Oropharyngeal Dysphagia

Aka: Oropharyngeal Dysphagia, Dysphagia from Oropharyngeal Cause, Causes of Oropharyngeal Dysphagia

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II. Causes: Neuromuscular Disorders

  1. Amyotrophic Lateral Sclerosis
  2. Myasthenia Gravis
  3. Bulbar Paralysis
  4. Cerebrovascular Accident
    1. See Dysphagia after Cerebrovascular Accident
  5. Parkinson Disease
  6. Multiple Sclerosis
  7. Polymyositis or Dermatomyositis
  8. Geriatric Degenerative Conditions
    1. Dementia (e.g. Alzheimer Disease)
    2. Frailty (Sarcopenia)

III. Causes: Extra-Oral Compression From Structural Disorders

  1. Head and Neck Mass (see Neck Masses in Adults)
  2. Head and Neck Surgery or Radiation Therapy
  3. Zenker Diverticulum
  4. Acute Calcific Tendonitis of the Longus Colli (ACTLC)
  5. Cervical Spine Osteoarthritis with osteophyte related posterior pharynx compression
  6. Lymphadenopathy
  7. Thyroid Goiter
  8. Cricopharyngeal bar

IV. Causes: Medications and Toxins

  1. Extrapyramidal Side Effect (e.g. Tardive Dyskinesia with ChoreiformTongue movements)
    1. Antipsychotic Medications (e.g. Haloperidol, Risperdal)
    2. Other agents (e.g. Levodopa, Metoclopramide, Phenytoin, Antidepressants)
  2. Local Medication Effects
    1. See Pharyngitis Causes
    2. See Medication Causes of Dry Mouth
    3. Stomatitis (e.g. Chemotherapy or Radiation Therapy induced)
  3. Toxins and Metabolic Conditions
    1. Hepatolenticular Degeneration (Wilson's Disease)
    2. Botulism
    3. Lead Poisoning
    4. Chemical Intoxication (e.g. Alcohol Intoxication)
    5. Unknown Ingestion with Altered Level of Consciousness
    6. Fluoride Overdose

V. Causes: Oral Conditions

  1. Extensive dental disease, poor Dentition or ill-fitting dentures
  2. Xerostomia or Dry Mouth (e.g. Sjogren's Syndrome)

VI. History

  1. See Dysphagia
  2. Difficulty initiating Swallowing?
  3. Swallowing leads to coughing or Choking?
  4. Swallowing with reflux into the nose or throat?
  5. Acute Oropharyngeal Dysphagia?
    1. Consider Cerebrovascular Accident
    2. Consider Pharyngitis
    3. Consider new medications with Xerostomia
  6. Progressive Oropharyngeal Dysphagia?
    1. Progressive neuromuscular disorder
    2. Head and Neck Mass
  7. Intermittent?
    1. Consider new medications
    2. Consider ill fitting dentures
  8. Is there difficulty with chewing?
    1. Chewing limited by jaw pain?
      1. Temporomandibular Joint Disorders
      2. Jaw Osteonecrosis
      3. Jaw Claudication (Temporal Arteritis)
      4. Dental Caries
    2. Chewing limited by Tooth Pain or malocclusion?
      1. Dental disease
      2. Ill-fitting dentures
    3. Chewing limited by weakness?
      1. Myasthenia Gravis
      2. Polymyositis
      3. Jaw Claudication (Temporal Arteritis)
  9. Is there liquid Dysphagia only?
    1. Solid Dysphagia or liquid and solid Dysphagia are more suggestive of Esophageal Dysphagia
  10. Are the new medications?
    1. Medication Causes of Dry Mouth
    2. Pill Esophagitis provocative medications
  11. Is there Unintentional Weight Loss?
    1. Consider head and neck malignancy

VII. Exam

  1. See Dysphagia
  2. General
    1. Cachexia or Muscle wasting (consider active malignancy)
    2. Frailty (Sarcopenia)
  3. Oropharynx
    1. Xerostomia
    2. Dentition or Dentures
    3. Tongue motor abnormalities (tongue Fasciculations, Tongue deviation)
  4. Neck
    1. Cervical Lymphadenopathy
    2. Thyromegaly or Thyroid Goiter
    3. Neck Mass
  5. Skin Exam
    1. Dermatomyositis findings (e.g. Gottron's Papules)
    2. Scleroderma findings (e.g. Sausage Digits)
  6. Neurologic Exam
    1. Altered Mental Status
      1. Transient, acute risk for Aspiration Pneumonitis
    2. Speech
      1. Weak, breathy or dysarthric in various neurologic and neuromuscular disorders
    3. Swallowing
      1. Coughing or Choking when Swallowing (Oropharyngeal Dysphagia)
    4. Focal Motor Weakness
      1. Cerebrovascular Accident
    5. Generalized Motor Weakness
      1. Myasthenia Gravis (Ptosis, Diplopia, Dysarthria)
    6. Cranial Nerves
      1. Eyelid Ptosis
      2. Gag Reflex loss (CN 9 and CN 10)
      3. Facial or Tongue neurologic deficits (CN 5, CN 7, CN 12)

