastinal diseases.
- Lateral Neck X-ray: Identifies cervical osteophytes or soft tissue lesions in the postcricoid or retropharyngeal space.
- Barium Swallow: Helps diagnose malignancy, achalasia, strictures, diverticula, hiatus hernia, and motility disorders. It shows intrinsic and extrinsic diseases but has limited sensitivity for pharyngeal disease and reflux detection.
6. Advanced Imaging
- CT Scan: Essential for staging malignant dysphagia and identifying extrinsic compression.
- MRI: Used to investigate neurological causes, such as multiple sclerosis, brainstem lesions, or vascular anomalies.
7. Videofluoroscopy (VF) VF offers dynamic swallowing assessment and is considered the gold standard. It evaluates all swallowing phases, especially oral and pharyngeal, and is useful for patients with neurological conditions or head and neck cancers. VF detects aspiration, using scales like the penetration–aspiration scale, and tests maneuvers to reduce aspiration.
8. Manometry and pH Studies Manometry assesses oesophageal motility by measuring pressures and acid reflux using a catheter with pressure transducers. This helps diagnose conditions like achalasia, diffuse oesophageal spasm, and scleroderma.
9. Oesophagoscopy A direct examination of the oesophagus using flexible or rigid scopes, enables biopsy. Transnasal oesophagoscopy (TNO) offers a less invasive, cost-effective option without sedation risks, useful for assessing oesophageal pathology.
10. 24-hour Ambulatory pH Monitoring The most accurate method for diagnosing gastro-oesophageal reflux disease (GORD), this test measures oesophageal pH over 24 hours, correlating with patient symptoms.
11. Gastroscopy An endoscopic procedure used to assess and biopsy oesophagitis, Barrett’s oesophagus, and tumours.
12. Fibre-optic Endoscopic Evaluation of Swallowing (FEES) Performed at the bedside, FEES assesses swallowing mechanics and aspiration risk, providing visual biofeedback for therapeutic manoeuvres.
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Reference Textbooks.
- Scott-Brown, Textbook of Otorhinolaryngology-Head and Neck Surgery.
- Cummings, Otolaryngology-Head and Neck Surgery.
- Stell and Maran’s, Textbook of Head and Neck Surgery and Oncology.
- Ballenger’s, Otorhinolaryngology Head And Neck Surgery
Author:
Dr. Rahul Bagla
MBBS (MAMC, Delhi) MS ENT (UCMS, Delhi)
Fellow Rhinoplasty & Facial Plastic Surgery.
Renowned Teaching Faculty
Mail: msrahulbagla@gmail.com
India
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