Dysphagia resident survival guide

Dysphagia Resident Survival Guide
Overview
Causes
Diagnosis
Treatment
Do's
Don'ts

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mounika Reddy Vadiyala, M.B.B.S.[2]

Synonyms and keywords: Approach to dysphagia, Dysphagia algorithm, Dysphagia workup, Dysphagia management, Dysphagia diagnostic approach

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Overview

Dysphagia is defined as "difficulty swallowing." It is a sensation that suggests difficulty in the passage of solids or liquids from the mouth to the stomach. According to the International Classification of Diseases (ICD-10) which is endorsed by the WHO, dysphagia is a symptom rather than a disease. Dysphagia can result from propulsive failure, motility disorders, structural disorders, intrinsic or extrinsic compression of the oropharynx or esophagus. Dysphagia is distinguished from similar symptoms including odynophagia, which is defined as painful swallowing, and globus, which is the sensation of a lump in the throat. The endoscopy for esophageal dysphagia should be performed when the patient presented with symptoms of difficulty swallowing, painful swallowing, and aspiration. This is the standard test performed when the patient has a risk of developing pneumonia and diagnosing swallowing difficulties. Videofluoroscopic swallowing study is performed for oropharyngeal dysphagia. It provides information about delay in initiation of pharyngeal swallowing, nasopharyngeal regurgitation, residue of ingested food within the pharyngeal cavity after swallowing, and aspiration of ingested food. The cornerstone of any dysphagia evaluation is a detailed history and a thorough review of symptoms that can differentiate esophageal from oropharyngeal dysphagia and help predict the specific etiology of dysphagia with an accuracy of approximately 80% confirmed by specific testing. How a patient describes his or her difficulty and its timing, associated symptoms, and other characterizations may specifically denote the anatomic level of swallowing dysfunction.

Causes

Life Threatening Causes

Life-threatening causes include conditions that may result in death or permanent disability within 24 hours if left untreated. There are no known life-threatening causes of dysphagia.

Common Causes

Depending upon the type of dysphagia, the causes can be categorized into two subsections:

Common Causes of Oropharyngeal Dysphagia

Common causes of oropharyngeal dysphagia
Neuromuscular disorders	Mechanical and obstructive causes	Medication side effects	Others
Stroke Parkinson's disease Brain stem tumors Cranial nerve palsy or Bulbar palsy Multiple sclerosis Amyotrophic lateral sclerosis Myasthenia gravis Poliomyelitis Myotonic dystrophy Oculopharyngeal muscular dystrophy Polymyositis and dermatomyositis	Zenker's diverticulum Cricopharyngeal bar Cervical osteophytes Thyromegaly Lymphadenopathy Cervical rings or cervical webs Strictures Oropharyngeal tumors Head and neck tumors Surgical and/or radiotherapeutic interventions on head and neck tumors Retropharyngeal abscess Congenital (cleft palate, diverticula, etc.)	Medications that reduce salivary flow: Anticholinergics Angiotensin-converting enzyme inhibitors Alpha blockers Angiotensin II receptor blockers Antihistamines Antiarrhythmics Antiepileptics Antipsychotics Mexiletine Opiates Diuretics Ipratropium bromide	Amyloidosis Cushing's syndrome Thyrotoxicosis Wilson disease Sjogren's syndrome Pharyngitis Dental disease Mucositis (Oral candidiasis, Herpetic lesions, Cytomegalovirus) Caustic ingestion/ injury Diphtheria Tetanus Botulism Lead poisoning Rabies

Common Causes of Esophageal Dysphagia

The common causes of esophageal dysphagia can be divided into four categories.

Structural (Mechanical) disorders				Motor disorders		Esophageal tumors	Systemic diseases	Miscellaneous
Intrinsic compression		Extrinsic Compression		Primary	Secondary
Mucosal rings and webs Schatzki Plummer-Vinson Multiringed esophagus (eosinophilic esophagitis)	Strictures: PUD Caustic Pill-induced Radiation-induced	Vascular compression: Dysphagia lusoria (aberrant right subclavian artery) Dysphagia aortica (enlarged aorta) Cardiomegaly (enlarged left atrium)	Mediastinal masses: Lung cancer Lymphoma Lymphadenopathy Thyromegaly Tuberculosis Histoplasmosis	Achalasia Diffuse esophageal spasm Hypertensive lower esophageal sphincter Ineffective esophageal motility disorder Nutcracker esophagus	Mixed connective tissue disease Scleroderma CREST syndrome SLE Rheumatoid arthritis Diabetes Chagas disease Paraneoplastic syndrome	Adenocarcinoma Squamous cell carcinoma Metastatic (breast carcinoma or melanoma) Leiomyoma, lymphoma, or granular cell tumor	Scleroderma (multifactorial) Pemphigus Lichen planus Crohn’s disease Rheumatoid arthritis	Functional dysphagia Postsurgery (laryngeal, esophageal, or gastric cancers) Infection esophagitis (Candida, Cytomegalovirus) Esophageal diverticula Foreign bodies

