Dysphagia

The sensation of impaired passage of food from the oropharynx to the stomach.

Dysphagia can occur at any age. It is the most common esophageal disorder in the elderly and is estimated to occur in up to 50% of patients in long-term care facilities.

Oropharyngeal Dysphagia

Difficulty in initiating swallowing or in transferring food from the oropharynx to the upper esophagus.

Etiology

Causes of oropharyngeal dysphagia are listed in Table 105-1.

Neurologic disorders may affect neuromuscular function by impairing motor function or sensation. The most common neurologic cause of oropharyngeal dysphagia in the elderly is a stroke, especially a stroke that affects the swallowing center in the midbrain (bilaterally in the reticular substance below the nucleus of the solitary tract) or the anterior cortical areas. Wallenberg's syndrome (a syndrome marked by ipsilateral loss of temperature and pain sensations of the face) may cause dysphagia by impairing the ipsilateral palatal muscles supplied by the lateral area of the medulla resulting from the occlusion of the posterior inferior cerebellar artery. As a result of bilateral multiple cerebral infarctions, pseudobulbar palsy may cause dysphagia by impairing the muscles supplied by the medulla oblongata. Bulbar palsy may also cause dysphagia by paralyzing or weakening the muscles supplied by the medulla oblongata, but bulbar palsy does not occur as a result of cerebral infarctions.

Parkinson's disease, amyotrophic lateral sclerosis, multiple sclerosis, brain tumors, and central nervous system degenerative diseases (eg, Alzheimer's disease) may cause dysphagia by affecting movements of the tongue, pharynx, or upper esophagus.

Muscular disorders (eg, oculopharyngeal muscular dystrophy, myasthenia gravis, Eaton-Lambert syndrome, dermatomyositis, polymyositis) may cause dysphagia by inhibiting neuromuscular function.

Upper esophageal sphincter abnormalities also affect neuromuscular function. The cricopharyngeus and some components of the inferior pharyngeal constrictor muscle are responsible for the high-pressure zone of the upper esophageal sphincter. Dysphagia can result from a hypertensive upper esophageal sphincter, a hypotensive upper esophageal sphincter (due to amyotrophic lateral sclerosis, myasthenia gravis, or myotonic muscular dystrophy), or incomplete upper esophageal sphincter relaxation (cricopharyngeal achalasia).

Anatomic abnormalities may cause difficult or incomplete passage of food through the esophagus. Head and neck tumors may cause oropharyngeal dysphagia in the elderly. Zenker's diverticulum is associated with premature closure of the upper esophageal sphincter, which increases resistance to the passage of a food bolus and leads to outpouching of the esophageal wall.

Cervical hypertrophic osteoarthropathy may cause dysphagia when the cervical osteophyte (spur) is extraordinarily large or when periesophagitis occurs from rapid expansion of the osteophyte. Osteophyte-induced dysphagia is very rare (only about 75 cases have been reported).

Cervical strictures and esophageal webs can also cause oropharyngeal dysphagia.

Symptoms and Signs

Patients may experience coughing or choking during swallowing, nasopharyngeal regurgitation, changes in speech, or recurrent aspiration. Globus sensation (a subjective sensation of cervical fullness or a "lump in the throat") may occur. Although the physiologic mechanisms underlying globus sensation are unknown, increased pressure or spasm of the upper esophageal sphincter or abnormal hypopharyngeal motility has been suggested. Functional chest pain may occur in patients with high levels of somatic concerns, anxiety, or depression. Obstructive disorders cause dysphagia, especially for solid foods.

Oropharyngeal dysphagia may be intermittent but, when due to neuromuscular disorders, typically progresses. Patients are at high risk of developing aspiration pneumonia.

Diagnosis

A barium swallow is routinely the initial examination and is often accompanied by videofluoroscopy to observe the rapid muscular coordination involved in swallowing. Endoscopy may also be used to assess muscular or anatomic abnormalities. Anatomic evaluation and observation of swallowing allow for an assessment of anatomic structures, uncoordinated movements, and aspiration or spillage.

A sensory deficit should be sought, as it may predispose to oropharyngeal dysphagia and aspiration. Testing the gag reflex is an incomplete assessment of the sensory fibers to the laryngeal and hypopharyngeal mucosa and is an inadequate predictor of aspiration. A fiberoptic endoscopic evaluation of swallowing with sensory testing can determine laryngopharyngeal sensory discrimination thresholds. This newly developed technique can be performed at the bedside and may identify sensory deficits causing aspiration that cannot be identified by barium swallow.

If a head or neck tumor is suspected after clinical assessment, evaluation should include direct laryngoscopy and CT of the head and neck. If cervical hypertrophic osteoarthropathy is suspected, evaluation should include plain cervical spine films with lateral views and barium videofluoroscopy with food bolus to determine the degree of compression during swallowing.

Treatment

Treatment requires identification of potentially treatable causes. Goals include identifying and maintaining safe swallowing techniques, avoiding aspiration, and providing adequate nutritional support.

For patients with oropharyngeal dysphagia due to untreatable neuromuscular disorders, altering the consistency of food may improve swallowing. Evaluation by a speech therapist may be beneficial, because some patients may be able to improve their swallowing function by changing their head position while eating, performing exercises that improve the ability to accommodate a food bolus in the oral cavity, strengthening and improving the coordination of the tongue, and learning different swallowing techniques.

Depending on the degree of dysphagia, drug treatment for neuromuscular disorders may not completely restore swallowing. For patients with severe dysphagia and recurrent aspiration, gastrostomy tube placement may be necessary.

For patients with oropharyngeal dysphagia due to a stroke, retraining the swallowing muscles may be effective. This rehabilitation is best combined with a videotaped barium swallow to assess the effects of different foods (eg, liquid, semisolid, solid) on swallowing and to evaluate for aspiration.

For patients with oropharyngeal dysphagia due to head and neck tumors, treatment involves surgery, radiation therapy, or chemotherapy as necessary. However, surgery or radiation therapy can result in esophageal stricture.

For patients with oropharyngeal dysphagia due to cervical hypertrophic osteoarthropathy, reassurance and support are usually effective. However, if the dysphagia is unremitting, surgical removal of the osteophyte may be necessary.

Esophageal Dysphagia

Difficulty in swallowing when ingested material cannot be transported from the hypopharynx through the esophagus into the stomach.

Causes of esophageal dysphagia are listed in Table 105-2. Neuromuscular causes include achalasia, diffuse esophageal spasm, and progressive systemic sclerosis. Obstructive causes include strictures, esophageal rings and webs, and tumors.

A less common obstructive cause is an esophageal vascular anomaly, which can cause dysphagia through compression of the esophagus. Dysphagia aortica, which occurs in the elderly, results from esophageal compression by a large thoracic aortic aneurysm or an atherosclerotic, rigid aorta.

Obstructive dysphagia can also result when a foreign body lodges in the esophagus. Some elderly persons may be susceptible to foreign body obstruction because visual acuity may decrease with age and denture wearing can decrease the ability to feel objects in the mouth.

Symptoms and Signs

The sensation is that of food being stuck in the esophagus and of retrosternal discomfort. However, the patient's subjective localization of the site of bolus impaction does not reliably predict the site of the actual problem. For example, impaction in the distal esophagus may produce symptoms in the lower neck.

Diagnosis and Treatment

A barium swallow is often the initial evaluation used. Endoscopy is also used to assess symptoms and to perform diagnostic biopsies. Treatment is tailored to the specific cause of the dysphagia.