Difficulty Swallowing

Anatomy/Physiology

• Oropharyngeal stage
  • oral phase
    • Prepares the bolus to be swallowable
    • Coordinated contraction of the tongue and striated muscles of mastication (cerebellar output from CNV3, CNVII and CNXII)
    • Can take between 1 and 10 secs depending on the liquidity of bolus
  • Pharyngeal phase
    • Involuntary swallow reflex- important to protect against aspiration
    • Rapid sequence of events
      • Soft palate rises
      • The hyoid bone and larynx move upward and forward
      • The vocal folds move into the midline
      • The epiglottis folds backward to protect the airway
      • The tongue pushes backward and downward on the bolus and the pharyngeal walls move inward from top to bottom, pushing the bolus down the back of the throat
      • The upper oesophageal sphincter relaxes and is pulled open by movement of the hyoid and larynx
      • The pharynx returns to resting
      • Under involuntary control from a number of cranial nerves (primarily CN IX and X)
      • The whole process lasts about a second
• Oesophageal phase
  • The bolus is propelled down by involuntary peristaltic contractions of the skeletal muscles of the upper oesophagus.
  • The lower oesophageal sphincter relaxes at the initiation of the swallow and persists until the bolus reaches the stomach
  • This lasts up to 20 secs

Dysphagia

Background

• Common (around 7-10% of adults >50 years old are reported to have some form of dysphagia
  • Incidence increases in hospital and nursing homes
• It is important to take a clear/thorough history to identify whether the patient actually has dysphagia
  • VS Globus VS heartburn
• Oropharyngeal dysphagia is more common in the elderly and can, but not always, be grouped with a number of other symptoms as part of an identifiable underlying cause (most commonly- stroke)
• Oesophageal dysphagia is caused by motility disorders or obstruction of the oesophagus by things like strictures/cancer/rings.

History

• HPC
  • Duration, severity, progression
    • Is it intermittent (e.g. rings/webs; diffuse oesophageal spasm, nutcracker oesophagus); is it gradually progressive? Does repeated swallowing help? (neuromuscular disorders); Does the valsava manoeuvre help? (obstructive?)
    • Any initiating factor; any provoking factors; any relieving factors?
    • Is the problem
      • at the start of swallow e.g. with choking, coughing, aspiration (oropharyngeal or neuromuscular problem);
      • after swallow e.g. food getting stuck in throat, regurgitation/vomiting
      • 
      • 
  • Any associated symptoms?
    • Pain (more likely in neuromuscular causes)
    • Change in appetite or ability to eat
      • Important to ask about weight loss
      • Ask about other red flags e.g. night sweats, fatigue
    • Ask about heartburn
    • Any regurgitation?
    • Any coughing/aspiration, any hallitosis (Zenker’s diverticulum)
    • Any hoarseness, problems with speech, hiccups
• PMHx
  • GORD, heartburn, diabetes, scleroderma
  • Ask about medications:
    • 
• Ask about other Social History (Alcohol and smoking in particular); Family History; ICE etc

Examination

• If necessary, it may be appropriate to measure the patient’s level of consciousness and cognition/mental status.
• Examination of the cranial nerves
  • In particular, sensory and motor function i.e. CN V, VII-XII (including gag function)
• Observe and palpate the neck, and assess whilst swallowing (may be useful to try water swallow)
• Examine, as much as possible, the oral cavity (if nasopharyngoscopy is possible, this can be used also)
• You may also want to do a cerebellar examination and assess motor, sensory and deep tendon reflexes elsewhere in the body if there is suspicion of a CNS problem.
• Assess weight, nutrition status etc if appropriate.
• Assess chest for signs of aspiration too.

Investigations

• Almost all patients should have endoscopy to look for any obvious structural abnormalities (NB normal endoscopy doesn’t rule out structure abnormality)
• Barium swallows are also commonly used in patients with dysphagia.
• Manometry is useful in patients who have a history suggestive of a motility disorder or in whom no abnormality has been found with endoscopy/barium studies

Differential Diagnosis

• Oropharyngeal
  • Neuromuscular
    • Disease of the CNS e.g. TIA/Stroke; Parkinson’s; Brainstem tumours; Degenerative diseases: e.g. ALS/MND; MS; Huntington’s
    • Postinfectious: Poliomyelitis; Syphilis
    • Peripheral neuropathy
    • Myaesthenia Gravis
    • Dermatomyositis
    • Muscular dystrophy
  • Obstructive
    • Tumours
    • Inflammatory masses
    • Trauma/surgery
    • Zenker’s Diverticulum
    • Oesophageal Webs
• Oesophageal
  • Neuromuscular disorders
    • Achalasia
    • Spastic motor disorders
      • Diffuse Oesophageal Spasm
      • Nutcracker oesophagus
      • Hypertensive LOS
    • Scleroderma
  • Obstructive lesions
    • Intrinsic
      • Tumours
      • Strictures
        • Peptic
        • Radiation-; chemical-; medication-induced
      • Lower oesophageal rings (Schatzki’s rings)
      • Oesophageal Webs
      • Foreign Bodies
    • Extrinsic
      • Vascular compressions
      • Mediastinal masses
      • Other cancers