Approach

A thorough history reveals the diagnosis in 80% to 85% of patients.[41] It is also useful in differentiating oropharyngeal dysphagia from oesophageal dysphagia.

Patients with oral dysphagia most often have problems initiating the swallow or in controlling the food in their mouth.

Pharyngeal dysphagia can manifest with drooling or spillage of food, post-nasal regurgitation, hoarseness, shortness of breath, coughing, choking, and dysphonia.

Patients with oesophageal dysphagia often report food sticking in their lower neck or mid-chest region. Patients may use different manoeuvres to help the food passing the oesophagus, or they may sip water to relieve the obstruction.

The key tests used for the evaluation of dysphagia are oesophagogastroduodenoscopy (OGD), barium x-ray, fibre-optic nasopharyngeal laryngoscopy, or oesophageal manometry. However, the choice of specific testing depends on the clinical presentation.

History

  • Age: dysphagia with food impaction in a young, adult, white male should raise suspicion for eosinophilic oesophagitis. In a patient >40 years of age this is commonly due to Schatzki ring.[42] Concern for oesophageal cancer must lead to investigation in patients older than 50 years of age.

  • Symptom onset: dysphagia primarily to solid foods is probably indicative of a structural lesion, whereas dysphagia to both solid and liquid from the onset of symptoms is most likely to be due to motility or neurological disorders of the pharynx or oesophagus.[43][44]

  • Duration and progression of symptoms: rapid progression of dysphagia, particularly with weight loss, is suggestive of malignancy, whereas patients with peptic strictures usually have long-standing history of dysphagia. Oesophageal rings tend to cause intermittent solid food dysphagia; however, stricture and cancer cause progressive dysphagia.

  • Site of dysphagia: the site where the patient localises dysphagia is of limited value; however, retrosternal or epigastric dysphagia usually corresponds with the location of the lesion, whereas suprasternal dysphagia is usually referred from the hypopharynx or lower in the oesophagus.[43][45]

  • Associated symptoms: difficulty initiating a swallow along with coughing, choking, hoarseness, gagging, and nasal regurgitation is more suggestive of oropharyngeal dysphagia. Neurological signs and symptoms may also present in patients with oropharyngeal dysphagia. Chest pain is often seen in idiopathic achalasia and diffuse oesophageal spasm.[24] Previous history of heartburn is suggestive of peptic stricture.

  • Medication history: radiation- and/or chemotherapy-induced oral mucositis may cause dysphagia. A thorough medication history should be elicited.

Physical examination

There are no specific examination findings for dysphagia, but there may be findings suggestive of the cause: for example, slurred speech, haemiplegia in stroke, or scleroderma manifestations.

Investigations

Patients presenting with associated neurological symptoms or physical findings without other aetiologies for dysphagia may require further evaluation. Laboratory assessment is usually ordered in oropharyngeal dysphagia to assess the neuromuscular causes:[9][46]

  • Thyroid function test (thyromegaly)

  • Cerebrospinal fluid analysis (multiple sclerosis)

  • Botulinum toxin assay

  • Liver enzymes

  • Ceruloplasmin levels (Wilson's disease)

  • 24-hour urinary copper (Wilson's disease)

  • Creatine phosphokinase (inflammatory myopathies)

  • Acetylcholine receptor antibodies (myasthenia gravis)

  • Anti-DNA and antinuclear antibodies (scleroderma).

Specific investigational studies:

  • Standardised bedside swallowing assessment

    • Remains an important early screening tool for dysphagia and aspiration risk.

    • Variable sensitivity and specificity depending on the method used.

    • Trial swallow tests using different viscosities have more sensitivity than using water. However, combining swallow tests with pulse oximetry (oxygen desaturation ≥2%) using subjective aspiration assessments has the highest sensitivity (63% to 98%) and is currently the best method of bedside screening in patients with neurological disorders.[47]

  • Fibre-optic nasopharyngoscopy/laryngoscopy

    • Routine office or bedside awake endoscopy to evaluate structure and some functional aspects of the oropharynx and larynx.

      Although cricopharyngeus and oesophagus are not visualised, pooling of secretions can suggest dysfunction.com.bmj.content.model.assessment.Caption@5e158274[Figure caption and citation for the preceding image starts]: Larynx as a result of cricopharyngeal dysfunctionFrom the collection of Dr S. Charous [Citation ends].

