Dysphagia

Aka: Dysphagia, Difficult Swallowing, Swallowing Disorder, Deglutition Disorder

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II. Definitions

  1. Dysphagia
    1. Disordered Swallowing

III. Causes

  1. See Oropharyngeal Dysphagia
  2. See Esophageal Dysphagia

IV. History

  1. Characteristics: Tell me about your Swallowing
    1. What happens when you swallow?
    2. Oropharynngeal Dysphagia
      1. Is it hard to start to swallow?
      2. Does Swallowing make you cough or choke?
      3. Does food feel as if it backs up into your nose of throat?
    3. Esophageal Dysphagia
      1. Does it feel as if food is becoming stuck in your chest?
  2. Timing
    1. Recent onset (acute Dysphagia)?
      1. Oropharynngeal Dysphagia
        1. Consider Cerebrovascular Accident
        2. Consider Pharyngitis, new medications with Xerostomia
      2. Esophageal Dysphagia
        1. Pill Esophagitis
        2. Esophageal Foreign Body
    2. Gradually worsening over time (progressive Dysphagia)?
      1. Oropharynngeal Dysphagia
        1. Progressive neuromuscular disorder
        2. Head and Neck Mass
      2. Esophageal Dysphagia
        1. Progressive Esophageal Motility Disorder
        2. Chest mass
    3. Intermittent?
      1. Consider provocative factors (e.g. medications, dentures, Esophageal Dysmotility)
  3. Provocative: Chewing (Oropharynngeal Dysphagia)
    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)
  4. Provocative: Solid or Liquid Dysphagia
    1. Oropharynngeal Dysphagia
      1. Liquid Dysphagia only
    2. Esophageal Dysphagia
      1. Liquid and Solid Dysphagia
        1. Esophageal Dysmotility (e.g. Achalasia)
      2. Solid Dysphagia only
        1. Intrinsic obstruction (e.g. Esophageal Ring, Esophageal Foreign Body, Esophageal Cancer)
        2. Extrinsic obstruction (e.g. mediastinal chest mass, thyromegaly)
  5. Provocative: Medications and Habits
    1. Medication Causes of Dry Mouth
    2. Pill Esophagitis provocative medications
    3. Esophageal Dysmotility provocative medications (e.g. Opioids)
  6. Palliative
    1. Antacid Medications (e.g. Proton Pump Inhibitors)
  7. Associated Symptoms
    1. Oropharynngeal Dysphagia
      1. Pharyngitis
    2. Esophageal Dysphagia
      1. Dyspepsia
      2. Reflux with halitosis
      3. Environmental Allergies (Eosinophilic Esophagitis)
    3. Malignancy
      1. Weight loss

V. Exam

  1. General
    1. Cachexia or Muscle wasting (consider active malignancy)
    2. Frailty (Sarcopenia)
  2. Oropharynx
    1. Xerostomia
    2. Dentition or Dentures
    3. Tongue motor abnormalities (tongue Fasciculations, Tongue deviation)
  3. Neck
    1. Cervical Lymphadenopathy
    2. Thyromegaly or Thyroid Goiter
    3. Neck Mass
  4. Chest
    1. Wheezing or Stridor
    2. Asymmetric lung sounds
    3. Supraclavicular Lymphadenopathy
    4. Chest mass or deformities
  5. Abdomen
    1. Portal Hypertension findings (e.g. Abdominal Distention, Jaundice, varicosities)
    2. Abdominal Mass
  6. Skin Exam
    1. Dermatomyositis findings (e.g. Gottron's Papules)
    2. Scleroderma findings (e.g. Sausage Digits)
    3. Skin changes suggestive of chemical dependency (e.g. needle tracks)
  7. 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)

VI. 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]

VII. Management

  1. Evaluation and management is specific to type (oropharyngeal or esophageal)
  2. See Oropharyngeal Dysphagia
  3. See Esophageal Dysphagia

VIII. References

  1. Jansson-Knodell (2017) Mayo Clin Proc 92(6): 965-72 [PubMed]
  2. Wilkinson (2021) Am Fam Physician 103(2): 97-106 [PubMed]

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