Dysphagia

Dysphagia is the medical term for difficulty in swallowing. It can manifest as trouble in the passage of solids or liquids from the mouth to the stomach, a lack of pharyngeal sensation, or other inadequacies of the swallowing mechanism.

Dysphagia is distinct from odynophagia (painful swallowing) and globus (sensation of a lump in the throat). A psychogenic form of dysphagia is known as phagophobia.

Classification

Dysphagia is classified into four major types:

1. Oropharyngeal dysphagia
2. Esophageal and obstructive dysphagia
3. Neuromuscular symptom complexes
4. Functional dysphagia, where no organic cause can be found.

Signs and Symptoms

Patients with dysphagia may have limited awareness of their condition, which can lead to pulmonary aspiration, aspiration pneumonia, dehydration, malnutrition, and kidney failure if left untreated. Signs of oropharyngeal dysphagia include difficulty controlling food in the mouth, difficulty initiating a swallow, coughing, choking, frequent pneumonia, unexplained weight loss, and a wet voice after swallowing. Patients often perceive the obstruction at the cervical level, but the actual site may be at or below this level.

Esophageal dysphagia commonly presents with an inability to swallow solid food, described by patients as 'becoming stuck' or 'held up' before passing into the stomach or being regurgitated. Pain on swallowing (odynophagia) may indicate carcinoma but has other potential causes. Achalasia, where fluid causes more difficulty than solids, is an exception due to idiopathic destruction of parasympathetic ganglia in the oesophagus.

Complications

Complications of dysphagia include aspiration, pneumonia, dehydration, and weight loss.

Causes

Dysphagia can have various causes, classified by the location affected:

• Oral dysphagia: Inflammation (tonsillitis, stomatitis), tongue cancer, neurological issues (paralysis of soft palate, Bell's palsy), dry mouth (Sjogren's syndrome).
• Pharyngeal dysphagia: Impacted foreign body, pharyngitis, malignant neoplasm, retropharyngeal abscess, lymphadenopathy, thyroid malignancy, Eagle syndrome, rabies.
• Esophageal dysphagia: Impacted foreign body, esophageal atresia, benign strictures, spasms, neoplasms, nervous disorders, Crohn's disease, Candida esophagitis, eosinophilic esophagitis, retrosternal goitre, malignancy, Zenker's diverticulum, aortic aneurysm, mediastinal growth, dysphagia lusoria, periesophagitis, hiatus hernia, gastric banding.

Opioid use can exacerbate dysphagia.

Diagnosis

Diagnostic tools for dysphagia include:

• Esophagoscopy and laryngoscopy for direct visualisation.
• Esophageal motility study for achalasia and esophageal spasms.
• Exfoliative cytology for early detection of malignant cells.
• Ultrasonography and CT scans for detecting masses in the mediastinum and aortic aneurysms.
• Fibreoptic endoscopic evaluation of swallowing (FEES) by a speech pathologist or deglutologist.
• Swallowing sounds and vibrations for early-stage dysphagia screening.

Treatment

Treatment for dysphagia involves a multidisciplinary team including a speech therapist, primary physician, gastroenterologist, nursing staff, respiratory therapist, dietitian, occupational therapist, physical therapist, pharmacist, and radiologist. The goal is to maintain or restore oral feeding while ensuring adequate nutrition and a safe swallow.

Treatment Strategies

Strategies should be personalised based on diagnosis, prognosis, severity, cognitive status, respiratory function, caregiver support, and patient motivation.

Oral vs. Nonoral Feeding

Maintaining adequate nutrition and hydration is very important. Nonoral feeding methods like nasogastric tubes, gastrostomy, or jejunostomy may be needed if oral feeding is unsafe or insufficient.

Swallowing Difficulties in Dementia

A 2018 Cochrane review found no certain evidence about the long-term effects of thickened fluids in dementia patients. While thickening fluids may help immediately, the long-term impact on health should be considered.

Treatment Procedures

• Compensatory Treatment Procedures: Postural techniques, food consistency changes, modifying volume and speed of food presentation, techniques to improve oral sensory awareness, and intraoral prosthetics.
• Therapeutic Treatment Procedures: Oral and pharyngeal range-of-motion exercises, resistance exercises, bolus control exercises, and swallowing manoeuvres like the supraglottic swallow, super-supraglottic swallow, effortful swallow, and Mendelsohn manoeuvre.

Epidemiology

Swallowing disorders can occur across all age groups due to congenital abnormalities, structural damage, or medical conditions. Dysphagia is more common in the elderly and stroke patients, affecting about 3% of the population.

Etymology

The word "dysphagia" is derived from the Greek dys meaning bad or disordered, and phag- meaning "eat".

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Self-assessment MCQs (single best answer)

What is dysphagia?

Which of the following is NOT a type of dysphagia?

Which symptom is commonly associated with esophageal dysphagia?

Which diagnostic tool is used to visualise the oesophagus and larynx directly?

Which of the following is a cause of oral dysphagia?

Which of the following is a compensatory treatment procedure for dysphagia?

Which of the following is NOT a potential complication of dysphagia?

What is the primary goal of dysphagia treatment?

In the context of dysphagia, what is phagophobia?

Which demographic is more commonly affected by dysphagia?