  • Transnasal oesophagoscopy

    • Unsedated office procedure performed under local anesthaesia to evaluate the entire oesophagus endoscopically.

    • Excellent oesophageal screening method capable of biopsies but not capable of dilatations or resections.[48][49]

  • OGD[20]

    • Almost all the patients require an endoscopy as the initial study to establish the diagnosis.

    • It reveals structural abnormalities as well as providing the opportunity to perform therapeutic intervention such as balloon dilation in idiopathic achalasia[24] and resection of webs.

    • Oesophageal biopsies taken during endoscopy, if positive, may confirm conditions such as eosinophilic oesophagitis, carcinoma, or gastro-oesophageal reflux disease as the cause of oesophageal dysphagia.

    • Oesophageal dilation at the time of endoscopy can be therapeutic for multiple disorders such as Schatzki rings, stricture, or stenoses.

  • Barium swallow (or oesophagram)

    • Radiographic examination of the oesophagus is indicated for the detection of structural abnormalities that OGD fails to identify; also useful in detecting pharyngeal motility disorders.

    • Double-contrast views are best for detecting mucosal lesions (e.g., tumours, oesophagitis). Prone single-contrast views are best for detecting lower oesophageal rings or strictures, as the distal oesophagus is inadequately distended when the patient is upright.[1][50][51]

  • Modified barium swallow

    • A videoradiographic swallow study is performed by a radiologist and speech therapist on patients with oropharyngeal dysphagia.

    • It focuses on the oral cavity, pharynx, and cervical oesophagus, recording to assess abnormalities of both the oral and oesophageal phases of swallowing.

    • Reveals oropharyngeal dysfunction as well as the risk of aspiration during swallowing in such groups of patients.

    • Patients are given various consistencies of barium to swallow; hence, the study is helpful in finding the optimal diet, by which the risk of aspiration is minimised.[1][52]

  • Fibre-optic nasopharyngolaryngoscopy evaluation of swallowing

    • Complementary to modified barium swallows in evaluating laryngeal penetration and aspiration.

    • An excellent addition to the bedside swallow in determining risk of aspiration, especially in the bedridden patient.

    • The sensory testing aspect of fibre-optic endoscopic evaluation of swallowing with sensory testing utilises an air pulse stimulus of mechanoreceptors within the larynx.[53]

  • Biphasic oesophagram

    • Permits detection of both structural and functional abnormalities of the oesophagus.

    • Double-contrast views are best for detecting mucosal lesions (e.g., tumours, oesophagitis).

    • Prone single-contrast views with continuous drinking of low-density barium are best for detecting lower oesophageal rings or strictures.[1]

  • Timed barium oesophagogram

    • Simple, non-invasive, widely available barium technique for evaluating oesophageal emptying in patients with achalasia.

    • The films are taken at 1, 2, and 5 minutes after the last swallow of barium; the purpose of 2-minute film is to assess interim emptying.[24]com.bmj.content.model.assessment.Caption@5dcf5530[Figure caption and citation for the preceding image starts]: Idiopathic achalasia: barium oesophagograms showing a dilated oesophageal body and a tapering stricture in the distal oesophagus ('bird's beak')From the collection of Dr S. Charous [Citation ends].

  • Oesophageal manometry

    • A diagnostic study that measures intraluminal pressure as well as co-ordination activity of the upper and lower oesophagus sphincter and the oesophageal body.

    • Solid-state, multi-channel catheters allow increased accuracy in evaluating oesophageal motility.

    • The diagnostic study of choice in patients with suspected motility abnormalities without evidence of mechanical obstruction.[54]

    • Also used for evaluation of dysphagia in patients treated for achalasia or who have undergone antireflux surgery.

  • Surface electromyography

    • This is a simple, radiation-free method for screening and preliminary differentiation between oral and pharyngeal dysphagia.

    • The needle electrodes are used within swallowing muscles in the neck to record the timing of muscle contraction patterns and amplitude of electronic activity of the muscles during swallowing.

    • Dysphagia following oral cavity conditions prolongs drinking time and decreases the activity of the masseter, but it does not affect pharynx and submental muscles.

    • Not appropriate for the diagnosis of suspected neurogenic dysphagia.[55]

Muscle tension dysphagia is a diagnosis of exclusion made with speech therapists. It cannot be diagnosed thus far with conventional testing.[14]

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