VIII. Evaluation: Screening Tools

  1. Eating Assessment Tool or EAT-10 (Nestle)
    1. https://www.nestlehealthscience.com/health-management/gastro-intestinal/dysphagia/eat-10
    2. Belafsky (2008) Ann Otol Rhinol Laryngol 117(12):919-24 +PMID:19140539 [PubMed]
  2. What About Swallowing?
    1. See Dysphagia
    2. Standard Dysphagia history is as effective as EAT-10 questionnaire
    3. Heijnen (2016) Dysphagia 31(2):214-22 +PMID:26753926 [PubMed]
  3. Swallowing Quality of Life Questionnaire (SWAL-QOL)
    1. Requires purchase of Questionnaire
  4. Sidney Swallow Questionnaire
    1. https://stgeorgeswallowcentre.org/sydney-swallow-questionnaire/
    2. Dwiveldi (2010) Oral Oncol 46(4):e10-4 +PMID:20219415 [PubMed]

IX. Evaluation: Diagnostics

  1. See Swallowing Evaluation for Oropharyngeal Dysphagia
  2. Undiagnosed Dysphagia and silent aspiration is common in the frail elderly
    1. Consider in those with prior Cerebrovascular Accident, Dementia or Neuromuscular Disorder
  3. Avoid over-aggressive treatment and dietary restrictions
    1. Educate patient and their family on findings on options for management
    2. Discuss risks and benefits of interventions
    3. Tailor management to patient preferences

X. Management

  1. Optimize meal schedule and eating environment to best suit the needs of the patient
  2. Eat mindfully
    1. Avoid foods that are more likely to cause Dysphagia
    2. Cut food into small pieces
    3. Eat slowly, with smaller bites and chew carefully
    4. Frequently drink liquids to dilute food bolus consistency
    5. Adding sauce to food may lubricate food bolus and allow easier Swallowing
  3. Dietary changes
    1. See Dysphagia Diet
    2. Mechanical Soft Diet
      1. Indicated in chewing weakness or poor Dentition
    3. Modified Consistency Diet (thickened foods and liquids that slow transit)
      1. Indicated in impaired Swallowing
    4. Pureed Diet
      1. Indicated in chewing weakness, poor Dentition or Xerostomia
  4. Swallowing Rehabilitation
    1. Muscular reconditioning Exercises
      1. Exercises to stengthen jaw, lips and Tongue in clinically stable patients with learning potential
    2. Compensatory safe Swallowing techniques (repositioning maneuvers)
      1. Eat while in upright position
      2. Chin-Tuck Maneuver
        1. Indicated in patients with aspiration risk due to stroke or neuromuscular disorder
        2. Directs food posteriorly, reducing the risk of aspiration
        3. Saconato (2016) Int Arch Otorhinolaryngol 20(1): 13-7 [PubMed]
      3. Head-Turn Maneuver
        1. Indicated in patients with Unilateral Weakness
        2. Turn head toward weak side
        3. Gravity directs food toward the stronger side
  5. Enteral Feeding
    1. Consider alternatives and follow patient wishes after education on choices
      1. Consider Palliative Care or hospice Consultation
      2. Careful hand feeding
        1. Non-invasive alternative to PEG Tubes with similar efficacy and safety
        2. DiBartolo (2006) J Gerontol Nurs 32(5):25-33 [PubMed]
    2. Nasogastric Tube
      1. Allows for acute nutrition and medication administration in the first week after Cerebrovascular Accident
    3. Percutaneous Endoscopic Gastrostomy (PEG)
      1. Allows for the longterm Oropharyngeal Dysphagia management in severe Dysphagia
      2. Does not reduce aspiration risk or decrease mortality
      3. Teno (2012) J Am Geriatr Soc 60(10): 1918-21 [PubMed]

XI. Complications

  1. Aspiration Pneumonia
  2. Geriatric Failure to Thrive
  3. Dehydration
  4. Malnutrition

XII. References

  1. Roden (2013) Otolaryngol Clin North Am 46(6): 965-87 [PubMed]
  2. Vose (2014) Curr Phys Med Rehabil Rep 2(4): 197-206 [PubMed]
  3. Wilkinson (2021) Am Fam Physician 103(2): 97-106 [PubMed]

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