Less Common Causes

Less common causes of dysphagia include:

• Scleredema adultorum
• Post chemotherapy and radiation therapy
• Descending thoracic aorta aneurysm
• Hypertrophy of cricopharyngeal muscles

To review a complete list of dysphagia causes, click here

Diagnosis

Patient with Dysphagia

Difficulty in initiating a swallow associated with cough, choking or nasal regurgitation

Dysphagia to solids and liquids, or solids, sensation of food stuck in esophagus (seconds after initiating swallow)

Oropharyngeal dysphagia

Esophageal dysphagia

Shown below is an algorithm summarizing the diagnosis of Oropharyngeal dysphagia according to the the World Gastroenterology Organisation Global Guidelines, International consensus (ICON) on assessment of oropharyngeal dysphagia and AGA technical review on management of oropharyngeal dysphagia.

Dysphagia

History and Physical examination

Identify alternate diagnoses such as xerostomia, globus, esophageal dysphagia

Laboratory findings and CNS imaging

Identify syndromes with specific treatment such as myasthenia gravis, toxic and metabolic myopathies, CNS tumors

No systemic disease identified

Neuromuscular disorders without specific treatment

Nasoendoscopy (to evaluate for structural causes of dysphagia)

Videofluoroscopic swallowing +/-manometry (to characterise severity and mechanism of swallow dysfunction)

Structural lesions with specific therapy such as zenker's diverticulum, orophayngeal tumors

Severe dysfunction or risk of aspiration pneumonia necessitating the institution of nonoral feeding, tracheostomy

Dysphagia ammendable to cricophayngeal myotomy

Dysphagia ammendable to specific therapy (diet modification, swallow therapy +/- temporary nonoral feeding)

Shown below is an algorithm summarizing the diagnosis of Esophageal dysphagia according the the World Gastroenterology Organisation Global Guidelines, and Clinical Practice Guidelines for the Assessment of Uninvestigated Esophageal Dysphagia.

Esophageal dysphagia

Dysphagia to solids and liquids

Dysphagia to solids (may progress to liquids)

Motility disorders

Mechanical obstruction

Intermittent

Progressive

Acute

Intermittent

Progressive

Chronic heartburn

Regurgitation and/or respiratory symptoms

Chronic heartburn

Elderly (>50 years), weight loss, anemia

Primary motility disorders

Secondary motility disorders

Scleroderma

Achalasia

Foreign body

Esophageal ring or eosinophilic esophagitis

Esophageal stricture / GERD

Esophageal or cardia carcinomas

Manometry

Endoscopy (+/-esophageal biopsy)

Barium Swallow indicated when: ❑ Endoscopy findings are normal ❑ Endoscopy is contraindicated due to: ❑ History of surgery for esophageal/laryngeal cancer ❑ History of radiation ❑ Caustic injury ❑ Complex stricture ❑ Risk of perforation ❑ Endoscopy access is limited

Treatment

Shown below is an algorithm summarizing the treatment of Oropharyngeal dysphagia according to the the World Gastroenterology Organisation Global Guidelines, International consensus (ICON) on assessment of oropharyngeal dysphagia and AGA technical review on management of oropharyngeal dysphagia.

Systemic disease with specific therapy such as myasthenia gravis, myopathies, parkinson's disease, infections and others

Treat the underlying disease

CNS tumors and oropharyngeal tumors

Surgical resection, chemotherapy or radiotherapy

Oropharyngeal dysphagia

Structural disorders such as cervical webs and rings, zenker's diverticulum and others

Treatment of the disorder

Medication side effects

Discontinue medication

Severe dysfunction and risk of aspiration pneumonia

❑ Non-oral feeding ❑ Tracheostomy

Neuromuscular disorder without specific therapy such as stroke, dengerative diseases and others

Cricopharynegal dysfunction

Cricopharyngeal myotomy

Rehabilitation

❑ Swallowing maneuvers and postural techniques ❑ Dietary modification ❑ Temporary non-oral feeding

Shown below is an algorithm summarizing the management of Esophageal dysphagia according the the World Gastroenterology Organisation Global Guidelines, and Clinical Practice Guidelines for the Assessment of Uninvestigated Esophageal Dysphagia.

Esophageal dysphagia

Age>50 years, weight loss, anemia and other alarm signs and symptoms

Endoscopy +/- other imaging studies

Surgical resection or chemotherapyof the detected esophageal carcinoma

No

GERD symptoms

Proton pump inhibitor trial for 4 weeks

No

Dysphagia unresolved

Structural or inflammatory lesions detected on endoscopy and/or barium swallow

Treat the detected lesions

No

Esophageal manometry

Treat the detected motility disorders

Do's

• Evaluate for drugs causing decreased salivary flow or those causing esophageal mucosal injury.
• Treat underlying disorders first.

Don'ts

• Don't perform endoscopy in patients with a history of prior radiation or caustic injury, history of surgery for laryngeal or esophageal cancer, complex stricture or risk of perforation.

References