Describe the causes and assessment of dysphagia.

Approach to Dysphagia

• Dysphagia is difficulty in swallowing.
• It differs from odynophagia (painful swallowing) and from globus (a sensation of a lump with normal swallowing).
• Dysphagia is always a significant symptom and is never dismissed.
• The first division IS oropharyngeal versus oesophageal, and the history makes it:
• Oropharyngeal (transfer) dysphagia — difficulty initiating the swallow, with coughing or choking on swallowing, nasal regurgitation, drooling, a wet or gurgly voice after swallowing, and recurrent chest infections. The patient points to the neck
• Oesophageal (transport) dysphagia — food sticking seconds after swallowing, with the patient pointing to the retrosternal region
• The second division IS solids versus liquids, and it is highly discriminating:
• Solids first, progressing to liquids — a mechanical obstruction, and if progressive with weight loss in an older patient, malignancy
• Solids and liquids equally from the outset, often intermittent — a neuromuscular or motility disorder
• Intermittent and non-progressive — a web, ring or spasm
• The red flags requiring urgent investigation — progressive dysphagia; weight loss; anaemia; a neck lump; hoarseness; referred otalgia; aspiration or recurrent pneumonia; and age over 45 with new dysphagia
• Causes — in the lumen: a foreign body or bolus obstruction
• In the wall — carcinoma of the pharynx, hypopharynx or oesophagus; benign stricture from reflux or corrosive ingestion; webs and rings; plummer-VINSON (paterson-brown-KELLY) syndrome; eosinophilic oesophagitis; infection — candidal, herpetic or tuberculous; and pharyngeal pouch
• Outside the wall — a thyroid goitre or retrosternal extension; mediastinal nodes or tumour; a vascular ring (dysphagia lusoria); and cervical osteophytes
• Neuromuscular causes, which are the commonest cause of oropharyngeal dysphagia — stroke, which is much the commonest; Parkinson disease; motor neurone disease; multiple sclerosis; myasthenia gravis, characteristically with fatigable weakness worsening through a meal; bulbar and pseudobulbar palsy; achalasia; diffuse oesophageal spasm; and scleroderma
• Plummer-VINSON syndrome — iron-deficiency anaemia, a postcricoid web and dysphagia, in middle-aged women, with koilonychia, angular stomatitis and glossitis. It is premalignant, predisposing to postcricoid carcinoma.
• Investigation — full blood count and iron studies; flexible nasendoscopy to see the pharynx and larynx and to assess pooling of saliva in the pyriform fossae; videofluoroscopy (modified barium swallow).
• Fibreoptic endoscopic evaluation of swallowing (fees) is performed at the bedside and is particularly useful in stroke
• Management — treat the cause; and involve a speech and language therapist early.
• Nutrition must be secured — nasogastric feeding for the short term and gastrostomy for the longer term, with the decision made with the patient and family