Dysphagia

Did You Know?

• Difficulty swallowing may be caused or exacerbated by the use of opioids; cocaine may also induce it.
• Swallowing disorders can result from congenital abnormalities, structural damage, and/or medical conditions.
• Achalasia is a major exception to the usual pattern of dysphagia in that swallowing fluid tends to cause more difficulty than swallowing solids.

Signs and symptoms

Some patients have limited awareness of their dysphagia, so absence of the symptom does not exclude underlying disease. Undiagnosed or untreated dysphagia carries high risk of pulmonary aspiration and subsequent aspiration pneumonia, as food or liquids enter the lungs. Some individuals present with silent aspiration, showing no cough or outward signs. Undiagnosed dysphagia can also lead to dehydration, malnutrition, and kidney failure. Signs of oropharyngeal dysphagia include difficulty controlling food or saliva in the mouth, trouble initiating a swallow, coughing, choking, frequent pneumonia, unexplained weight loss, gurgly or wet voice after swallowing, and nasal regurgitation. Patients often point to the cervical region as the site of obstruction, though the actual obstruction is at or below that level. Esophageal dysphagia most commonly presents as inability to swallow solid food, described as becoming stuck or held up. Odynophagia can be highly indicative of carcinoma but has many other causes. In achalasia, swallowing fluid causes more difficulty than solids due to idiopathic destruction of parasympathetic ganglia of the Auerbach's plexus, leading to functional narrowing of the lower esophagus and peristaltic failure.

Diagnosis

Esophagoscopy and laryngoscopy allow doctors to see directly inside the throat and esophagus. An esophageal motility study helps diagnose achalasia and diffuse esophageal spasms. Cells from an esophageal wash, collected during esophagoscopy, can be examined for early signs of cancer. Ultrasound and CT scans are not great at pinpointing why someone has trouble swallowing, but they can find masses in the chest or aortic aneurysms. A procedure called FEES, sometimes with sensory testing, is typically done by a speech pathologist or deglutologist; the patient swallows foods of various textures. Using swallowing sounds or vibrations for screening is still being researched. Many conditions can cause dysphagia, and all are considered possible diagnoses. These include 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 the paraesophageal type), dysphagia lusoria, stroke, Fahr's disease, Wernicke encephalopathy, Charcot-Marie-Tooth disease, Parkinson's disease, multiple sclerosis, amyotrophic lateral sclerosis, rabies, and cervical spondylosis.

Treatments

Treatment for dysphagia includes swallowing therapy, dietary changes, feeding tubes, certain medications, and surgery, managed by a multidisciplinary team. This team comprises 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 each member depends on the type of swallowing disorder; for example, the swallowing therapist treats oropharyngeal dysphagia, while a gastroenterologist handles esophageal disorders. Treatment strategy is based on thorough evaluation by the multidisciplinary team and differs per patient, structured to meet individual needs. Factors influencing strategy include diagnosis, prognosis, reaction to compensatory strategies, severity of dysphagia, cognitive status, respiratory function, caregiver support, and patient motivation. Adequate nutrition and hydration must be preserved throughout treatment. The overall goal is to maintain or return the patient to oral feeding while ensuring a safe swallow without aspiration. If oral feeding leads to insufficient intake or unsafe aspiration despite compensatory strategies, nonoral feeding may be needed, such as nasogastric tube, gastrostomy, or jejunostomy. Some patients, especially near end of life, may choose to continue oral feeding even when deemed unsafe, a practice known as risk feeding.